assess exam 2 PRACTICE

You are caring for a patient with a chest tube. For patient safety you check to be sure you have the necessary emergency equipment at the bedside including which of the following. Select all that apply. - sterile saline - An obturator - Kelley clamps - A Pulse oximeter

- sterile saline - Kelley clamps

A chest drainage system is being chosen for a client who is ambulating daily. Which system would be the best choice for this client? - Traditional water seal - Wet suction - Dry suction water seal - Dry suction/one-way valve system

Dry suction/one-way valve system

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? - It is dissecting - It is distended - It is inflamed - It is normal

It is distended

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: - Ptosis - Entropion - Ectropion - Miosis

Ptosis

When inserting a nasogastric tube, the nurse knows to advance the tube when the patient: - Holds their breath - Flexes their neck - Swallows a sip of water - Takes a deep breath

Swallows a sip of water

The nurse is preparing to begin a health assessment with a new client. Which nursing consideration will help to establish a safe and appropriate environment for conducting the health assessment? - There is adequate time to perform the assessment. - The room is private, quiet, warm, and has adequate light. - Family members are present to answer specific questions. - The assessment should be conducted after all tests and procedures.

The room is private, quiet, warm, and has adequate light.

Which of the following drains require the use of an occlusive dressing? - Vacuum drain - Jackson-pratt - Penrose - Hemovac

Vacuum drain

what does murmur grade I/VI mean? - a grade 1 murmur - a grade 6 murmur - a 1/6th murmur

a grade I murmur

A nurse is caring for a patient with a descending colostomy. What type of stools would she expect to find in the colostomy bag: - Formed - None - Liquid - Watery

formed

which of the following findings would be the most concerning when assessing the parotid lymph nodes? - tender to the touch - hard and nodular - enlarged to 1cm - multiple discrete nodes

hard and nodular

why is a double lumen trach preferable for patients with copious secretions? - inner cannula can be removed for cleaning - maintains tighter oxygen control - helps them to speak easier - decreases the risk of aspiration

inner cannula can be removed for cleaning

which patient would have an uncuffed tracheostomy? - ventilated - copious secretions - long term care needs

long term care needs

The type of suctioning that suctions the back of the throat through the mouth is called - airway suctioning - mouth suctioning - endotracheal suctioning - nasopharyngeal suctioning - oropharyngeal suctioning

oropharyngeal suctioning

what can a nurse ask a patient to do before suctioning to prevent hypoxemia? - breath normally for at least 5 minutes - lie flat in bed and practice relaxation techniques - sit in an upright position and cough - take several deep breaths

take several deep breaths

T / F We ask open ended questions to allow our patients to be open and share information with us. The more comfortable they feel, the more accurate our health history collection will be.

true

A question starting with _____ may make a patient feel like we are accusing them of something rather than wanting to learn more. - Who - What - Where - Why - How

why

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? - "This is nothing to worry about. I won't hurt you." - "Some of the examinations may be painful, but I will be gentle." - "Let me explain to you what I will be doing during your assessment." - "I have to do this, so just relax and it won't last long."

"Let me explain to you what I will be doing during your assessment."

You are performing an abdominal assessment on your patient who has a NG tube. Your assessment includes which of the following. Select all that apply. - Abdominal tenderness - Complaints of nausea - Bowel sounds - Amount of gastric drainage - Drainage color & consistency - Abdominal distention

- Abdominal tenderness - Complaints of nausea - Bowel sounds - Amount of gastric drainage - Drainage color & consistency - Abdominal distention

Nasogastric tubes have multiple uses in health care. Select typical uses from the list below: - Nutrition - Lavage - Weight loss - Decompression - Hydration

- Nutrition - Lavage - Decompression

what if the chest tube becomes dislodged from the patient?

- cover site with sterile occlusive dressing + tape on 3 sides

you are caring for a patient with a chest tube. for patient safety you check to be sure you have the necessary emergency equipment at the bedside including which of the following? - kelley clamps - sterile saline - a pulse oximeter - a tracheostomy tube

- kelley clamps - sterile saline

What function does a wet to moist dressing have that a wet to dry dressing does not? - A wet to moist protects - A wet to moist improves circulation - A wet to moist debrides - A wet to moist heals

A wet to moist heals

When caring for a client with a tracheostomy, the nurse would perform which recommended action? - Clean the wound around the tube and inner cannula at least every 24 hours. - Assess a newly inserted tracheostomy every 3 to 4 hours. - Use gauze dressings over the tracheostomy that are filled with cotton. - Suction the tracheostomy tube using sterile technique.

Suction the tracheostomy tube using sterile technique.

