The nurse is working in the Emergency Department and is assessing ...

[Caiter2013]

The nurse is working in the Emergency Department and is assessing the client who is experiencing paradoxic movements of the right lung. The nurse should further assess the client for:
 
  1. apnea.
  2. heart failure.
  3. rib fractures.
  4. contusion.

Question 2

A client recovering from thoracic surgery has a chest tube to water seal drainage. The family ambulates the client. What should the nurse teach the client and family at this time?
 
  1. To cough while walking
  2. To keep the collection device below the chest
  3. To disconnect the collection device when ambulating
  4. To walk with a pillow

[samiel-sayed]

Answer to Question 1

Answer: 3

1. The client with flail chest will experience dyspnea.
2. Heart failure is not a result of flail chest.
3. Rib fractures often cause flail chest, which causes paradoxic movement of the lung during breathing.
4. A contusion is bruising, and does not result in paradoxic movement of the chest.

Answer to Question 2

Answer: 2

1. Ambulating will mobilize secretions, but the client can deep-breathe and cough when finished ambulating.
2. If the collection device is held at or higher than the chest, secretions will not flow out of the lung.
3. The collection device is never discontinued until the physician removes the chest tube.
4. The client should be taught to use a pillow to splint the wound during deep breathing and coughing.

[Caiter2013]

Excellent

[Kedrick2014]

Gracias!