Case study AH2 pg 122

Professor Johanna Ramirez

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Slides (29)

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The admitting nurse assesses his oxygenation/gas exchange. Which is 89% RA and he states SHOB at rest that is worsening. What should the nurse include in the assessment. Select all that apply.

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Upon assessment the Nurse observes Eric and finds a temp 100.00, HR 88 BP 110/78, RR 30. Sats 89% RA SHOB pain in chest 5/10, worse with deep breaths. Upper lobes clear and lower lobes diminished. What concerns the nurse the most?

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Based on the assessment what is the nurse's top priorities x 3?

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A chest X-ray is ordered and the results are as follows: There is a right lower lobe pleural effusion and consolidation of mid-lower lobe. What can the nurse make from the report?

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Given the information that the nurse knows about Eric's condition which nursing intervention would be contraindicated ?

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Eric recieved a Thoracentesis where 800mls were removed and was sedated with versed 2mg IV. He was stabalized and sent back to floor. The nurse enters Erics room finds Eric's RR 10 and O2 sat 99% Room air and pt is non labored with breathing. What should the nurse do.

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Before the Nurse calls the HCP what additional assessments are priority? Select all that apply.

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The HCP orders and X-ray and 70% pneumothorax and orders for a chest tube is placed with drainage system. What order should the nurse assess?

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What is the main purpose of a chest tube?

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THe nurse is evaluating the fluid in the collection chamber that is serous and notes intermittent bubbling in the water seal chamber. What conclusion does the nurse make?

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As the nurse what is the purpose of the water seal chamber?

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Upon assessment the nurse notes rice crispy pops around the chest tube dressing. What does the nurse suspect?

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Fill in the Blank: When patients arrive back with chest tube and drainage system the nurse should watch the system every--------- for the first -------- hours. Select 2

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True of False: The level of water in the suction control chamber determines the amount of suction. If there's less water, there's less suction.

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