(Detail Solutions and Resource for the
test)
A nurse caring for a client who is 1 hr postoperative following acute thoracentesis.Which
of the following is the priority assessment finding?
Tracheal deviation to the unaffected side
A nurse in the emergency department is caring for a client who is experiencing a
pulmonary embolism. Which of the following actions should the nurse take first?
Apply supplemental oxygen
A nurse is assessing a client who has a chest tube in place following thoracic surgery.
Which of the following findings indicates a need for intervention?
Continuous bubbling in the water seal chamber.
Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The
nurse should check the system for external, correctable leaks while she is waiting for instructions from the provider.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS).
Which of the following findings should the nurse report to the provider?
Intercostal retractions
A nurse is assessing a client who has emphysema. The nurse should report which of the
following assessment findings?
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, Elevated temperature
A nurse is assisting with a thoracentesis. Which of the following actions is appropriate
for the nurse to take when assisting with this procedure. SATA
Wear goggles and mask during
theprocedure
Cleanse the area with an antiseptic
solution
Apply pressure to the site after the needle is
withdrawn
A nurse is caring for a client following the insertion of a chest tube following a
lobectomy. The nurse should plan to have which of the following items in the
clientsroom?
Container of sterile water
The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected
in order to prevent a pneumothorax.
A nurse is caring fora client in acute respiratory failure who is receiving mechanical
ventilation. Which of the following assessments is the priority for the nurse to use to
evaluate the effectiveness of the mechanical ventilation?
Arterial blood gases
A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm
sounds. Which of the following should the nurse recognize as a cause of the alarm?
Artificial airway cuff leak
A nurse is caring for a client who has acute respiratory failure. Which of the following
laboratory findings should the nurse expect?
PaO2 58 mm Hg
Anurseiscaringforaclientwhohasapulmonaryembolism. Which of the following
interventions is the priority?
Administer heparin via continuous IVinfusion
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