CAI - week 5 quiz
A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus?
A client who has a chest tube following a pneumothorax
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism?
A sudden onset of dyspnea
A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a MVA. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax?
Absence of breath sounds
A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 ml of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.)
Absent breath sounds on the right side Neck vein distention Tracheal deviation to the left
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
Administer oxygen therapy
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Administer oxygen via nasal cannula.
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)
Apply elastic compression stockings. Perform passive range of motion exercises. Assess legs for redness.
A client comes to the emergency department in severe respiratory distress following left sided blunt chest trauma. The nurse notes absent breath sounds on the clients left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?
Chest tube insertion
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
Continue to monitor the client
A postoperative patient has a right-sided pleural chest tube connected to a chest drainage device. There is continuous bubbling in the suction-control chamber of the wet-suction collection device. Which action would the nurse take?
Continue to monitor the collection device.
A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?
Continuous bubbling in the water-seal chamber
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following?
Crepitus
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons?
Draining blood and fluid from the pleural space
A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?
Encourage the client to take deep breaths
The nurse in the trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Evaluate chest expansion
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
Heparin
A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take?
Immerse the end of the chest tube in a bottle of sterile water
A client who was admitted with a pulmonary embolism has a change in oxygen saturation (SpO2) from 94% to 88%. Which action would the nurse take?
Increase the prescribed O2 flowrate.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Keep the drainage system below the level of the client's chest at all times
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings is it most important for the nurse notify the provider?
Movement of the trachea toward the unaffected side
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?
PaCO2 50 mm Hg
What assessment finding would indicate the presence of a tension pneumothorax in a client with chest trauma?
Severe respiratory distress and tracheal deviation
A nurse in a medical surgical units is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?
Stabbing chest pain
A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?
Tape all connections between the chest tube and drainage system
An unlicensed assistive personnel (UAP) is taking care of a client with a chest tube. The nurse should intervene when she observes the UAP
stripping or milking the chest tube to promote drainage