A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results? - The client will experience lapses in short- and long-term memory. - The client will likely have difficulty expressing or understanding abstract concepts. - The client's reaction time will likely be slower than that of a younger adult. - The client's arm and leg strength will be more asymmetric than that of a younger client.

The client's reaction time will likely be slower than that of a younger adult.

A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving? - The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. - The palate and pharynx move as the client says "ah." - The client's tongue remains midline when it protrudes from the mouth. - The client is able to turn the head to the side and shrug the shoulders against resistance.

The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma? - Use water only - Use alcohol based sanitizer - Use water and mild soap - Use mineral oil

Use water and mild soap

Which of these statements is NOT an example of an open ended question? - How would you describe your pain? - When I press here, does it hurt? - What have you been doing to relieve your indigestion issues? - How many times a week do you go to physical therapy?

When I press here, does it hurt?

You are assessing the wound of a patient prior to repacking the wound. You know that the ideal environment to promote wound healing is that the: - Wound is moist and the surrounding skin is dry - Wound is wet and the surrounding skin is moist - Wound is moist and the surrounding skin is moist - Wound is wet and the surrounding skin is dry

Wound is moist and the surrounding skin is dry

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? - outer cannula - obturator - cuff - inner cannula

inner cannula

a patient has a tracheostomy and the nurse is preparing to perform tracheostomy care. what part of the tracheostomy tube is removed for cleaning? - outer cannula - cuff - obturator - inner cannula

inner cannula

your patient has a double lumen fenestrated tracheostomy tube. when auscultating the lungs you find your patient has significant rhonchi and you determine that you need to perform tracheal suctioning. prior to performing suctioning you make sure that : - the cuff is inflated - the patient is able to cough - the patient is in the supine position - the inner cannula is in place

the inner cannula is in place

A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set? - 60 to 80 mmHg - 80 to 125 mmHg - 100 to 130 mmHg - 100 to 150 mmHg

80 to 125 mmHg

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? - Dark pink and moist - Red and dry - Off-white or pale pink - Dark purple-blue

Dark pink and moist

Which tube permits speech through the upper airway? - Two-piece tube - Fenestrated tube - Uncuffed tube - Cuffed tube

Fenestrated tube

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first? - Inspect the left lower leg for areas of redness. - Lightly palpate the left leg, assessing for edema. - Assess for pain by deeply palpating the left leg. - Palpate the popliteal and posterior tibial pulses of both legs.

Inspect the left lower leg for areas of redness.

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? - Small amount of subcutaneous air is detected at the site of tube insertion. - Dressing is moist and intact. - Respirations are at 20 breaths per minute. - Drainage system is positioned slightly above chest level.

Respirations are at 20 breaths per minute.

when you auscultate the pulmonic valve, you expect to hear: - S2 louder than S1 - S1 = S2 - S1 louder than S2 - a third heart sound

S2 louder than S1

The nurse is preparing to assess a client's cranial nerves. Which technique should a nurse use to assess cranial nerve III? - Shine a bright light in the client's eyes and observe for bilateral pupillary response. - Ask the client to close the eyes, occlude a nostril, and then identify the smell of different substances. - Determine visual acuity using a Snellen chart. - Occlude the client's right ear, whisper a word into the left ear, and ask the client to repeat it.

Shine a bright light in the client's eyes and observe for bilateral pupillary response.

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory? - "What did you eat for dinner last night?" - "What are the three objects I told you earlier?" - "What is meant by 'an ounce of prevention is worth a pound of cure'?" - "What are the month, date, and the year of your birth?"

"What are the month, date, and the year of your birth?"

Immediately following the removal of your patient's chest tube, you expect the patient to have which of the following? Select all that apply. - Occasional respiratory distress - A chest x-ray ordered - The need for frequent suctioning - An occlusive dressing

- A chest x-ray ordered - An occlusive dressing

You are providing endotracheal tube care to your patient who is on a mechanical ventilator. To follow proper procedure when changing the tape you are sure to do which of the following. Select all that apply. - Check the ET tube markings to ensure accurate placement - Move the ET tube to the alternate side of the mouth - Assess breath sounds and respiratory status after taping - Assess the patient for the need for pain medication

- Check the ET tube markings to ensure accurate placement - Move the ET tube to the alternate side of the mouth - Assess breath sounds and respiratory status after taping - Assess the patient for the need for pain medication

What characteristics would you observe for in a wound healing by secondary intention? Select all that apply. - Granulation tissue - Contraction effect - Edges are approximated - Potential for tunneling

