Adult 2 Test 1
A PT admitted to critical care after left pneumonectomy receives 40% O2 via simple facemask. Dx with right lower lobe pneumonia. After eating breakfast, PT aspirates and vomits. Becomes agitated, decreased LOC, inability to maintain saturation, nurse anticipates which next action?
placement of PT on vent
PT with increased capillary permeability. Which finding does nurse anticipate in PT?
pulmonary edema
The nurse receives report on assigned clients. One client is reported to be at nadir for his cancer chemotherapy. How will this affect the nursing care plan?
reinforce precautions for decreasing infections
Nurse is suctioning client via intratracheal tube. HR is increasing. Which nursing intervention is appropriate?
stop procedure and reoxygenate PT
PT immediately after removal of ET, which symptom is reported immediately?
stridor
Following surgery a radical neck dissection for laryngeal cancer, the priority of the nursing care is?
suction the laryngeal tube as much as needed
client with acute respiratory failure. considered for weaning. high pressure alarm keeps going off. vent inoperable alarm sounds. nurse should do what
take off and ventilate them manually
A PT undergoing chemotherapy has a WBC of 2,300, a hemoglobin of 9.8, platelets of 80,000, and potassium of 3.8. What finding should take priority?
temp of 101
A client is receiving high dose chemotherapy for a large rapidly dividing tumor. What is the person developing?
tumor lysis syndrome
Low pressure alarm. Nurse assesses client then attempts to determine cause. If can't determine cause of alarm, what action should be priority?
ventilate PT manually
A client has treatment for lymphoma complains of headaches, vomiting fatigue, and constipation, serum electrolyte testing reveals calcium of 14. The appropriate treatment is?
normal saline
Aortic aneurysm repair with graft placement 30 mins ago. Posterior tibial pulse not palpable. Nurse priority action is
notify surgeon
A client with a family history of cancer asked what the single most important risk factor for cancer. What risk factor should the nurse discuss?
age
18 year old involved in MVA with pneumothorax. Chest tube with constant bubbling in water sealed chamber most likely a result of?
air leak
A client is beginning external beam therapy to the right axilla after a lumpectomy after breast cancer. Which of the following should the nurse include in client teaching?
apply deodorant only under the left arm
Which information should be included in the teaching plan for a PT with cancer who is experiencing thrombocytopenia? SATA
avoid frequent flossing monitor temp report bleeding
PT with chest trauma after MVA, O2 60% via venturi mask. Which assessment finding indicates ARDS? SATA
BL wheezing and stridor progressive hypoxia
A female client who has undergone replacement radiation therapy asks if she can with her husband to the lounge at the end of the hall. Which response is the most appropriate?
Because of the treatment you are receiving you need to remain in your room
Nurse is assessing PT given opiod analgesic. Which ABG value indicates PT is at risk for respiratory failure?
CO2 of 80
Which assessment finding indicates ET tube placement might need to be further evaluated? SATA
Chest rise noted on right side only breath sounds noted over epigastric breath sounds audible only on right side
PT with pulmonary embolus. Which assessment data requires immediate intervention?
The client's ABG's are pH 7.36, PaCO2 38, HCO3 24
PT with thorax aneurysm. Which intervention should nurse include in plan of care
administration of antihypertensive meds
Older client receiving oxygen. PT coughing- possible treatment intervention? SATA
chest x-ray to check placement auscultate lungs BL
PT with ARDS in prone position for 30 mins. Which of the following will require discontinue of position?
client is tachycardic with drop in BP
Nurse assessing client on vent with ET. Which data confirms tube has migrated too far into trachea?
decreased breath sounds over left side of chest
Low pressure alarm sounds on vent. Cause for alarm may be?
displaced tube
client with pneumothorax has chest tube. Gentle bubbling in suction control chamber. Which action is appropriate?
do nothing, expected in chamber
High pressure alarm goes off. Which action should the nurse take?
empty excess accumulated water in tube
A nurse is caring for a client with bladder cancer and bone METS, which S&S would the nurse recognize as indications of a possible oncological emergency?
facial edema serum calcium of 12
The nurse is teaching a 17 year old client and the clients family about what to expect with high dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client?
fever
a client with advanced small lung cell cancer presents with complaining of SOB and weakness, a serum sodium of 116 is reported by the lab. The nurse can anticipate which order from the physician?
fluid restriction and 3% saline
Pulmonary embolus, when suction nurse should do what?
hyperoxygenate before and after suctioning
A client receiving chemotherapy for breast cancer develops myelosuppression. The nurse should include all of the following in the PT's discharge planning except
increase in fresh vegetables
During the initial chemo client with leukemia develops hyperkalemia and hyperuricemia. The nurse recognizes that these symptoms are an oncological emergency and anticipates which priority treatment?
increase urine output with hydration therapy
