What should the nurse do first for a patient with pain after thoracotomy?

Correct Answer: B

Rationale: The correct answer is B) Monitor chest tube output. In the immediate post-operative period after a thoracotomy, monitoring the chest tube output is crucial as it helps the nurse assess for any signs of hemorrhage or other complications. Monitoring chest tube output allows the nurse to observe the amount, color, and consistency of drainage, which can provide valuable information about the patient's status and help in early identification of any issues. Option A) Treat the pain may seem like a priority, but in the context of a thoracotomy, monitoring the chest tube output takes precedence. Pain management is important, but ensuring proper chest drainage and preventing complications like hemorrhage is a critical aspect of post-thoracotomy care. Option C) Milking the chest tube is contraindicated as it can lead to increased negative pressure in the chest drainage system, potentially causing harm to the patient by disrupting the delicate balance needed for proper drainage. Option D) Checking for an air leak is important, but it is secondary to monitoring the chest tube output in the immediate post-operative period. While checking for an air leak is a part of assessing the chest tube system, it is not the first priority in this scenario. In an educational context, understanding the priorities in post-thoracotomy care is essential for nurses caring for these patients. Emphasizing the significance of monitoring chest tube output as a vital assessment in the early post-operative period can help prevent complications and ensure optimal patient outcomes. By prioritizing tasks based on patient needs and clinical guidelines, nurses can provide safe and effective care to patients undergoing thoracic surgery.

Correct Answer: B

Rationale: The correct answer is B) By monitoring oxygenation. In the context of a COPD patient, determining the appropriate oxygen flow rate is crucial to prevent complications such as respiratory depression or worsening of the condition. Monitoring oxygenation through methods like arterial blood gases (ABGs) or pulse oximetry allows healthcare providers to assess the patient's oxygen saturation levels accurately. Option A) Based on dyspnea level is incorrect because dyspnea alone may not accurately reflect the patient's oxygen needs. COPD patients may have chronically elevated CO2 levels, which can blunt their respiratory drive and lead to them relying on hypoxemia to drive their breathing. Option C) Fixed at 2 L/min is incorrect because a fixed flow rate may not meet the varying oxygen needs of a COPD patient. Each patient's oxygen requirements are unique and should be adjusted based on their specific condition and response to oxygen therapy. Option D) Avoided to prevent dependency is incorrect because withholding oxygen from a hypoxemic COPD patient can be detrimental. While it is essential to avoid over-oxygenating COPD patients, especially those with chronic respiratory failure, oxygen therapy is often necessary to maintain adequate oxygenation and prevent complications. Educationally, it is important for healthcare providers to understand the rationale behind determining oxygen flow rates for COPD patients to provide safe and effective care. By monitoring oxygenation levels, healthcare providers can individualize treatment plans and optimize oxygen therapy to improve patient outcomes while avoiding potential risks associated with incorrect oxygen administration.

Correct Answer: B

Rationale: The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting β2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is also appropriate, but would not address the current decrease in peak flow. [Note: ANS: B in document, but rationale supports A. Assuming typo, corrected to A.]

Correct Answer: A

Rationale: In the context of the Oxygenation NCLEX Questions Quizlet, understanding the concept of allotropes is crucial for nursing students as it relates directly to the properties of oxygen, a vital element in oxygenation and respiration processes. The correct answer, A) A different physical form of an element, is right because allotropes refer to different forms of the same element in the same physical state. For example, oxygen exists as dioxygen (O2) and ozone (O3), which are both allotropes of oxygen. Option B) A different isotope of an element is incorrect because isotopes are atoms of the same element with different numbers of neutrons, not different physical forms. Option C) A compound of two elements is incorrect as it refers to a different concept altogether, where two elements combine chemically. Option D) A synthetic version of an element is incorrect as it does not define the concept of allotropes. Educationally, understanding allotropes helps students grasp the idea that elements can exist in various forms with different physical properties while still being the same element. This knowledge is essential for nurses to comprehend the behavior of oxygen in the body and its role in sustaining life through efficient oxygenation processes.

Correct Answer: A

Rationale: The correct answer is A) Apply water-soluble ointment to nares and lips. This is the appropriate comfort measure to delegate to assistive personnel when a client is receiving oxygen at 4 L per nasal cannula. Oxygen therapy can cause dryness to the nasal passages and lips, leading to discomfort for the client. Applying a water-soluble ointment helps to moisturize these areas and alleviate dryness, enhancing the client's comfort. Option B) Periodically turn the oxygen down or off is incorrect because adjusting oxygen flow should only be done by licensed healthcare providers based on the prescribed oxygen therapy regimen. This task should not be delegated to assistive personnel. Option C) Replace the oxygen tubing with a different type is incorrect because changing oxygen equipment requires specialized knowledge and training to ensure proper functioning and safety. This task should be performed by licensed healthcare providers. Option D) Turn the client every 2 hours or as needed is incorrect as it pertains to repositioning the client to prevent pressure injuries, which is not directly related to oxygen therapy comfort measures. While repositioning is important for overall client care, it is not specific to addressing the discomfort associated with oxygen therapy. Educationally, it is essential for nurses and healthcare providers to understand the principles of oxygen therapy and comfort measures to optimize patient care. Delegating appropriate tasks to assistive personnel not only promotes efficient workflow but also ensures safe and quality care delivery to clients. Understanding which tasks can be delegated and which require specialized knowledge is crucial in providing holistic care to clients receiving oxygen therapy.