A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma Take no further action with the collection device. Which finding indicates the presence of a pneumothorax in this client? A. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? A. Metabolic acidosis Older adult who is following a carbohydrate-free diet c. C. bronchospasms 2. Notify the surgeon of a possible pneumothorax. Tracheal deviation. The client has severe INTRODUCTION — . The nurse should take which immediate action, A client who just returned from the recovery Traumatic pneumothorax must be a suspected diagnosis in any blunt or penetrating chest trauma. Tension pneumothorax C. Which of the following does the nurse understand is an early sign of uncal herniation? A. A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. His breath sounds are equal bilaterally, and his jugular veins are normal. Clamp the chest tube prior to transferring the client to a Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client following a gunshot wound to the chest. Decreased Study with Quizlet and memorize flashcards containing terms like An unconscious teenager is brought to the emergency department with a respiratory rate of 6 breaths/min following a suspected opioid drug overdose. A nurse is evaluating a client who has a tension pneumothorax and received a tube thoracostomy placed to water seal. Which of the following findings should the nurse expect following tracheal deviation? A. Study with Quizlet and memorize flashcards containing terms like The nurse is assessing an adult client following a motor vehicle accident. tracheal deviation to the unaffected side. Extra drainage system B. 58, PaO2 The nurse assesses for which earliest sign of ARDS? a. Which of the following should be prioritized assessment? A. Pneumothorax B. Subcutaneous emphysema A client with a chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The presence of a barrel chest d. When the high-pressure alarm sounds, A nurse in an ED is assessing a client who has a flail chest from blunt chest trauma. Which of the following findings should indicate to the nurse that the patient is experiencing hypoxia? The clients heart rate increases If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. ) a low respiratory rate B. Ipsilateral pupillary dilation C. Which of the The nurse is assessing a client who has a chest tube connected to a water seal chest tube drainage system. d) Draining secretions and blood while allowing air to Study with Quizlet and memorize flashcards containing terms like The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. Night sweats D. Which finding indicates the presence of a pneumothorax in this client? a. The presence of a barrel chest 4. Which of the following findings is a clinical manifestation of pulmonary tuberculosis (TB)? Pericardial friction rub Weight gain Night sweats Cyanosis of the finger, A charge nurse receives notification of the admission A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. Notify the health care provider of the amount of chest tube drainage. Which of the following findings should the nurse report to the provider? A. pleural friction rub. Hypoxia b. Dyspnea E. Which of the following actions should the nurse perform first? A. Diminished breath The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. During patient assessment, which of the Study with Quizlet and memorize flashcards containing terms like A nurse in a providers office is assessing a client who states he was recently exposed to TB. ***2. However, small pneumothoraces are often missed on physical exam and chest X-ray and may be present on CT chest during a diagnostic workup for other injuries. Which action by the nurse is most appropriate? a. What should the nurse conclude? a) The client has a pneumothorax. Dilated ventricles C. Which of the following ABG values indicates the Study with Quizlet and memorize flashcards containing terms like A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. How should the nurse best respond to this assessment finding? A client has a chest tube in place following a left lower A nurse in an emergency department is assessing a client who has a flail chest from blunt chest trauma. The nurse should identify that which of the following findings are manifestations of a pneumothorax? (Select all that apply. The presence of a barrel chest. Which action is best for the nurse to take next? a. Which finding should the nurse consider to be abnormal?, The nurse is caring for a client with a chest tube and chest drainage system. Which of the following findings is an indication of pneumothorax? a) The client's ribs slope downward at a 45 degree angle b) The client is making a pitched crowing sound that can be heard in the neck area. Choice B: Testing visual acuity is a way to assess cranial nerve II (optic), which is responsible for the sense of vision. Blunt trauma is a more common cause of traumatic injuries and may be life-threatening. , A 21-year-old male client is transported by ambulance to the emergency A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. Study with Quizlet and memorize flashcards containing terms like A patient has a chest tube inserted for a pneumothorax. A sucking sound at the site of injury, During Nurse Clara is assessing Ms. paradoxical motion. ) Diminished breath sounds, A nurse is caring for a client who is post operative and has a respiratory rate of 9/min A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Cyanosis of the fingertips, A nurse is providing discharge instructions to a client who Study with Quizlet and memorize flashcards containing terms like The client is admitted to the emergency department with chest trauma. Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client who has Chronic Kidney Disease (CKD) about dietary management. tracheal deviation, A young adult is admitted to the emergency department after an automobile accident. Decreased cardiac output Chest trauma can result from penetrating or blunt trauma. Milk the chest tube gently to remove Study with Quizlet and memorize flashcards containing terms like 1. , The nurse is assisting a health care provider with the removal A nurse is assessing clients who are at risk for acid-base imbalance. 06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3 - 24 mEq/L B. Collapsed neck veins on the affected side. Which of these signs would indicate the presence of a pneumothorax in this client? A. A nurse is assessing a client while suctioning the client tracheostomy tube. Which of the following findings should the nurse expect? A- Bradycardia B- Cyanosis C- Hypertension D- Dyspnea E- Paradoxical chest movements Study with Quizlet and memorize flashcards containing terms like A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. This condition happens when an opening to the intrapleural space creates a two-way valve which causes pressure to Start by identifying the signs and symptoms of tension pneumothorax, the first of which is decreased or absent breath sounds on the affected side. Your assessment reveals a flail chest segment to the right side of his chest. Study with Quizlet and memorize flashcards containing terms like Gina, a home health nurse is visiting a home care client with advanced lung cancer. Percussion of the The nurse should identify these findings as manifestations of which of the following complications? A. The nurse should plan to include what in the client's discharging An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. What should the nurse include int he teaching instructions?, A nurse is teaching a client about ways to maintain bladder health. The direct effects of these injuries on pulmonary and cardiovascular function can be life threatening, accounting for 25% of all deaths from trauma. A sucking sound at the site of injury, A Study with Quizlet and memorize flashcards containing terms like 1. periodic bubbling in the water seal chamber immediately after insertion 2. Study with Quizlet and memorize flashcards containing terms like A nurse is developing a teaching plan for a client about preventing acute asthma attacks. An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. It may result from blunt trauma, penetrating chest or abdominal trauma, or diaphragmatic tears. Pericardial friction rub B. Frothy bloody Call the health care provider B. positive pressure ventilation. Bloody fluid in the drainage-collection chamber on the first postop day 3. Which action should the nurse take first?, Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues Study with Quizlet and memorize flashcards containing terms like An unconscious teenager is brought to the emergency department with a respiratory rate of 6 breaths/min following a suspected opioid drug overdose. ) Elevated temperature C. A low respiratory rate B. Respiratory alkalosis Client on mechanical ventilation at a Study with Quizlet and memorize flashcards containing terms like A client has been treated for pleural effusion with a thoracentesis. b. continuing education courses related to direct patient care shall address at least one The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. b) The system has an air leak. Replace the chest tube system immediately D. These signs are associated with which condition? a. A nurse is assigned to care for the following clients in the ED. B. The injury mechanism informs both primary and secondary surveys from the care team, especially what type of imaging modalities are indicated and when to involve a surgical consult. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client in the immediate postoperative period. Paradoxical chest movement Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. Atelectasis C. which of the - brainly. which of the - Study with Quizlet and memorize flashcards containing terms like A client with emphysema has been admitted to the hospital. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the healthcare provider? A. Mr. The client reports shortness of breath and becomes tachypneic. Obtain a large-bore IV Nursing management of a patient with pneumothorax includes the following steps. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A. The nursing assistant allowed the client out of the bed. The finding that nurse must expect with respect to tension pneumothorax is a. Leaks can occur within the drainage unit, or at the insertion site. large amount of bloody While caring for a client who has a chest tube, the nurse takes measures to prevent a tension pneumothorax. ) Rhonchi on inspiration B. Cyanosis of the fingertips, A nurse is providing discharge instructions to a client who Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who recently had a chest tube inserted. You should suspect: a. What is the nurse's most appropriate action?, The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that Study with Quizlet and memorize flashcards containing terms like The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. The nurse should identify these findings as manifestations of which of the following complications?, A charge nurse receives notification of the admission of a client who The finding that nurse must