An otherwise healthy 25-year-old male arrived to the emergency department today with complaints of sudden shortness of breath and left-sided chest pain. A chest x-ray confirmed a spontaneous left-sided closed pneumothorax. A chest tube was inserted into his left midaxillary area in the emergency department and he was admitted and transported to a medical unit in the hospital. Currently he is alert, oriented, and anxious. He verbalized 6/10 pain using the pain intensity scale. Vital signs: Blood pressure=138/80 mm Hg, pulse = 115 bpm, respirations = 24 breaths per minute and shallow. Left-sided breath sounds are absent upon auscultation. Oxygen saturation is 91%. His chest tube is attached to a three-chamber wall suction chest drainage unit.

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action would the nurse take first?

A patient has a diagnosis of acute myocardial infarction, and his cardiac rhythm is sinus bradycardia with 6 to 8 premature ventricular contractions (PVCs) per minute. The pattern that the nurse recognizes as the most characteristic of PVCs is:

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? 

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data indicate to the nurse that the goals of treatment with the IABP are being met?

A patient diagnosed with terminal cancer expresses concern about undergoing aggressive treatments that are recommended by their physician, stating, “I just want to be comfortable and spend time with my family.” What is the nurse’s best action to advocate for this patient?

The nurse is caring for a patient, in cardiogenic shock, receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?

A patient who has colon cancer and is near the end of life tells the nurse that estranged family members may try to take over health decisions when the patient is unable to make them. The patient would prefer that a long-term partner make any needed health decisions. Which recommendation is most important for the nurse to make?

A patient requires arterial pressure monitoring. Which action would the nurse plan to take?

A patient with pericarditis expresses anxiety and fear about their condition, stating, “I keep hearing the nurses talk about listening for a friction rub, and it sounds serious.” How should the nurse respond to address the patient’s concerns and promote psychosocial well-being?