Hesi Review - Med Surg
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?
"I didn't shampoo my hair." Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves.
A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications he is taking. Which of the following serum creatinine results does the nurse document as normal?
1.0 mg/dL Rationale: The normal serum creatinine level ranges from 0.6 to 1.3 mg/dL.
A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin (Dilantin). Which result indicates that the prescribed dose of phenytoin is therapeutic?
16 mcg/mL Rationale: The therapeutic serum phenytoin range is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.
A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than:
200 mg/dL Rationale: A normal cholesterol value ranges between 140 and 199 mg/dL. The client should be counseled to keep the total cholesterol level at 200 mg/dL or less. This reduces the risk of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.
Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician's prescriptions to ensure that the prescribed flow is not greater than:
3 L/min Rationale: Because the client with emphysema has long-standing hypercapnia, the respiratory drive is triggered by a low oxygen level rather than by a high carbon dioxide level. Too much oxygen in this client could cause respiratory failure.
A client with cardiovascular disease is scheduled to receive a daily dose of furosemide (Lasix). Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the physician before administering the dose?
3.0 mEq/L Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L.
A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which of the following serum amylase values, noted by the nurse reviewing the results, would be expected in this client at this time?
395 units/L Rationale: The normal serum amylase range is 25 to 151 units/L. In acute pancreatitis, the amylase level is greatly increased; the level starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain.
An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client's laboratory work that the client's hematocrit is normal?
43% Rationale: The normal hematocrit for an adult female client ranges from 35% to 47%.
Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level?
5.8 mg/dL Rationale: The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL for females.
A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than:
7% Rationale: An acceptable measure of diabetic control is present if the client's glycosylated HbA1C is 7.0% or less. Specific values may vary slightly, depending on the laboratory and the procedure.
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
Administer oxygen via nasal cannula Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the physician is notified.
A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client has misunderstood the directions if the client indicates that as part of aftercare he plans to:
Apply cool compresses to the site twice a day for 20 minutes Rationale: Cool compresses are not used on biopsy sites.
A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of the following measures should the nurse take during this procedure?
Asking the client to void, discarding the specimen, and noting the start time Rationale: Because the 24-hour urine collection is a timed quantitative determination, the test must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection.
A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client?
Assess the patency of the airway Rationale: The first action of the nurse is to assess the patency of the airway. REMEMBER: ABCs!
A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which of the following findings should the nurse assess the client?
Bleeding Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first:
Check the degree of suction Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased.
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first:
Checks for kinks Rationale: : If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system.
A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately:
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution. Rationale: These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response.
A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which of the following signs does the nurse anticipate that this client will exhibit?
Decreased heart rate and decreased blood pressure Rationale: Hypothermia decreases the heart rate and blood pressure, because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases, with corresponding drops in both heart rate and blood pressure.
A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 80 seconds. The client's baseline before the initiation of therapy was 30 seconds. Which action does the nurse anticipate is needed?
Decreasing the rate of the heparin infusion Rationale: The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal.
A client with a history of lung disease is at risk for respiratory acidosis. For which of the following signs and symptoms does the nurse assess this client?
Disorientation and dyspnea Rationale: The client with respiratory acidosis would exhibit the symptoms identified in the correct option. The client will experience dyspnea and may be disoriented as a result of hypoxia and retention of carbon dioxide
A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:
Hold it in on removal Rationale: The client is asked to take a deep breath because the airway will be temporarily obstructed during tube removal. The client is then asked to hold the breath while the tube is being withdrawn.
A client has been given a diagnosis of multiple myeloma. Which of the following results does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis?
Increased calcium level Rationale: Multiple myeloma is characterized by hypercalcemia, anemia, increased BUN, and an increased number of plasma cells in the bone marrow. Hypercalcemia is a result of the release of calcium from deteriorating bone tissue.
A nurse reviews a client's urinalysis report. Which finding does the nurse recognize as abnormal?
Ketones The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present.
A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?
Nausea & vomiting Rationale: Zofran is an antiemetic, post operatively, patients may experience nausea/vomitus.
A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:
No fluctuation in the water seal chamber Rationale: When the client's lung is fully reexpanded, the drainage system will no longer drain and fluctuation in the water seal chamber will be absent. This is because the lung has reexpanded and the pleural space is again a potential space.
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
Notify the surgeon Rationale: Hemorrhage is a common complication after tonsillectomies.
A client has just undergone a renal biopsy. Which intervention should the nurse include intervention in the post-procedure plan of care?
