CAI quiz 4

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent pulmonary embolism?

Assess legs for redness Apply elastic compression stockings Perform passive ROM

A nurse is caring for a postoperative client who has a chest tube connected to suctions and water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Continuous bubbling within the water seal chamber

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Eat foods that contain plenty of potassium.

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest?

Paradoxical chest movement

What assessment finding would indicate the presence of tension pneumothorax in a patient with chest trauma?

Severe respiratory distress and tracheal deviation

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water seal chamber

A nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Evaluate chest expansion

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Increasing dyspnea

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs o be transported to x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea to the unaffected side

A nurse in the ED is caring for a client who had cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79, and apical heart rate 112/min. Which of the following interventions is the nurse's priority?

Provide the client with supplemental oxygen at 5 L/min via facemask

An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP

Stripping or milking the chest tube to promote drainage

A male client has chronic obstructive pulmonary disease (COPD) and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring?

Spontaneous pneumothorax

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Verify that the suction regulator is n and check the tubing for leaks

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

administer oxygen therapy

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

continue to monitor the client

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?`

hypoxemia