The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. - ANS-Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? - ANS-Perform the Valsalva maneuver. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? - ANS-Check for an air leak, because the bubbling should be intermittent. The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? - ANS-Flushing The emergency department 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? - ANS-Diminished breath sounds The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. - ANS-A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? - ANS-Promote carbon dioxide elimination. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. - ANS-Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? - ANSBronchospasm The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? - ANS-10 seconds The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? - ANS-Stop the procedure and reoxygenate the client. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? - ANS-Pain, especially with inspiration A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? - ANS-Paradoxical chest movement The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? - ANS-Increased respiratory rate The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? - ANS-"I should not be contagious after 2 to 3 weeks of medication therapy." A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? - ANS-Chest pain that occurs suddenly A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? - ANS-Positive A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? - ANS-Dyspnea The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? - ANS-Shortness of breath The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? - ANS-Mask An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? - ANS-Venturi mask The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? - ANS-Sitting up and leaning on an overbed table The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. - ANS-Dyspnea Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? - ANS-Sputum culture