Periodically testing the urine for occult blood Rationale: After renal biopsy, bed rest is maintained and the client's vital signs and puncture site are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a complication.
A nurse is preparing for intershift report when a nurse's aide pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?
Placing the client in a modified Trendelenburg position Rationale: The client is exhibiting signs of shock and requires emergency intervention. The first action is to place the client in a modified Trendelenburg position to increase blood return from the legs, which in turn increases venous return and subsequently the blood pressure.
A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume?
Pulse rate Rationale: Cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate.
A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to:
Remove all metal and jewelry before the test Rationale: A barium swallow, or esophagography, is an x-ray in which a substance called barium is used to provide contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications are withheld before the test. The client should self-monitor for constipation, which may occur as a result of the presence of barium in the GI tract, after the procedure.
A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The physician has prescribed a clear liquid diet for the client. Which of the following items does the nurse ensure is available in the client's room before allowing the client to drink?
Suction equipment Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia.
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:
The test will need to be confirmed with the use of a Western blot Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be confirmed with the use of the Western Blot.
A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:
The tube is patent Rationale: With normal breathing and a patent chest tube, the fluid level in the water seal chamber rises with inspiration and falls with expiration.
A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should tell the client:
To report to the physician the development of fever or redness and heat at the site Rationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heat at the site should be reported to the physician.
A nurse in a physician's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should tell the client to:
Wear comfortable rubber-soled shoes such as sneakers Rationale: The client should wear comfortable rubber-soled, such as sneakers, for the procedure. The client wears light, loose, comfortable clothing; a shirt that buttons in front is helpful for electrocardiogram (ECG) lead placement.
A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. Immediately after the tube is placed in the trachea, the nurse should:
Auscultate both lungs for the presence of breath sounds Rationale: Immediately after an endotracheal tube is inserted, tube placement is verified. Initially the lungs are assessed for bilateral breath sounds and the chest is observed to see whether it rises and falls symmetrically with ventilation. After it has been determined that the client is being adequately ventilated, the tube is taped in place and placement is verified by means of chest x-ray. The depth of tube insertion is documented.
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. The immediate priority on the part of the nurse is:
Covering the insertion site with a sterile occlusive dressing Rationale: : If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing.
A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply.
Hematocrit 30% Hemoglobin 8.9 Rationale: Routine screening tests include complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. These labs were not within normal range.
A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring?
Distant muffled heart sounds Rationale: After effective pericardiocentesis, an increase in blood pressure and a decrease in CVP are expected. The pulse may slow because less cardiac work is needed to produce adequate cardiac output. Distant muffled heart sounds that were noted before the test should become clear with effective pericardiocentesis. A return of distant muffled heart sounds indicates returning pericardial effusion and possible tamponade.
A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure?
Drink 6 to 8 glasses of water without voiding Rationale: Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth.
A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which of the following signs and symptoms does the nurse assess this client?
Dysrhythmias and decreased respiratory rate and depth Rationale: The client with metabolic alkalosis is likely to exhibit dysrhythmias and a decreased respiratory rate and depth as a compensatory mechanism.
A nurse is preparing a client for transfer to the operating room. Which of the following actions should the take in the care of this client at this time?
Ensuring that the client has voided Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place.
A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure?
Left Sims' position Rationale: The client is placed in the left Sims' position, which utilizes the client's anatomy to advantage for introducing the colonoscope, for the procedure.
A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL. After the nurse calls the physician to report the finding and monitors the client closely for:
Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism, which are acidotic, can cause the condition known as diabetic ketoacidosis.
A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?
Oranges Rationale: Citrus fruits and juices are especially high in vitamin C.
A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client's medical history?
Pacemaker insertion Rationale: The candidate for MRI must be free of metal devices or implants. A careful history is conducted to determine whether any such metal objects, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside the client. These may heat up in the magnetic field generated by the MRI device, become dislodged, or malfunction during the procedure.
A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting:
Pallor and coolness of the right leg Rationale: Complications of renal angiography include allergic reaction to the dye, dye-induced renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and embolism. The nurse detects these complications by monitoring the client for signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and signs of diminished circulation to the affected leg.
A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of:
Respiratory distress Rationale: Signs of an allergic reaction to contrast dye include early signs, such as localized itching and edema, followed by more severe symptoms, such as respiratory distress, stridor, and decreased blood pressure.
A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply.
