What should govern the nurse’s actions regarding Mr. West rubbing Mrs. West’s calf?

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: "A thrombus becomes an embolus when dislodged." This answer is correct because when a thrombus, which is a blood clot, becomes dislodged from its original site, it can travel through the bloodstream as an embolus and potentially cause a blockage in a blood vessel, which can lead to serious complications like a pulmonary embolism if it reaches the lungs. Option A: "Touch is an important method of communication," is incorrect in this context because the question is specifically asking about the action of Mr. West rubbing Mrs. West's calf, which does not relate to touch as a method of communication. Option B: "It is important to involve family members in patient care," is incorrect as it is not directly related to the action of rubbing Mrs. West's calf or the potential risk of dislodging a thrombus. Option C: "Massage increases circulation, therefore reducing tenderness," is incorrect because while massage can increase circulation and reduce tenderness in some cases, in the context of a patient with a thrombus, the risk of dislodging the clot and causing harm outweighs the potential benefits of massage. In an educational context, it is crucial for nurses to be aware of the potential risks associated with certain actions, especially when caring for patients with underlying health conditions such as thrombus formation. Understanding the pathophysiology of conditions like thrombus formation and embolism can help nurses make informed decisions to provide safe and effective care to their patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Open pneumothorax. When a chest tube is accidentally pulled out, it results in an open pneumothorax, also known as a "sucking chest wound." This condition occurs when there is a communication between the pleural space and the external environment, leading to air entering the pleural cavity during inspiration and causing lung collapse. This is a medical emergency that requires immediate intervention to prevent respiratory distress and potential complications. Option A) Tension pneumothorax is incorrect because this condition is characterized by a buildup of air under pressure in the pleural space, usually due to a one-way valve effect, and can lead to a mediastinal shift and compromise cardiac output. Option C) Hemopneumothorax is incorrect as it refers to the presence of blood and air in the pleural cavity, often seen in trauma patients with chest injuries. Option D) Paradoxic respirations is incorrect as it describes a phenomenon where a segment of the chest moves in the opposite direction to the rest of the chest during breathing, typically seen in flail chest or diaphragmatic paralysis. Educationally, understanding the complications of chest tube removal is crucial for healthcare providers managing patients with chest tubes. Prompt recognition and appropriate management of an open pneumothorax are essential to prevent respiratory compromise and ensure patient safety. This knowledge underscores the importance of proper chest tube care and patient monitoring in the clinical setting.

Correct Answer: C

Rationale: In the context of preparing a patient like Mr. Jackson for a chest tube insertion, option C) teaching him to splint his chest wall is the most appropriate choice. Splinting the chest wall can help reduce pain and discomfort during the procedure by stabilizing the chest wall and minimizing movement, which is crucial for successful chest tube insertion. This education empowers the patient to actively participate in their care and promotes a sense of control and comfort during a potentially distressing procedure. Option A) explaining the etiology of his condition may be important for overall patient education and understanding, but it might not directly help Mr. Jackson prepare for the chest tube insertion procedure at that moment. Option B) asking if he has any questions about the insertion procedure is a good practice for patient-centered care, but it does not actively involve Mr. Jackson in a practical way to physically prepare for the procedure. Option D) reassuring him that the procedure is painless, although well-intentioned, may not be entirely accurate as chest tube insertion can be uncomfortable. Providing realistic expectations and practical strategies like splinting the chest wall would be more beneficial in this situation.

Correct Answer: A

Rationale: In the context of pharmacology and medical-surgical nursing, understanding the potential complications of tracheal suctioning is crucial for safe and effective patient care. The correct answer is A) Acute hypoxemia. Tracheal suctioning is a common procedure to remove secretions from the airway. However, it can lead to a temporary decrease in oxygen levels due to the interruption of airflow during the suctioning process. This can result in acute hypoxemia, which is a serious complication that can compromise oxygen delivery to tissues and organs, leading to potential respiratory distress and further complications. Option B) Gastric dilatation is incorrect because tracheal suctioning is not directly related to the gastrointestinal system and would not typically cause gastric dilatation. Option C) Hypervolemic shock is incorrect as tracheal suctioning does not involve a significant loss of blood volume or fluid to cause hypervolemic shock. Option D) Epiglottitis is incorrect as this condition is typically caused by infection and inflammation of the epiglottis, not by tracheal suctioning. Educationally, this question highlights the importance of understanding the potential complications of common nursing procedures like tracheal suctioning and the need for vigilant monitoring of patients undergoing such interventions to ensure prompt identification and management of any adverse events that may arise.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Teach him pursed-lip breathing. Pursed-lip breathing is a technique that helps improve breathing efficiency by reducing airway collapse during exhalation, maintaining positive pressure in the airways, and promoting oxygenation. This technique is particularly beneficial for patients with respiratory conditions like COPD, as it helps control breathing rate, decrease shortness of breath, and improve oxygen exchange. Option A) Encouraging coughing and deep breathing may be helpful in some situations to clear secretions and promote lung expansion, but it does not specifically address Mr. Puff's breathing pattern issue. Option B) Providing nasal O₂ at 6 L/min may improve oxygenation but does not directly address the breathing pattern concern. Option C) Sitting him in a chair may help with comfort and lung expansion but does not target the specific breathing pattern concern. Educationally, understanding and teaching patients techniques like pursed-lip breathing is crucial for nurses in managing respiratory issues effectively. By selecting the correct answer, nurses can improve patient outcomes, enhance comfort, and promote optimal respiratory function.