Ch. 30 Lower Respiratory Problems

After change-of-shift report, which patient would the nurse assess first?

A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action would the nurse take?

Administer prescribed morphine.

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern?

400 mL of blood in the collection chamber

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse?

Paradoxical chest movement

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient?

Chest tube connected to suction

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?

Observe for distended neck veins.

A patient is admitted to the emergency department with an open stab wound to the left chest. Which action would the nurse take?

Tape a nonporous dressing on three sides over the wound.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective?

“I will use the incentive spirometer every hour or two during the day.”

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (AP)?

Document the amount of drainage every 8 hours