After extensive chemotherapy, a client requires a right thoracotomy for removal of the middle and lower
lobes. The nurse is assessing the two chest tubes that are attached to a chest drainage system to re-establish
negative pleural pressure. Which finding provides the earliest indication that the client is experiencing chest
tube displacement?
A.) Increased serousangious chest tube drainage.
B.) Diminished right lower lobe breath sounds.
C.) Air bubbles noted in the air leak meter.
D.) Reports of intense pain at insertion site
B.) Diminished right lower lobe breath sounds.
Diminished or absent lung sounds indicate that the lung is being inadequately ventilated, which can be a result
of chest tube dislodgement.
,A client admitted with thyroid storm is placed on an intravenous esmolol drip. Which outcome should the
nurse expect if the medication is effective?
A.) Apical heart rate and blood pressure within normal range.
B.) Respiratory rate within normal range.
C.) Body temperature within normal range.
D.) Thyroid stimulating hormone (TSH) within normal range
A.) Apical heart rate and blood pressure within normal range.
Thyroid storm, thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive
release of thyroid hormones (THs). Esmolol is a beta-adrenergic blocker that decreasess the apical heart rate
and blood pressure in a client with thyroid storm.
A client arrives in the emergency department experiencing difficulty breathing. Which finding requires further
assessment?
A.) Use of accessory respiratory muscles.
B.) Auscultation of crackles in lower lobes.
C.) Flushed skin.
D.) Production of white sputum
A.) Use of accessory respiratory muscles.
A client who is experiencing dyspnea and is using accessory respiratory muscles with severe respiratory effort
requires further assessment and management.
,A client arrives in the emergency department with a gunshot wound to the chest. The client is short of breath,
has tracheal deviation to the unaffected side of the chest, and an O2 saturation of 84%. Which
pathophysiologic process is precipitating the client's findings?
A.) Tension pneumothorax.
B.) Flail chest.
C.) Pulmonary contusion.
D.) Acute respiratory distress syndrome
A.) Tension pneumothorax
A gunshot wound that penetrates the chest wall allows air to enter the pleural space causing respiratory
distress due to a tension pneumothorax that shifts the trachea from midline and to the unaffected side of the
chest.
, A client in the intensive care unit begins to manifest seizure activity while the unlicensed assistive personnel
(UAP) is providing a bedbath. The UAP pulls the emergency call bell and calls for help. Which action by the
UAP should the nurse correct?
A.) Restraining the client's extremities.
B.) Loosening restrictive clothing.
C.) Padding the raised side rails.
D.) Placing the client in a lateral position
A.) Restraining the client's extremities.
A client should be protected as much as possible during seizure activity. The nurse should direct the UAP to
refrain from restricting the client's extremities with restraints, which can cause injury to the client and the
person who is holding or applying restraints on the client.
lobes. The nurse is assessing the two chest tubes that are attached to a chest drainage system to re-establish
negative pleural pressure. Which finding provides the earliest indication that the client is experiencing chest
tube displacement?
A.) Increased serousangious chest tube drainage.
B.) Diminished right lower lobe breath sounds.
C.) Air bubbles noted in the air leak meter.
D.) Reports of intense pain at insertion site
B.) Diminished right lower lobe breath sounds.
Diminished or absent lung sounds indicate that the lung is being inadequately ventilated, which can be a result
of chest tube dislodgement.
,A client admitted with thyroid storm is placed on an intravenous esmolol drip. Which outcome should the
nurse expect if the medication is effective?
A.) Apical heart rate and blood pressure within normal range.
B.) Respiratory rate within normal range.
C.) Body temperature within normal range.
D.) Thyroid stimulating hormone (TSH) within normal range
A.) Apical heart rate and blood pressure within normal range.
Thyroid storm, thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive
release of thyroid hormones (THs). Esmolol is a beta-adrenergic blocker that decreasess the apical heart rate
and blood pressure in a client with thyroid storm.
A client arrives in the emergency department experiencing difficulty breathing. Which finding requires further
assessment?
A.) Use of accessory respiratory muscles.
B.) Auscultation of crackles in lower lobes.
C.) Flushed skin.
D.) Production of white sputum
A.) Use of accessory respiratory muscles.
A client who is experiencing dyspnea and is using accessory respiratory muscles with severe respiratory effort
requires further assessment and management.
,A client arrives in the emergency department with a gunshot wound to the chest. The client is short of breath,
has tracheal deviation to the unaffected side of the chest, and an O2 saturation of 84%. Which
pathophysiologic process is precipitating the client's findings?
A.) Tension pneumothorax.
B.) Flail chest.
C.) Pulmonary contusion.
D.) Acute respiratory distress syndrome
A.) Tension pneumothorax
A gunshot wound that penetrates the chest wall allows air to enter the pleural space causing respiratory
distress due to a tension pneumothorax that shifts the trachea from midline and to the unaffected side of the
chest.
, A client in the intensive care unit begins to manifest seizure activity while the unlicensed assistive personnel
(UAP) is providing a bedbath. The UAP pulls the emergency call bell and calls for help. Which action by the
UAP should the nurse correct?
A.) Restraining the client's extremities.
B.) Loosening restrictive clothing.
C.) Padding the raised side rails.
D.) Placing the client in a lateral position
A.) Restraining the client's extremities.
A client should be protected as much as possible during seizure activity. The nurse should direct the UAP to
refrain from restricting the client's extremities with restraints, which can cause injury to the client and the
person who is holding or applying restraints on the client.