Setting the suction pressure to 60 mm Hg Applying suction throughout the procedure Placing the client in a supine position before the procedure Rationale: The client with a tracheostomy tube should be positioned with the head of the bed elevated. Correct suction pressure for the adult client is 80 to 120 mm Hg. Suction is applied intermittently during catheter withdrawal. Breath sounds should be assessed before the procedure to help determine the need for suctioning. The client should be hyperoxygenated with 100% oxygen before suctioning.
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which of the following actions should the nurse take first?
Slowly lower the head of the bed Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly until the dizziness is relieved.
A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?
Tachypnea, dizziness, and paresthesias Rationale: The client who is anxious is at risk for respiratory alkalosis as a result of hyperventilation. The client is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities.
A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take?
Take Vitals Rationale: The nurse would first assess the client for the return of the gag reflex, which is part of managing the client's airway. The client's vital signs should be checked next; a sudden sharp increase in temperature could indicate perforation of the gastrointestinal tract (this would be accompanied by other signs, such as pain, as well).
A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should tell the client that:
The client may have feelings of warmth or flushing during the procedure The procedure may take as long as 2 hours, during which time the client may feel various sensations including a feeling of warmth or flushing, with catheter passage and dye injection.
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.
Unequal chest expansion Diminished breath sounds in the right lung Rationale: After thoracentesis, the nurse assesses the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Each of these signs must be reported to the physician immediately.
A physician is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client?
Upright Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally empties the bladder, and then sits upright in a chair with the feet flat on the floor.
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
95% Rationale: In the absence of underlying respiratory disease, the expected reading is at least 95%.
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:
Checks the client's overall intake and output Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation.
A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?
Dry mouth Rationale: Scopolamine, an anticholinergic medication, often causes the side effects of dry mouth, urine retention, decreased sweating, and pupil dilation
A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which of the following actions should the nurse plan to take as part of routine after-care for this client?
Encouraging fluid intake Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to consume extra fluids to replace those lost during diuresis of the contrast dye.
A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure?
Flat Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other options are incorrect.
A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client?
Metabolic acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. In conditions such as diarrhea, these fluids may be lost from the body before they can be reabsorbed. The decreased bicarbonate level produces the actual base deficit of metabolic acidosis.
A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client?
Metabolic alkalosis Rationale: Loss of gastric fluid by way of nasogastric suction or vomiting results in metabolic alkalosis.
A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk?
Metabolic alkalosis Rationale: Oral antacids commonly contain sodium or calcium bicarbonate or other alkaline components. These substances bind to the hydrochloric acid in the stomach to neutralize it. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis over time.
A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?
Taping the connections between the chest tube and the drainage system Rationale: The nurse tapes all system connections to prevent accidental disconnection. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter.
A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which of the following measures should the nurse take before the procedure?
Telling the client that the procedure is painless and takes 30 to 60 minutes to complete Rationale: In echocardiography, ultrasound is used to evaluate the heart's structure and motion. It is a noninvasive, risk-free, pain-free test that involves no special preparation and is commonly performed at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed.
A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.
That informed consent is required That food and fluids will be withheld before the procedure That multiple position changes may be necessary to pass the tube Rationale: The client must sign informed consent before the procedure, which takes about an hour to perform. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Food and fluids are withheld before the procedure to prevent aspiration. Multiple position changes may be necessary to facilitate the passage of the tube.
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply).
Assessing the system for an external air leak Documenting assessment findings, actions taken, and client response Rationale: : Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the physician is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. The nurse would first:
Disconnect the suction source from the catheter Rationale: This is indicative of bronchospasm and bronchoconstriction.
A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess:
The chest tube connections Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection.
A nurse is performing nasotracheal suctioning on a client. Which of the following observations should be cause for concern to the nurse? Select all that apply.
The client becomes cyanotic. Secretions are becoming bloody. Rationale: The nurse monitors the client for adverse effects of suctioning, which include cyanosis, an excessively rapid or slow heart rate, and the sudden appearance of bloody secretions. If any of these findings is noted, the nurse stops suctioning and contacts the physician immediately.
A nurse is watching as a nursing assistant measures the blood pressure (BP) of a hypertensive client. Which actions on the part of the assistant that would interfere with accurate measurement would prompt the nurse to intervene? Select all that apply.
Used a cuff with a rubber bladder that encircles at least 60% of the limb Measuring the BP after the client reports that he just drank a cup of coffee Allowing the client to talk as the blood pressure is being measured Rationale: The client should not smoke tobacco or drink a beverage containing caffeine for at least 30 minutes before having the BP measured. The bladder of the cuff should encircle at least 80% of the limb being measured. The client should be seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should rest quietly for 5 minutes before the reading is taken.