expect with respect to tension pneumothorax is a. d) The system is functioning normally. Decreased use of accessory muscles E. Students should be well-versed in assessing chest tube systems using the "TWO AA's" approach, which involves monitoring tidaling (movement of fluid 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 client's left side and a tracheal shift to the right. Respiratory distress. A client who is 8hr postoperative following an open surgical appendectomy. Clamping the chest tube does not relieve chest burning or improve drainage or ventilation. Which of these signs would indicate the presence of a pneumothorax? a. 4 F), and SaO2 92% on room air. ) Barrel-shaped chest D. According to the illustration shown, what should the nurse do? 1. Cyanosis C. clamp the chest tube near the insertion site to prevent air from entering the pleural cavity. Increased severity of Study with Quizlet and memorize flashcards containing terms like Which assessment finding is commonly seen in a patient with a tension pneumothorax?, Which treatment modality is the focus during the management of an uncomplicated rib fracture?, What term describes air in the pleural space? and more. 2. A nurse is assessing a client who has emphysema. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for an unresponsive client suspected of having uncal herniation after traumatic brain injury. 114 It is a serious condition, because it may eventually develop into tension pneumothorax. Which action should the nurse take? A patient is brought to the emergency department with a blunt trauma injury to the chest following a car crash. D. How does the nurse best Blunt chest trauma and penetrating chest trauma are the primary causes of traumatic and tension pneumothorax. These findings indicate the infant is developing a: A. Clients w/renal vascular disease have a higher risk of developing pulmonary edema Study with Quizlet and memorize flashcards containing terms like A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Subcutaneous emphysema on the second postop day 4. The nurse suspects _____has developed. Cardiac ischemia C. the client's perception of the disease process and what might have triggered past Study with Quizlet and memorize flashcards containing terms like A nurse in a providers office is assessing a client who states he was recently exposed to TB. A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. 6 (101. This compression A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1. - A: The oval window is located between the middle ear and the inner ear structures - B: The auricle is the external ear - C: The tympanic membrane, often referred to as the eardrum, separates the Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has emphysema. Which of the following subtypes should the nurse identify as having a complication of pneumothorax?, In which of the following types of pneumonia does consolidation involve the entire lobe of the lung?, A nurse is caring for a client with May 26, 2023 · The finding that nurse must expect with respect to tension pneumothorax is a. 3. A client A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Bronchovesicular lung sounds and bradypnea. The client with pneumothorax would have absent breath sounds and tachypnea. Tachypnea B. how to eliminate environmental triggers that precipitate attacks b. which of the following aquired risk factors should the nurse include?, a nurse is assisting in the care of A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. What findings indicates a tension pneumothorax?, A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. 111, 112, 113 In addition, OPTX develops in 51% of trauma patients with pneumothorax. Increase the suction pressure so that the bubbling becomes vigorous. Document the presence of a large air leak. collapsed neck veins on the affected side b. Check for an air leak because the bubbling should be intermittent. Constant bubbles in the water-seal chamber 1 hour after insertion Rationale: Constant bubbles in the water-seal chamber after initial insertion indicate an air leak in the system. Consolidation occurs when there is no air moving through the alveoli as in pneumonia; frothy sputum occurs with congestive heart failure. A sucking sound at the site of injury A nurse is assigned to care for the following clients in the ED. The patient is experiencing respiratory distress, and his oxygen saturation is 78%. Increase the A nurse is assessing a client who has a gunshot wound to the chest. ) A. Nonadherent pads, A nurse in the emergency department is caring for a client The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. Tracheal deviation to the unaffected side. The nurse should recognize the possibility of what condition? A. d. , You suspect that your patient has a tension pneumothorax. Clots in the tubing during the first postop day 2. Which assessment finding would be Study with Quizlet and memorize flashcards containing terms like A nurse should interpret which of the follow ing as an early sign of a tension pneumothorax in a client with chest trauma? 1. The client coughs and expectorates a large The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. Bradycardia D. 6 C (101. The patient has The finding that nurse must expect with respect to tension pneumothorax is a. , A 21-year-old male client is transported by ambulance to the emergency Following blunt trauma to the anterior chest, a 44-year-old woman presents with restlessness, respiratory distress, perioral cyanosis, Which of the following clinical findings would MOST likely differentiate a massive hemothorax from a tension pneumothorax? Hemoptysis. Blood-tinged sputum c. A client who stepping on a nail & sustained a puncture wound of the foot D. Absence of dyspnea B. The nurse should assess the following: Tracheal alignment. Which of these signs would indicate the presence of a pneumothorax in this client? 