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The nurse is caring for a 48-year-old patient who is intubated and on the ventilator following extensive abdominal surgery. Although the patient is on sedation, he is responsive and easy to arouse. Which of the following methods would be appropriate for the nurse to assess the patient’s pain level? (Select all that apply)

The nurse is assessing a patient. Which assessments would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? Select all that apply.

Your patient, Mr. H was intubated and ET tube placement was confirmed. You note that the 23-cm mark on the ET tube is at the level of Mr. H’s teeth and is connected to the ventilator with the following settings:            Tidal Volume= 700 ml            Rate=   14            Fio2= 60 %            PEEP= 10cm            Mode= SIMV            ABGs are obtained 30 minutes later after Mr. H is placed on the ventilator.            pH= 7.31            PaCo2= 65 mmHg            PaO2= 80 mmHg            HC03= 20            O2 saturation – 90%Which ventilator change do you anticipate based on your analysis of the above ABG?

The ER nurse receives a radio call from an ambulance transporting a patient who suffered chest trauma and has a severe flail chest. The nurse ensures that which of the following items needed for definitive treatment of this problem is in the treatment area being set up for this patient’s arrival?

A nurse is caring for a patient with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention?

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action for the nurse to take is

At 11:00 am, a patient is placed on a T-piece for weaning from the ventilator.  The nurse arranges for a follow up ABG to be drawn at:

Mrs. L develops a hemothorax and the physician inserts a chest tube, which is connected to a dry suction drainage system. In the next hour, 500 ml of blood drains. Which of the following actions by the nurse is most appropriate?

The nurse would determine that a patient with fractured ribs needs further self-care teaching if which of the following statements is made by the patient?

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?