Passage / Scenario

Medical History
Day 1:
Client has a history of emphysema and reports smoking 21 packs of cigarettes per year.

Vital Signs
Day 1:
Temperature 37.6┬░ C (99.7┬░ F)
Blood pressure 114/56 mm Hg
Heart rate 78/min
Respiratory rate 20/min
Pulse oximetry 93% on room air
Day 2:
1000
Temperature 36.9┬░ C (98.4┬░ F)
Blood pressure 88/56 mm Hg
Heart rate 118/min
Respiratory rate 32/min
Pulse oximetry 85% on room air

Diagnostic Results
Day 1:
Chest x-ray shows lung hyperinflation.
Day 2
1000:
Chest x-ray shows right upper lobe pneumothorax.

Nurses' Notes
Day 2:
0800:
Voided 350 mL of clear yellow urine in a bedpan.
1000:
Client reports sudden, sharp, right upper chest pain.
Client appears anxious and states pain increases with deep breathing.
Respirations labored with use of accessory muscles noted.
Crepitus palpated on right upper chest.
Trachea midline, breath sounds decreased in right upper lobe.