Pulmonary Embolism
A client diagnosed with pulmonary embolism reports shortness of breath. Which nursing action should be done first?
A. Elevate the legs
B. Place the client in high Fowler’s position
C. Administer morphine sulfate
D. Start chest physiotherapy
B. Place the client in High - Fowler's position in bed.
Which assessment finding would the nurse expect in a client with a pneumothorax?
A. Bilateral crackles
B. Dullness to percussion
C. Absence of breath sounds on affected side
D. Increased tactile fremitus
C. Absence of breath sounds on affected side
What is the expected chest tube drainage appearance in a patient with hemothorax?
A. Clear yellow
B. Purulent green
C. Bright red
D. Pink and frothy
C. Bright red
A nurse is monitoring a client with suspected PE. Which of the following lab tests would best support this diagnosis?
A. BNP
B. D-dimer
C. Troponin I
D. ABG
B. D - dimer
Following a motor vehicle accident, a client is suspected to have a pneumothorax. What is the priority nursing action?
A. Insert a nasogastric tube
B. Position client in supine
C. Prepare for chest tube insertion
D. Increase IV fluid rate
C. Prepare for chest tube insertion
A client with a hemothorax has a chest tube connected to suction. Which nursing action requires intervention?
A. Checking for fluctuation in the water seal chamber
B. Clamping the chest tube during ambulation
C. Assessing for subcutaneous emphysema
D. Monitoring drainage output hourly
B. Clamping the chest tube during ambulation
A nurse is caring for a post-op orthopedic client who suddenly develops chest pain, tachypnea, and hemoptysis. Which order should the nurse question?
A. Administer IV heparin
B. Prepare for chest CT with contrast
C. Elevate lower extremities
D. Encourage early ambulation
C. Elevate the lower extremeties
After chest tube insertion for pneumothorax, the nurse observes continuous bubbling in the water seal chamber. What does this indicate?
A. Normal function
B. A clogged chest tube
C. A pleural leak has resolved
D. An air leak in the system
D. An air leak in the system
The nurse receives report on a client with hemothorax and 250 mL/hr of blood drainage from the chest tube. What is the best nursing action?
A. Reposition the client
B. Notify the healthcare provider
C. Increase suction level
D. Document and reassess in 30 minutes
B. Notify the healthcare provider
Which ECG finding is most commonly associated with a pulmonary embolism?
A. ST-segment elevation
B. Peaked T waves
C. S1Q3T3 pattern
D. Ventricular fibrillation
C. S1Q3T3 pattern
The nurse notes a sudden drop in SpO₂ and tracheal deviation to the left in a client with right-sided chest trauma. What should the nurse do first?
A. Increase oxygen flow rate
B. Notify the physician
C. Perform needle decompression
D. Prepare for emergency chest tube insertion
D. Prepare for emergency chest tube insertion
Which finding would require immediate intervention in a client with a chest tube for hemothorax?
A. Drainage of 50 mL/hr
B. Diminished breath sounds
C. Sudden cessation of chest tube drainage
D. Continuous bubbling in suction chamber
C. Sudden cessation of chest tube drainage
A patient receiving anticoagulation therapy for PE begins to exhibit signs of hematuria and ecchymosis. What is the priority nursing intervention?
A. Notify the physician immediately
B. Document and continue monitoring
C. Stop anticoagulants and give Vitamin K
D. Assess PT, aPTT, and platelet count
D. Assess PT, aPTT, and platelet count
A patient with spontaneous pneumothorax asks why they are getting oxygen. The nurse’s best response is:
A. "It helps calm your breathing."
B. "Oxygen helps reduce the size of the pneumothorax."
C. "It treats infection in the pleural space."
D. "Oxygen prevents emboli from forming."
B. "Oxygen helps reduce the size of the pneumothorax."
A patient with massive hemothorax is hypotensive and has a rapid heart rate. The chest tube is draining bright red blood. What is the priority nursing diagnosis?
A. Ineffective breathing pattern
B. Impaired gas exchange
C. Fluid volume deficit
D. Risk for infection
C. Fluid Volume Deficit