1.
When caring for a client with a post right thoracotomy who has
undergone an upper lobectomy, the nurse focuses on pain management to
promote:
Correct Answer
B. Deep breathing and coughing
Explanation
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
2.
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
Correct Answer
D. Continue to monitor the rate of drainage
Explanation
Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest
3.
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
Correct Answer
D. Serum potassium 6 mEq/L
Explanation
Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
4.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
Correct Answer
B. Assess for post operative arrhythmias
Explanation
The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
5.
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
Correct Answer
B. “The tube will remove excess air from your chest.”
Explanation
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
6.
A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?
Correct Answer
A. Notify the pHysician
Explanation
The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.
7.
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?
Correct Answer
C. Lower the oxygen rate
Explanation
A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.
8.
The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:
Correct Answer
C. Reinforce the dressing and elevate the leg
Explanation
Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.
9.
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?
Correct Answer
B. Perform a quick assessment of the client’s condition
Explanation
A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
10.
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?
Correct Answer
D. Serum potassium 6 mEq/L
Explanation
Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
11.
A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?
Correct Answer
D. Continue to monitor the rate of drainage
Explanation
Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
12.
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
Correct Answer
B. Coughing and deep breathing
Explanation
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
13.
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Correct Answer
C. Dyspnea
Explanation
Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
14.
The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?
Correct Answer
C. Pulse oximetery of 88
Explanation
Pulse oximetry should not be lower than 90.
15.
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
Correct Answer
B. Leukopenia
Explanation
Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
16.
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
Correct Answer
B. “The tube will remove excess air from your chest.”
Explanation
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
17.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?
Correct Answer
B. Assess for post operative arrhythmias
Explanation
The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
18.
The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:
Correct Answer
B. Assist client to turn, cough and deep breathe
Explanation
Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
19.
The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
Correct Answer
B. “I am allergic to shrimp.”
Explanation
A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.
20.
A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
Correct Answer
C. Loss of pulse in the extremity
Explanation
Loss of the pulse in the extremity would indicate impaired circulation.