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NRS 461 Chest Tube & Trauma questions | LATEST UPDATE
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NRS 461 Chest Tube & Trauma questions | LATEST UPDATE
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1. A patient is admitted to the hospital with injuries from a motor vehicle crash. During thenurse’s initial assessment, the patient develops hypotension and severe jugular
distension with a tracheal deviation. What should the nurse suspect is occurring in this
patient?
a. Tension pneumothorax
b. Hemorrhage
c. Compensatory shock
d. Hypovolemic shock
2. A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor
vehicle crash. What should the nurse assess first when the patient arrives in the
emergency department?
a. airway for patency
b. abdomen for any abnormalities
c. cervical spine for tenderness
d. signs of neurological deficits
3. The nurse is assessing a patient recovering from a motor vehicle crash. Which
assessment finding indicates that the patient is experiencing a pneumothorax?
a. hyperresonance to percussion at the apex of the left lung
b. dullness to percussion at the base of the left lung
c. crackles throughout the left lung
d. shallow breathing
4. A 20-year-old patient who is asking questions about smoking cessation tells the nurse
about an upcoming class on scuba diving. The nurse recognizes that this patient might
be at risk for developing what health problem?
a. pleural effusion
b. pleurisy
c. pneumothorax
d. hemothorax
5. The nurse is caring for a patient on mechanical ventilation with positive end expiratory
pressure (PEEP). When assessing the patient, which finding would indicate the
possibility of tension pneumothorax?
a. New onset of absent breath sounds
b. blood pressure of 170/80
c. pulse oximetry readings ranging from 94% to 96%
d. crackles and wheezing heard in both lungs
6. A patient is diagnosed with a tension pneumothorax. What should the nurse expect to
assess in this patient? Select all that apply.
a. Hypertension
b. distended neck veins
This study source was downloaded by 100000829818949 from CourseHero.com on 04-10-2022 13:00:07 GMT -05:00
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, c. bradycardia
d. absent breath sounds on the affected side
e. tracheal deviation toward unaffected side
7. The nurse observes air bubbles in a patient’s chest tube water seal chamber. How
should the nurse interpret this finding?
a. normal
b. an emergency
c. an indication that the pneumothorax is worsening
d. an indication to remove the chest tube
8. A patient has a chest tube inserted for a pneumothorax. What should the nurse expect
when assessing the drainage system?
a. periodic bubbling in the water seal chamber immediately after insertion
b. No evidence of tidaling
c. Vigorous bubbling in the suction control chamber
d. Large amount of bloody drainage in the drainage collection chamber
9. During the assessment of a patient’s respiratory status, the nurse notes paradoxical lung
movements. This finding is consistent with what health problem?
a. flail chest
b. pleurisy
c. pneumothorax
d. pneumonia
10. The client is admitted to the emergency department with chest trauma. Which
signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
a. Bronchovesicular lung sounds and bradypnea.
b. Unequal lung expansion and dyspnea.
c. Frothy, bloody sputum and consolidation.
d. Barrel chest and polycythemia.
11. The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax.
Which action should the nurse implement if there is no fluctuation (tidaling) in the
water-seal compartment?
a. Obtain an order for a STAT chest x-ray.
b. Increase the amount of wall suction.
c. Check the tubing for kinks or clots.
d. Monitor the client’s pulse oximeter reading.
12. Which intervention should the nurse implement for a male client who has had a left-
sided chest tube for six (6) hours and who refuses to take deep breaths because of the
pain?
a. Medicate the client and have the client take deep breaths.
This study source was downloaded by 100000829818949 from CourseHero.com on 04-10-2022 13:00:07 GMT -05:00
https://www.coursehero.com/file/95855273/Chest-Tube-Trauma-questionsdocx/
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