1. Intercostals retraction d. Choice C: Observing for facial symmetry is a way to assess cranial nerve Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a chest tube following a lobectomy. Study with Quizlet and memorize flashcards containing terms like The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. The nurse checks the incision and notes the presence of wound dehiscence. When air becomes trapped in the pleural space under Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has emphysema. Increased venous return B. What signs and symptoms would the nurse anticipate recording to support this diagnosis? Select All That Apply 1. com Major trauma incidents, particularly motor vehicle accidents, frequently involve serious injuries to the thorax. A sucking sound at the site of D. The nurse understands that the most likely cause is: an increase of blood in the pleural space. Findings include BP 108/55, HR 124/min, RR 36/min, temperature 38. 115 Therefore, OPTX should be kept in mind in A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The patient asks the nurse why it is so hard to breathe. Which are the expected assessment findings? Select all that apply. Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is assessing a client who was in a motor vehicle crash. A low respiratory rate. tension pneumothorax B. A low respiratory rate 2. What is the nurse's most appropriate action?, The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that Study with Quizlet and memorize flashcards containing terms like A nurse should interpret which finding as an early sign of a tension pneumothorax in a client with chest trauma? 1. Which of the following manifestations should the nurse expect? a. The nurse should assess the client further for which symptom? 1. Taping on three sides prevents the development . pH 7. During the last hour, 90 mL of serosanguinous fluid was removed into a drainage collection chamber, fluctuation of water appears in the water seal chamber when the client breathes in and out, and bubbling in the suction control chamber has been continuous. Which Study with Quizlet and memorize flashcards containing terms like A nurse working in the emergency department is caring for a client following a chest trauma. Barrel chest Study with Quizlet and memorize flashcards containing terms like A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. . Expansion of the chest. See an expert-written answer! An emergency room nurse is assessing a client who is complaining of dyspnea. Which action should the nurse take first?, Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues Traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. Nonadherent pads, A nurse in the emergency department is caring for a client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for four clients. Inspiratory crackles c. Container of sterile water D. The nurse's priority would be to prevent: 1) atelectasis 2) bronchitis 3) pneumonia 4) pneumothorax, A nurse is assessing a client who has been given an opioid analgesic. Which of the following actions should the nurse take Which of the following findings should the nurse identify as an abnormality that should be reported?m95CLOSETOOLS +FLAGBubbling during expirationA rise in fluid level with inspirationAbsence of bubblingPain at the insertion site. Which of the following subtypes should the nurse identify as having a complication of pneumothorax?, In which of the following types of pneumonia does consolidation involve the entire lobe of the lung?, A nurse is caring for a client with Study with Quizlet and memorize flashcards containing terms like A nurse should interpret which of the follow ing as an early sign of a tension pneumothorax in a client with chest trauma? 1. When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. 4), and SaO2 95% on oxygen 15L/min via non-rebreather mask. diminished breath sounds 2. 4. collapsed neck veins on the unaffected side c. The nurse checks the client when the alarm on the ventilator sounds and notes that the client has an absence of breath sounds in the right upper lobe of the lung. A nurse working in the emergency department is caring for a client following an acute chest trauma. Which of the following interventions would the nurse most likely employ? is essential. The client reports dyspnea and pain. underweight appearance 3. frothy, pink-tinged sputum. Which of the following findings should the nurse expect? Here’s the best way to solve it. Nonadherent pads, A nurse in the emergency department is caring for a client The nurse is assessing a client who had a chest tube inserted for a chylothorax three hours ago. respiratory distress 4. Which action should the nurse take first?, Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues Study with Quizlet and memorize flashcards containing terms like Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:, A male patient has a sucking stab wound to the chest. , The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Paradoxical chest movement Study with Quizlet and memorize flashcards containing terms like Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:, A male patient has a sucking stab wound to the chest. Aspiration D. When air builds up in the pleural space and