Practice Quiz

CCNS Certified Clinical Nurse Specialist

Category - Adult

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Antonio is a patient who is on his first day following a right pneumonectomy. After the morning rounds, he suddenly sits straight up in bed. He has labored breathing; he is making a crowing sound; and his skin is pale, moist, and cool to touch. The nurse should immediately:
  1. Auscultate the left lung
  2. Call the physician
  3. Assess the operative site for bleeding
  4. Check the patency of the chest tube
Explanation
Answer - A - The nurse should immediately auscultate the left lung. Assessment of the airway would be the priority. A mediastinal shift with airway obstruction may occur because pressure builds up on the operative side, causing the trachea to deviate toward the nonoperative side.
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