Skills Lab and Pharmacology Final

A patient needs suctioning due to:

-Unable to clear secretions -Ineffective cough

To prevent complications associated with endotracheal or tracheostomy tubes, the nurse needs to:

-Use aseptic technique -Monitor temperature and WBC

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American patient?

2 cm area purplish blue in color surrounded by lighter-colored skin located on right heel

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

"I respect your wish not to look at it right now"

A tension pneumothorax occurs when:

-Air accumulates in the pleural space faster than it is dispersed -High pressures collapse lung function

What prevents air from re-entering the pleural space when chest tubes are inserted?

A closed water-seal drainage system

During auscultation which findings suggest a right pneumothorax?

Absence of breath sound in the right thorax

Constant bubbling in the water seal chamber of a chest tube drain indicates:

An air leak

A group of nursing students is practicing suctioning technique in the lab. One student asks what the benefit of in-line (closed suction) suctioning is. What would be the instructor's best response?

In-line suctioning decreases hypoxemia

Which nursing entry is most complete in describing a client's wound?

Incisional edges approximated without redness or drainage; two 4x4s applies

Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first:

Apply an occlusive dressing such as petroleum jelly gauze

The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning?

Applying intermittent suction for 10 seconds during catheter removal

The nurse is preparing to suction a patient with an artificial airway tube. What would be the nurse's first step in the suctioning process?

Assess the patient's lung sounds and SAO2 via pulse oximeter

After the patient with a chest tube returns from radiology, the RN identifies new continuous bubbling in the water seal chamber. The RN clamps the chest tube at the dressing site and bubbling in the water seal chamber stops. What is the next appropriate nursing action?

Call the provider immediately. Do not leave the patient's bedside because of the risk of respiratory failure

When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area?

Clean the area with mild soap, dry, and add a protective moisturizer

A client comes to the ED following an injury. The nurse implements appropriate first aid for the client when:

Elevating an affected part that is bleeding

The RN caring for a patient with a chest tube after a left pneumonectomy must:

Encourage coughing and deep breathing

The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

Extending only to the upper edger of the wound

A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?

Inner cannula

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

It is inserted into the space between the lining of the lungs and the ribs

Under normal conditions, pleural pressure is:

Negative

The RN assessing for tracheal displacement knows that the trachea will deviate toward the:

Opposite side in a hemothorax

The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape:

Parallel to the skin surface while pulling toward the wound

The nurse is concerned that the client's midsternal wound is at risk for dehiscence. What is the best intervention to prevent this complication?

Place a pillow over the incision site when the client is deep breathing or coughing

While repositioning a patient with a chest tube, the chest tube disconnects from the suction. What should be the first nursing action?

Place a sterile dressing over the disconnection site

A client has a healing abdominal wound. The wound has collagen formation and minimal exudate. The wound is identified by the nurse as being in which phase of healing?

Proliferative phase

The client is experiencing low back pain and is to have an aquathermia pad applied. The nurse recognizes that safe application of heat to a client's injury includes:

Providing a timer for the client

Granulated tissue is best described as:

Red, moist, and vascular-rich

The nurse is planning a program on wound healing and includes information that smoking influences healing by:

Reducing functional hemoglobin in the blood

The nurse prepares to irrigate the client's wound. The primary reason for this procedure is to:

Remove debris from the wound

The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to:

Replace the oxygen and allow rest in between suctioning passes

What nursing diagnosis would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

Risk for infection

A student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse?

Saline is no longer recommended for routine suctioning

When cleansing a wound, the nurse should:

Start at the drainage site and move outward with circular motions

Upon changing the client's dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is:

Sterile saline

A nurse is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

Stridor

Which of the following statements is true regarding patient movement while a chest tube is in place? There are provider orders for increased activities of daily living and ambulation are on the chart.

The drain is disconnected from suction and the chest drain remains to gravity drainage (below the chest)

What is the rationale for placing a writing board in the room of a patient who has had surgery to insert a tracheostomy tube?

The patient is not able to speak

A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?

The safety measures necessary to prevent a fire

Which of the following situations is most likely to result in an absence of fluctuation in the chest drainage tubing?

The tubing is occluded

The most important part of a chest drainage system is:

The water seal

Fluctuation of the water level in the water seal chamber with respiration is called:

Tidaling

What instruction is most important for the nurse to provide during discharge teaching who underwent a laryngectomy?

Tracheostomy care

While caring for a patient with an artificial airway tube, the nurses recognizes that suctioning is required

When adventitious breath sounds are auscultated

A patient in the ICU has had an endotracheal tube for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best answer?

When an endotracheal tube is left in for more than 3 weeks, there is an increased risk of complications such as damage to the laryngeal nerve

When a patient is discharged home and will need tracheostomy care. The nurse assesses:

-How is family's ability to cope with cares and condition -A referral for home health care support -Care takers have demonstrated proper technique right before discharge

The purpose of a chest drainage unit is:

-Evacuation of air from the chest cavity -Evacuation of fluid form the chest cavity -Assist in reestablishing normal intra-thoracic pressure

The nurse is aware that application of cold is indicated for the client with:

A fractured ankle

The client is brought into the ED with a knife wound. The nurse correctly documents the client's wound as an ______________

Acute wound

The RN is caring for a client who has recently had a chest tube inserted to treat a pneumothorax. Bubbling is noted in the suction control chamber. What action should the RN take?

Do nothing, this is an expected finding

What can a nurse ask a patient to do before suctioning to prevent hypoxemia?

Take several deep breaths

A nurse observes a client who is on mechanical ventilation to be fighting the ventilator. Pancuronium bromide is ordered for the client. This medication is classified as:

A neuromuscular blocking agent

What would the critical care nurse recognize as a condition that may indicate the patient's need to have a tracheostomy?

A patient who requires permanent ventilation

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated and WBCs move into the wound

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?

Further assess the client for re-inflation of the lung

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. The initial nursing action is to:

Grasp the rentention sutures to spread the opening, insert the obturator

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the rationale for this?

Maintaining a patent airway

While assessing a thoracotomy incisional area from which a chest tube exits, the RN palpates a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action?

Mark the periphery of the crackling

The nurse is caring for a client with chest tubes that are connected to water seal drainage. Which of the following cares is most appropriate?

Mark the time and amount of drainage on the collection container

During a dressing change, the nurse assesses a protrusion of intestines through an open wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

Notify the physician and prepare for surgery