cannot leave, it can result in tension pneumothorax, a potentially fatal disease that increases pressure on the damaged lung and shifts mediastinal structures. Study with Quizlet and memorize flashcards containing terms like A perioperative nurse is caring for a postoperative client. Which intervention should the nurse include when planning this client's care?, A victim has sustained a blunt force trauma to the chest. The client has a chest tube attached to suction. increased breath sounds on the affected side. Which further assessment finding would support the presence Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has COPD. A pulmonary contusion is suspected. Increased coughing B. The client's airway secretions were last suctioned 2 hr ago C. Which signs would the nurse expect the patient to exhibit during evaluation?, A patient arrives in the Emergency Department and is diagnosed with flail chest. "This procedure will require local anesthetic rather than general anesthetic. 42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3 - 23 mEq/L C. During the last hour, 90 mL of serosanguinous fluid was removed into a drainage collection chamber, fluctuation of water appears in the water seal chamber when the client breathes in and out, and bubbling in the suction control chamber has been The nurse should identify which condition is associated with flail chest and may contribute to mortality?, a nurse is reinforcing teaching with a client who has a pulmonary embolism about modifiable risk factors to prevent future embolism. Study with Quizlet and memorize flashcards containing terms like A nurse should interpret which of the follow ing as an early sign of a tension pneumothorax in a client with chest trauma? 1. Clamp the chest tube and notify the primary health care provider immediately. Multiple vital thoracic structures are at risk of injury from blunt chest trauma such as rapid deceleration and direct injury. Flapping tremors D. Which of these signs A male client was admitted with chest trauma after a motorbike accident and has undergone subsequent intubation. A hemothorax and pneumothorax are suspected. Shortness of breath2. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. 109, 110 OPTX occurs in 2%–20% of patients with blunt trauma. Which of the following should the nurse identify as characteristics of COPD?, A nurse is caring for a client who has pulmonary edema & chronic condition known as renal vascular disease. A sucking sound at the site of While assessing the chest tube drainage system of a patient with a pneumothorax, the nurse observes that the level in the water-seal chamber rises and falls with respirations. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? 1. A nurse working in an emergency dept is caring for a client following an acute Chest Trauma. Paradoxical chest movement d. Thompson, a 45-year-old patient with chest trauma from a motor vehicle accident, is on mechanical ventilation. Paediatric patients with traumatic haemo/pneumothorax have sustained a major trauma and are at risk of other serious injuries - all should undergo a comprehensive trauma assessment Management of tension pneumothorax and massive haemothorax with obstructive shock require urgent pleural decompression by thoracostomy. HTN D. The chest wound is located on the left mid-axillary area of the chest. Respiratory obstruction – D. Dull percussion notes over lung tissue D. ) a. A low respiratory 2. Which of the following points should the nurse plan to discuss first? a. Suture removal kit C. The nurse should identify that the client is experiencing which of the following complications? pneumonia pulmonary embolus tension pneumothorax tuberculosis, A nurse is caring for a client who is in skeletal traction following a femur fracture. What action is most appropriate? Do nothing because this is an expected finding. Room 208 is a private, negative-pressure airflow room; room 212 is semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. The client is unable to speak B. A client who is 48hr postoperative following a total hip arthroplasty. Pulmonary a. Asymmetry of the chest The nurse is providing postop care to a client with cancer of the lung who had a lobectomy. When air builds up in the pleural spac a nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. as it can cause air or fluid accumulation in the pleural space and lead to tension pneumothorax. Diminished breath sounds 3. A sucking sound at the site of A nurse is assessing a client who has tension pneumothorax. Increased respiratory rate, An emergency room nurse is assessing a client who has sustained a blunt injury to the chest wall. Unequal lung expansion and dyspnea. Adequate history, physical exam and chest X-rays are the mainstays of the diagnosis. Delirium c. A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall. Fluctuation of the water level in the water-seal chamber with inspiration and expiration is an expected and normal finding. For which of the following findings should the nurse monitor to detect a pneumothorax? (SATA) A) Tachypnea B) Deviation of the trachea C) Bradycardia D) Decreased use of accessory muscles E) Pleuritic pain, A nurse is caring for a A nurse in the emergency department is assessing a client who has experience thoracic trauma from a motor vehicle crash. Tracheal deviation to the affected side D. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. , A 21-year-old male client is transported by ambulance to the emergency A nurse in an ED is assessing a client who has a flail chest from blunt chest trauma. Tension pneumothorax. Pulmonary The finding that nurse must expect with respect to tension pneumothorax is a. muffled heart sounds 3. Question: A nurse is caring for a client who has a tension pneumothorax. