Med Surg Exam 3 Quiz Question

T/F: IF a pt is having trouble maintaining oxygen saturation, even with increases in supplemental oxygen, the first thing the nurse should do is notify the position.

False

T/F: In a pt having trouble mobilizing secretions the nurse should make sure and limit daily fluids.

False

T/F: In a pt with a newly inserted chest tube the nurse would document no tidaling in the water seal chamber as an expected finding.

False

T/F: In the pt with a pneumothorax the nurse will hear audible wheezing.

False

T/F: It is a routine part of chest tube procedural care to encourage the pt to clamp the chest tube momentarily when transporting the pt to the bathroom.

False

T/F: It is acceptable practice to clamp a chest tube every shift as needed.

False

T/F: Regarding oxygenation variables, there is no difference in bronchial responsiveness based on gender.

False

T/F: The amount of suction in the chest tube system is determined by the amount of wall suction applied.

False

T/F: The dressing should be changed daily in a pt with a chest tube.

False

T/F: Usually a pneumothorax is painless, but he pt complains of sudden onset of SOB

False

T/F: With droplet respiratory isolation the nurse should use a N-95 respirator when entering the patient's room

False

T/F: you should empty the drainage out of the collection chamber of the chest tube drainage system every shift

False

T/F; the water seal chamber should gently bubble

False

The nurse is teaching a pt to use incentive spirometry. It is important to instruct the pt to breath through the nose when using the spirometer.

False

Tuberculosis is a contagious bacterial infection caused by mycobacterium tuberculosis and it only affects the lungs.

False

A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition: Select all that apply

Hypotension Jugular Vein Distention Trachael deviation

The health care provider (HCP) prescribed knee-high sequential compression devices. The client reports new pain localized in the right calf area. The nurse notes the area is reddened and warm to touch. What should the nurse do first?

Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings.

A client is undergoing testing to see if he has a pleural effusion. Which of the nurses resp assessment findings would be most consistent with this diagonsis?

Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

The nurse reviews the morning laboratory results from a client admitted with a deep vein thrombosis. The client is receiving intravenous heparin. Based on the client's current laboratory values, what should the nurse do?

Maintain the current rate of the heparin infusion.

Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?

No special PPE is needed

As the nurse you know that one of the reasons for an increase in multi-drug-resistant tuberculosis is:

Noncompliance due to duration of medication treatment needed

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as

Open pneumothorax

If a patient has a open pneumothorax which of the following nursing interventions would you provide to the patient?

Place a sterile occlusive dressing over the chest wound and tape it on three sides

When admitting a pt who has a pleural effusion, which techniques will the nurse use to assess tactile fremitus?

Place the palms of the hands on the chest wall.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids?

Presence of cough and gag reflex

You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?

Rifampin

The client returns to the hospital 3 days after diagnosis of deep vein thrombosis, with reports of cough, hemoptysis, shortness of breath, and sharp pain under the right scapula. The client is subsequently is diagnosed with a pulmonary embolus (PE). The client asks the nurse, "How did I even get a pulmonary embolus?" What is the best response by the nurse? Select all that apply.

-venous endothelial changes -having any condition that produces venous stasis -increased blood coagulability

The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number.

12

A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in _________ so the results can be interpreted?

48-72 hours

A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sounds should the nurse expect to asses on auscultation?

Crackles

While assess a client who has pneumonia, the nurse has the client repeat the letter E and when they auscultate it, they hear A. What finding is this?

Egophony

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees.

T/F: An allen test should be performed before an arterial blood gas stick and if positive then it is okay to perform the radial artery puncture.

False

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

-a client who is on complete bed rest following extensive spinal surgery -a client who has a large venous stasis ulcer on the right ankle area -a client who has recently been admitted with a broken femur and is awaiting surgery -a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy

Which of the following are best practices when caring for a client with a chest tube?SATA

-check the pt at least every 2hr or more frequently as needed to ensure chest tube patency -tape all tubing junction -avoid dependent loops of the chest tube -keep sterile gauze and sterile water at the bedside

T/F: Dressing changes for chest tubes are daily

False

T/F: Dressing changes for chest tubes daily

False

T/F: IF a client has a chest tube the nurse should encourage strict bed rest for 24hrs.

False

While caring for a patient with a suspected pneumothorax, you note there are several areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are located on the patient's neck, face, and abdomen. On palpation on these areas, you note they feel "crunchy". When charting your findings you would refer to this finding as?

Subcutaneous emphysema

A patient has a positive PPD skin test that shows a 12 mm induration. As the nurse you anticipate which of the following?

The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.

Which of the following is a LATE sign of the development of a tension pneumothorax?

Tracheal deviation

Management of epistaxis includes no vigorous exercise for several days, avoid tobacco, and avoiding forceful nose blowing

True

Management of sleep apnea include weight managment, position changes, and avoidance of alcohol

True

T/F: A patient w a hemoglobin of 9 would most likely have problems with effective oxygenation.

True

T/F: Absence of fluctuation in the water seal chamber means there is a kink, clot, or the lung has re-expanded.

True

T/F: IF there is a crack in the chest tube drainage system, the nurse should place the tip of the chest tube in sterile water and set up new tubing.

True

T/F: Sudden decrease in draingage from a chest tube could indicate a blood clot in the tubing

True

T/F: The nurse should place a pt returning from a pneumonectomy on the operative side and closely monitor.

True

T/F: The nurse would suspect a tension pneumothorax in a pt post MVA when the pt exhibits tracheal deviation and cold, clammy skinny.

True

T/F: The physician should be notified if the chest tube drainage is greater than 100mL/hr or stops suddenly

True

T/F: The physician should be notified if the chest tube drainage is greater than 100ml/hr or stops suddenly

True

T/F: the pt with a chest tube coughs and the nurse notes there is intermittent bubbling in the water seal chamber. Once the pt stops coughing and the bubbling continues the nurse should then check for air leaks.

True

T/F; The water seal chamber should be filled to the 2cm marking and checked regularly and refilled if the water is below that line.

True

The proper amount of PPD for administration is 0.1 mL

True

Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?

Uric acid level

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?

Venturi Mask

A nurse is caring for a client with deep vein thrombosis. Which change in assessment findings would the nurse be alert for related to the condition?

chest pain and dyspnea

On auscultation of a pt's lungs, the nurse hears short, high-pitched sounds just before the end of inspiration in the left lower lobe. Finding:

inspiratory wheezes in the left lung base

A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. What should the nurse include in the plan of care for this client?

monitoring the client's activated partial thromboplastin time (aPTT)

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

protamine sulfate