when assessing a patient who has just arrived after an automobile accident the emergency department nurse notes tachycardia and absent breath sounds o when assessing a patient who has just arrived after an automobile accident the emergency department nurse notes tachycardia and absent breath sounds o
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NCLEX RN Prioritization Questions

1. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Correct answer: Insertion of a chest tube with a chest drainage system

Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.

2. A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?

Correct answer: Stools test negative for occult blood.

Rationale: The best indicator that propranolol has been effective in a patient with cirrhosis and esophageal varices is when the stools test negative for occult blood. Propranolol is prescribed to decrease the risk of bleeding from esophageal varices. This medication's effectiveness is primarily assessed by the absence of blood in the stools, indicating a reduction in the risk of bleeding from the varices. Monitoring for chest pain, blood pressure control, and a decrease in heart rate are important parameters in other conditions treated with propranolol, such as hypertension, angina, and tachycardia, but in this particular case, the absence of occult blood in the stools is the most relevant indicator of treatment success.

3. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

Correct answer: Maintain in a flat position, logrolling as needed

Rationale: In the immediate post-operative period following spinal fusion for scoliosis in a 13-year-old, it is important to maintain the patient in a flat position and perform logrolling as needed. This helps prevent injury to the surgical site and ensures proper spinal alignment. Raising the head of the bed at least 30 degrees is contraindicated as it can put strain on the surgical site. Encouraging ambulation within 24 hours may be appropriate in the recovery process but not in the immediate post-operative period. Encouraging leg contraction and relaxation after 48 hours may also be part of the rehabilitation process but is not a priority in the immediate post-operative period.

4. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

Correct answer: Sunburn

Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.

5. Which of the following measures would be appropriate for a nurse to teach the parent of a nine-month-old infant about diaper dermatitis?

Correct answer: Discontinue a new food that was added to the infant's diet just prior to the rash

Rationale: Diaper dermatitis can be caused by various factors, one of which includes introducing new foods to the infant's diet. Discontinuing the new food that was added just before the rash can help identify and eliminate the potential cause. Options A and C are not directly related to addressing the cause of diaper dermatitis. While using cloth diapers rinsed in bleach may be a preventive measure for diaper dermatitis, it is not addressing a specific cause. Option B, advising against using occlusive ointments on the rash, may actually be beneficial in managing diaper dermatitis, but it does not address the cause of the condition.

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Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?

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