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. the client's perception of the disease process and what might have triggered past Study with Quizlet and memorize flashcards containing terms like A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Ecchymosis of the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a chest tube following a lobectomy. Such injuries include pneumothorax, haemothorax, pulmonary contusion, cardiac tamponade, flail chest and aortic laceration. 98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3 - 18 mEq/L D. flail chest. Which of the following clinical manifestations correlate with a A client with a chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. Which of the following items should the nurse keep easily accessible for the client? A. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. c. Which of the following actions should the nurse take? A. Ribs four through nine are the most commonly fractured because: Study with Quizlet and memorize flashcards containing terms like Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:, A male patient has a sucking stab wound to the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next? Study with Quizlet and memorize flashcards containing terms like A movement of ribs in a flail segment that is opposite to the direction of movement of the rest of the chest cavity is called: A. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. The nurse reassess the client 30 minutes later. Which of the following clients is at greatest risk for pulmonary embolism? A. Deviation of the trachea C. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Diaphragmatic Study with Quizlet and memorize flashcards containing terms like The emergency room nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of the following indicates that the nurse should suction the client's airway secretions? A. Bilateral crackles b. Respiratory alkalosis D. Tension pneumothorax occurs when air is drawn into the pleural space from a Study with Quizlet and memorize flashcards containing terms like The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Flail chest D. The nurse Study with Quizlet and memorize flashcards containing terms like An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. For which of the following finders should the nurse 9. Place the tube in a bottle of sterile water C. A sucking sound at the site of injury, A nurse is A nurse is assessing a client who has bacterial pneumonia. Findings include absent breath sounds in the left lower lobe with dyspnea, BP 118/68 mmHg, HR 124 bpm, RR 38, Temp 38. Bronchospasm does not decrease mucus production; instead, it primarily affects the smooth muscles surrounding the bronchioles, leading to their constriction and narrowing of Study with Quizlet and memorize flashcards containing terms like An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Acute Question: 1. ) a sucking sound at the site of injury, The Study with Quizlet and memorize flashcards containing terms like An unconscious teenager is brought to the emergency department with a respiratory rate of 6 breaths/min following a suspected opioid drug overdose. Choice A: Eliciting the gag reflex is a way to assess cranial nerve IX (glossopharyngeal) and X (vagus), which are responsible for the sensation and motor function of the pharynx and larynx. On expiration, because the intrathoracic pressure exceeds atmospheric Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. You also note a "sucking" Study with Quizlet and memorize flashcards containing terms like A nurse is providing a presentation to colleagues on emphysema. A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. CXR cannot diagnose more than half of pneumothorax cases. Bradycardia B. A nurse is assessing a A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which assessment finding includes a complication? 1. Nursing Assessment. Diminished breathe sounds 3. A victim has sustained a blunt force trauma to the chest. Which arterial blood gas (ABG) value would indicate that this client is at risk Study with Quizlet and memorize flashcards containing terms like A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. Which of the following findings should the nurse expect? (select all that apply) A. Acute respiratory distress syndrome (ARDS) B. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. Unequal lung expansion and dyspnea would indicate a pneumothorax. Study with Quizlet and memorize flashcards containing terms like A man called EMS 12 hours after injuring his chest. Major concerns include chest wall injury (eg, rib fractures or flail chest), cardiovascular injury (eg, blunt aortic injury [BAI] or cardiac contusion), and pulmonary injury (eg, pneumothorax, contusions, or lacerations). flail Study with Quizlet and memorize flashcards containing terms like What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. Diminished breath sounds. b) Chest tubes allow air into the pleural space. ) diminished breath sounds C. Respiratory depression B. Check for an air leak because the bubbling needs to be intermittent. Johnson, a patient who sustained a blunt chest wall injury. Collapsed neck veins on unaffected side C. no evidence of tidaling 3. the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. Which of the following findings should the nurse expect? A. Other possible causes include therapeutic procedures such as thoracotomy, thoracentesis, and insertion of a central line. