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- 1. Multiple Choice
The ED nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
A low respiratory rate
Diminished breath sounds
The presence of a barrel chest
A sucking sound at the site of injury
- 2. Multiple Choice
The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the UAP? Select all that apply
Assess puncture site and dressing for leakage
Check vital signs Q 15min for 1 hour
Auscultate for absent or reduced lung sounds
Remind the patient to take a deep breaths
Take the specimens to the laboratory
- 3. Multiple Choice
The nurse is responsible for the care of a postoperative patient with thoracotomy. Which action should the nurse delegate to the UAP?
Instructing the patient alternate rest and activity periods
Encouraging,monitoring, and recording nutritional intake
Monitoring cardiorespiratory response to activity
Planning activities for periods when the patient has the most energy
- 4. Multiple Choice
The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately?
Chest tube drainage of 10 to 15 ml/hr
Continuous bubbling in the water-seal chamber
Report of pain at the chest tube site
Chest tube dressing dated yesterday
- 5. Multiple Choice
The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion?
Tracheal deviation from midline
Inspiration phase is greater than expiration
Diaphragmatic excursion 3 cm
Vesicular breath sounds noted on auscultation
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