Question

A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung. The client has a patient control analgesic (PCA) pump and 2 right chest tubes which are clamped for the surgeon to release serosanguineous drainage. Which assessment finding requires immediate intervention by the nurse?

a. Pain at level of 5 on a scale of 1 to 10 with use of PCA.
b. Absence of lungs sounds on the operative side.
c. A high-pitched, course sound over the trachea.
d. Requests to see his family at his bedside immediately.

Answer 1

The assessment finding that requires immediate intervention by the nurse is absence of lungs sounds on the operative side, which could indicate a potential complication such as pneumothorax.

Step-by-step explanation:

The assessment finding that requires immediate intervention by the nurse is b. Absence of lungs sounds on the operative side. This finding could indicate a potential complication such as pneumothorax, where air enters the pleural space and causes the lung to collapse. The nurse should assess the client's vital signs, respiratory distress, and notify the surgeon immediately for further investigation and intervention.