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has experienced a gun shot wound. a tension pneumothorax. The nurse should record the Traumatic pneumothorax. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. tracheal deviation to the unaffected A nurse is reviewing the prescription for a client who has a pneumothorax. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. 13 of 20. Diminished bilateral breath sounds. A client with 9/10 pain & swelling with deformity after ankle injury sustained after misstep from a curb B. com Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a chest tube following a lobectomy. The nurse should assess for which earliest sign 130. The presence of a barrel chest D. When air becomes trapped in the pleural space under Recall the elements of the primary assessment for patients with suspected blunt chest trauma and the common causes. The nurse should expect the 1. tension. pH 6. The nurse should address the client's increased risk for what complication? A. frequent coughing, A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Paradoxical chest movement The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. Which of the following clients should the nurse assess first? A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet. vigorous bubbling in the suction control chamber 4. Which statement is CORRECT about a tension pneumothorax? A. pneumothorax. A nurse working in an emergency department is caring for a client following an acute chest trauma. Breath sounds. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. A client with syncope, chest pain, & SOB who has a HR of 180/minute C. Which of the following instructions should the nurse include in the teaching?, A nurse is caring Study with Quizlet and memorize flashcards containing terms like A client hospitalized with pneumonia has thick, tenacious secretions. Which of the following findings should the nurse report to the provider?, A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Hyperventilation d. What action is appropriate? Simple. ", 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. Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a patient with a hemothorax. Which of the following findings should indicate to the nurse that the A charge nurse is panning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive mantoux test. Place a sterile dressing over the disconnection site, The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. a nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which clients are correctly paired with the acid-base imbalance? (Select all that apply. Identify three types of blunt chest trauma seen in the ED and the appropriate interventions based on standard protocols and guidelines. Which finding would indicate the presence of a pneumothorax in this client? a. Tracheal deviation to the Study with Quizlet and memorize flashcards containing terms like A nurse is providing a presentation to colleagues on emphysema. Assess the client's pain B. Decreased tactile fremitus over lung tissue C. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain b. What should the nurse expect when assessing the drainage system? 1. Which sign would indicate the Study with Quizlet and memorize flashcards containing terms like The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. A low respiratory rate b. Muffled heart sounds. A client who is 2hr postoperative following an open reduction Choice A Reason: Decreased mucus production contributes to airway constriction: This statement is incorrect. Study with Quizlet and memorize flashcards containing terms like A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. Which action is most appropriate for the nurse to implement?, The nurse is caring for a client who has a chest tube Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A. Which finding indicates the presence of a pneumothorax in this client? 1. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next? Study with Quizlet and memorize flashcards containing terms like 19. During the assessment, 30. A sucking sound at the site of Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client following a gunshot wound to the chest. What is the nurse's most appropriate action?, The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that Study with Quizlet and memorize flashcards containing terms like An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. a bilateral pneumothorax. Pulmonary edema. c) The chest tube is obstructed. trauma. Eustachian tube The Eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat. Bilateral wheezing b. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? The nursing assistant has the chest tube attached to suction. A tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall. Blunt chest trauma is far more common The client is admitted to the emergency department with chest trauma. a decrease in pressure in the tube. Diminished breath sounds C. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? a. which of the following findings should the nurse expect? a. Diminished breath sounds c. Diminished Bilateral Breath Sounds. ) the presence of a barrel chest D. The nurse checks the client when the high-pressure alarm on the ventilator makes sounds and notes down The nurse is assessing a client who had a chest tube inserted for a chylothorax three hours ago. copious sputum 4. The nurse assesses for which earliest sign of ARDS? a. Weight gain C. plsm jmhqi jpbug zryc njald xikr ofibyx avtiy vblmj hxhuy