Med-Surg II Exam I

A nurse asseses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management and complication prevention (Select all that apply)?

Correct: elevated temperature, shallow breathing, poor cough effort Incorrect: hypoglycemia, confusion

After surgery, a client is extubated in the postanesthesia unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all the apply.

Correct:Tachycardia & confusion Incorrect: slow resp reate, constricted pupils, hypocapnia

a patient with chronic obstructive pulmonary disease arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion which assessment finding by the nurse is most important to report to the healthcare provider

correct: it's respirations have dropped to 10 breaths/minute incorrect:the patient's respirations have dropped to 10 breaths a minute, or is sitting in tripod position, or has bibasilar crackles, pulse oximetry indicate 91% o2 saturation

a patient underwent a laryngectomy 2 days ago when teaching the patient how to care for the next stoma the nurse should include which instruction?

correct: keep the stoma moist incorrect: have a family member perform stoma care keep stoma dry keep stoma uncovered

when providing tracheostomy care, the nurse does which of the following?

correct: secures clean ties before removing soiled ties incorrect: cleanses the incision with an iodine-based antiseptic, uses clean technique to cleanse the outer cannula, cuts the dressing using sterile scissors

a client who had a laryngectomy for cancer of the larynx has been transferred from this post aanesthesia care Unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room?

correct: suction supplies incorrect: incentive spirometer, tracheostomy set, writing materials

to determine whether there is a delay in impulse conduction through the ventricles the nurse will measure the duration of the patients

correct: QRS complex, incorrect: PR interval, Q wave, P wave the QRS complex represents ventricular depolarization. The P wave represents the depolarization of the Atria. The PR interval represents depolarization of the Atria atrioventricular node bundle of His bundle branches and per country fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short.

an hour after a thoracotomy, a patient complains of incisional pain at a level 7 and it has decreased left-sided breath sounds. The pleural drainage system has a hundred mL of bloody drainage and a large air leak. Which action should the nurse take?

correct: administer the prescribed morphine incorrect: assist the patient with incentive spirometry, milk the chest tube to remove any clots, clamp chest tube in two places

while close family members are visiting, a patient has respiratory arrest, and resuscitation is started. Which action by the nurse is best?

correct: ask family members if they wish to remain in the room during resuscitation incorrect: assign a staff member to wait with family members just outside the patient room, take the family members quickly out of the patient room and remain with them, it's all the family members that watching the resuscitation will be very stressful

which intervention should the nurse Implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

correct: encourage coughing and deep breathing incorrect: position the client prone on a soft mattress, deferred pain medication the first day after injury, apply a thoracic binder for support

when caring for a patient with mitral valve stenosis, it is most important for the nurse to assess for

correct: shortness of breath on exertion incorrect: peripheral edema, diastolic murmur, right upper quadrant tenderness