Nursing Comprehensive Exit exam

A nurse is caring for a woman who has undergone a radical mastectomy for breast cancer. She tells the nurse, "I'm worried because my spouse won't touch me since my breast was removed." Which of the following is the most appropriate response by the nurse?

"How do you feel about your mastectomy?"

A nurse is caring for a client who took an overdose of antidepressants and was discovered by his spouse. What is the best response by the nurse when the spouse states, "If I hadn't come home early from my business trip, my spouse might have died. I'm in a state of shock."?

"This is a very overwhelming situation for you. Can you tell me what you are feeling now?"

Which of the following pediatric clients would require prompt reporting to the authorities by the nurse?

A 4-year-old who fell from a swing set with 1 fracture of the ulna and 2 healed fractures of the humerus on X-ray

A nurse is caring for a client in the emergency department who complains of epigastric pain and feeling lightheaded. The client has a blood pressure of 140/80 mmHg with a heart rate of 75/min while supine and 110/65 mmHg sitting with a heart rate of 100/min. Which of the following tasks should the nurse perform next?

Anticipate administration of intravenous crystalloid solution.

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

Arterial blood gases. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor client's respiratory status

A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings?

Document the findings in the client's medical record.

A nurse is assessing a client following a thoracentesis. Which of the following findings should the nurse report?

Dyspnea Fever Hypotension Dyspnea can indicate a pneumothorax or a re-accumulation of fluid, fever can indicate an infection, and hypotension can indicate intrathoracic bleeding.

A nurse is caring for a client who is experiencing respiratory distress. Sort the following manifestations of hypoxemia by whether it is an early or late manifestation of hypoxemia (inadequate level of oxygen in the blood).​​

Early manifestation: Tachypnea Tachycardia Anxiety and restlessness Late manifestation Cyanosis Bradycardia

A nurse is caring for a 62-year-old client who has been diagnosed with emphysema. The nurse understands that the client is at high-risk for pulmonary infection. Which of the following conditions predisposes the client to infection?

Pooling of respiratory secretions.

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?

Position the client upright, leaning over the bedside table. Positioning the client in an upright position, bent over the bedside table, widens the intercostal space for the provider to access the pleural fluid.

two exhalation ports have flaps covering them that prevent room air from entering the mask.

Venturi mask. Venturi mask is the most accurate device to use to deliver a precise concentration of oxygen, because it has an adapter that allows specific amounts of air to mix with oxygen. FiO2 24% to 50% at flow rates of 4 to 10 L/min

A nurse is caring for a client who has a three- chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

continue to monitor the client

nurse is monitoring a client who has a chest tube in place connected to wall suction due to right sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

reposition the client

A nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

Which of the following risk factors are part of the Braden Scale for Predicting Pressure Sore Risk? (Select all that apply.)

Friction and shear Nutrition The risk factors associated with the Braden Scale include sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times.

A nurse is planning care for a client who is receiving mechanical ventilation. Nursing actions to maintain the client's airway: Assess the position and placement of the tube. Document tube placement in centimeters at the client's teeth or lips. Use two staff members for repositioning and resecuring the tube. Apply protective barriers (soft wrist restraints) according to hospital protocol to prevent self-extubation. Use caution when moving the client. Suction oral and tracheal secretions to maintain tube patency. Support ventilator tubing to prevent mucosal erosion and displacement. Have a resuscitation bag with a face mask available at the bedside at all times in case of ventilator malfunction or accidental extubation.

NCLEX Connection: Physiological Adaptation, Alterations in Body Systems

Which of the following methods of oxygen delivery should a nurse use to administer oxygen for a client with a drop in oxygen saturation from 96% to 88% on room air after receiving morphine to relieve pain after colon resection? (The client is resting but remains oriented and can be easily aroused by verbal stimuli.)

Nasal cannula

Manifestations of hypoxemia are shortness of breath, anxiety, tachypnea, tachycardia, restlessness, pallor or cyanosis of the skin or mucous membranes, adventitious breath sounds, and confusion. Manifestations of hypercarbia (elevated levels of CO2) are restlessness, hypertension, and headache.

Oxygen toxicity can result from high concentrations of oxygen (typically above 50%), long durations of oxygen therapy (typically more than 24 to 48 hr), and the client's degree of lung disease. Manifestations include a nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation.

The percentage of oxygen delivered is expressed as the fraction of inspired oxygen (FiO2). Nasal cannula A length of tubing with two small prongs for insertion into the nares. FiO2 24% to 44% at flow rates of 1 to 6 L/min. Provide humidification for flow rates of 4 L/min and greater. Simple face mask Covers the client's nose and mouth. FiO2 40% to 60% at flow rates of 5 to 8 L/min. (The minimum flow rate is 5 L/min to ensure flushing of CO2 from the mask.). Assess proper fit to ensure a secure seal over the nose and mouth. Ensure that the client wears a nasal cannula during meals.

Partial rebreather mask Covers the client's nose and mouth FiO2 40% to 60% at flow rates of 6 to 11 L/min. The mask has a reservoir bag attached with no valve. Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep it inflated. Covers the client's nose and mouth FiO2 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir bag two-thirds full during inspiration and expiration. Has a one-way valve situated between the mask and reservoir, and the two exhalation ports have flaps covering them that prevent room air from entering the mask.

A nurse is assessing a client who has a chest tube and drainage system in place. The following are expected findings: - Gentle constant bubbling only in the suction control chamber; air is being removed. A suction pressure of -20 cm H2O is commonly prescribed. - Rise and fall in the level of water in the water seal chamber with inspiration and expiration (Tidaling); the drainage system is functioning properly. - keep the chamber upright and below the chest tube insertion site at all times - Position the client in the semi- to high-Fowler's position. - Ensure that the tubing is straight to promote drainage via gravity.

Unexpected findings: - Continuous bubbling in the water seal chamber indicates an air leak in the system; tighten the connection, replace drainage system. Check all connections. - Do not clamp, strip, or milk tubing; only perform this action when prescribed. - Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red to the provider. - If there is not bubbling in the suction control chamber, check for leaks and make sure the suction is on.

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. In what order should the nurse perform the following actions?

1. Apply sterile gauze to the insertion site. 2. Place tape around the insertion site. 3. Assess respiratory status. 4. Obtain a chest x-ray. Also, If the chest tube drainage system is compromised, immerse the end of the chest tube in sterile water to provide a temporary water seal.

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Bronchospasms Bronchospasms can indicate the client is having difficulty maintaining a patent airway. Blood-tinged sputum, a dry, nonproductive cough, and a sore throat are expected findings following a bronchoscopy.

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following actions should be included in the plan of care?

Encourage the client to cough and deep breathe. Check for continuous bubbling in the suction chamber. Obtain a chest x-ray.

A nurse is planning care for a client who has acute respiratory distress syndrome. Which of the following interventions should the nurse include in the plan?

Place in prone position