- Granulation tissue - Contraction effect - Potential for tunneling

You are caring for a patient who has a chest tube placed after thoracic surgery. You know that principles of caring for patients with chest drainage units include which of the following. Select all that apply. - Position the collection device at chest level - Observe for gentle bubbling in the suction chamber - Clamp the tube when the patient ambulates - Observe for tidaling in the water seal chamber - Empty the drainage device every shift

- Observe for gentle bubbling in the suction chamber - Observe for tidaling in the water seal chamber

Healing benefits of using vacuum assisted closure include which of the following. Select all that apply. - Promotes angiogenesis - Causes debridement - Promotes the contraction effect - Decreases microbial bioload - Promotes increased circulation

- Promotes angiogenesis - Promotes the contraction effect - Decreases microbial bioload - Promotes increased circulation

What can a nurse ask a patient to do before suctioning to prevent hypoxemia? - Lie flat in bed and practice relaxation. - Take several deep breaths. - Sit in an upright position and cough. - Breathe normally for at least 5 minutes.

- Take several deep breaths.

Upon percussion, you know that the bladder is distended. What measure can you take to gather more detailed information: - Use a bladder scanner - Insert an indwelling catheter - Bring the patient to the bathroom - Insert a straight catheter

- Use a bladder scanner

immediately following the removal of your patient's chest tube, you expect the patient to have which of the following? - occasional respiratory distress - a chest xray ordered - the need for frequent suctioning - an occlusive dressing

- a chest xray ordered - an occlusive dressing

you are caring for a patient who has a chest tube placed after thoracic surgery. you know that principles of caring for patients with chest drainage units include which of the following? - observe for tidaling in the water seal chamber - position the collection device at chest level - observe for gentle bubbling in the suction chamber - make sure there is emergency equipment at the bedside - clamp the tube when the patient ambulates

- observe for tidaling in the water seal chamber - observe for gentle bubbling in the suction chamber - make sure there is emergency equipment at the bedside

what should I do if my patient's chest tube detaches from the drainage system?

- quickly submerge end of chest tube in 1" sterile water - prepare system for reattachment to replacement unit

You are assessing placement of a NG tube. You suspect that the tube has advanced into the small intestines when the pH test result is: - 4.5 - 6 - 8 - 5.5

8

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? - Turn off the suction for 30 minutes and then turn it on again. - Attempt to irrigate the NG tube with water or normal saline. - Instill digestive enzymes. - Remove the NG tube and replace it with a large-bore tube, as ordered.

Attempt to irrigate the NG tube with water or normal saline.

A duoderm/ occlusive dressing promotes what type of debridement? - Autolytic - Mechanical - Surgical - Enzymatic

Autolytic

The nurse is palpating a client's precordium. Which result is an expected clinical finding? - Palpable pulsation over the mitral area - Palpable thrill over the aortic area - Palpable heave over the pulmonic area - Palpable vibration over the right sternal border

Palpable pulsation over the mitral area

The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag? - Fresh lettuce - Steamed rice - Baked beans - Cooked pasta

Baked beans

which part of the tracheostomy tube provides a good seal to help control the influx of air when a patient is on a ventilator? - obturator - outer cannula - cuff - inner cannula

cuff

A homecare nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? - Evisceration - Dehiscence - Fistula - Infection

infection

should I clamp my patient's chest tube during transportation to another department?

no * clamping puts patient at risk for tension pneumothorax

are there any times when I should strip or milk a chest tube?

no (unless ordered) * can injure pleural membranes + tissues

when auscultating the carotid pulses, what is a normal finding? - a beat simultaneous with the heart rate - no sound - a soft blowing sound - a loud grunting noise

no sound

Your patient has a double lumen fenestrated tracheostomy tube. When auscultating the lungs, you find that the patient has significant rhonchi and you determine that you should perform nasopharyngeal suctioning. Prior to suctioning the patient, you make sure that: - the patient is able to cough - the cuff is inflated - the patient is in a supine position - the inner cannula is in place

the inner cannula is in place

how often should I replace the disposable closed-chest drainage system my patient has?

unless system has been compromised, no need to replace until drainage chamber is nearly full

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter. What condition could occur? - Trauma to the tracheal mucosa - Prevention of suctioning - Loss of sterile field - Suctioning of carbon dioxide

Trauma to the tracheal mucosa

you are to insert a NG tube and connect to continuous low suction. what tube do you insert? - single lumen tube - levin tube - double lumen tube - both salem sump and double lumen - none of the above - salem sump tube - all of the above

both salem sump and double lumen

You are preparing your patient for the insertion of a tracheotomy tube. Your patient has excessive secretions and is at risk for aspiration. You expect the physician to put in a: - fenestrated tube - uncuffed tube - endotracheal tube - cuffed tube - single lumen tube

cuffed tube