pneumothorax/hemothorax

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

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

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

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

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