Situation I -- Nurse a is assigned in the emergency unit meeting. Varied opportunities that developed her nursing skills.
1. A 17-year old is admitted following an automobile accident He is very anxious, dyspneic, and in severe pain. The left chest wall movesin during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of:
a. Hemothorax b.
c. Atelectasisd. Pleural effusion
. A young man is admitted with a flail chest following a car accident. He is intubated with an endotracheal tube and is placed on amechanical ventilator (control mode, positive pressure). Which physical finding alerts the nurse to an additional problem in respiratoryfunction?
a. Dullness to percussion in the third to 5th intercostals space, midclavicular line b. Decreased paradoxical motionc.
Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases
. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system (Pleur-evac). To ensure that thesystem functions effectively the nurse should:
Observe for intermittent bubbling in the water seal chamber
b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hoursc. Maintain the client in an extreme lateral positiond. Strip the chest tubes in the direction of the client
. The nurse enter the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube isdislodge from the chest. The most appropriate nursing intervention is to:
a. Notify the physician b. Insert a new chest tubec.
over the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives
. A 71-year old is admitted to the hospital with congestive heart failure. She has shortness of breath and a +
peripheral edema. Thecare plan to reduce the client's edema should include nursing strategies for:
a. Establishing limits on activity b. Fostering a relaxed environmentc. Identifying goals for self cared.
estricting IV fluids
Situation 2 - Oxygen is the most vital physiologic need for survival.
. Mr. Sison,
years old has been smoking since he was 11 years old. He has long history of emphysema. Mr. Sison is admitted to thehospital because of a respiratory infection, which has not improved with outpatient therapy. Which finding would the nurse expect toobserve during Mr. Sison's nursing assessment?
a. Electrocardiogram changes b.
Increased anterior-posterior chest diameter
c. Slow labored respiratory patternd. Weight-Height relationship indicating obesity
7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering the oxygen via the low-flow system recognizes that this methodof delivery:
ixes room air with oxygen
b. Delivers a precise concentration of oxygenc. Requires humidity during deliveryd. Is less traumatic to the respirator tract
. Which statement by Mr. Sison indicates that client teaching regarding oxygen therapy has been effective?
a. "I was feeling fine so I removed my nasal prongs." b. "I've increased my fluids to six glasses of water daily."c. "Don¶t forget to come back quickly when you get me out of the bed; I don't want to be without my oxygen for too long."d.
y family was angry when I told them they could not smoke in my room.
. Supplemental low-flow oxygen therapy is prescribed for a man with emphysema. Which is the most essential for the nurse to initiate?