1. A 17-year old is admitted following an automobile accident He is very anxious, dyspneic, and in severe pain. The left chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of:
2. A young man is admitted with a flail chest following a car accident. He is
intubated with an endotracheal tube and is placed on a mechanical ventilator
(control mode, positive pressure). Which physical finding alerts the nurse to an
additional problem in respiratory function?
a. Dullness to percussion in the third to 5th intercostals space, midclavicular line
b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases
3. 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 the system functions effectively the nurse should:
a. Observe for intermittent bubbling in the water seal chamber
b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hours
c. Maintain the client in an extreme lateral position
d. Strip the chest tubes in the direction of the client
4. 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 is dislodge from the chest. The most
appropriate nursing intervention is to:
a. Notify the physician
b. Insert a new chest tube
c. Cover the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives
5. A 71-year old is admitted to the hospital with congestive heart failure. She has
shortness of breath and a +3 - 4 peripheral edema. The care plan to reduce the
client's edema should include nursing strategies for:
a. Establishing limits on activity
b. Fostering a relaxed environment
c. Identifying goals for self care
d. Restricting IV fluids
6. Mr. Sison, 65 years old has been smoking since he was 11 years old. He has long
history of emphysema. Mr. Sison is admitted to the hospital because of a respiratory
infection, which has not improved with outpatient therapy. Which finding would the
nurse expect to observe during Mr. Sison's nursing assessment?
a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d. Weight-Height relationship indicating obesity
a. Mixes room air with oxygen
b. Delivers a precise concentration of oxygen
c. Requires humidity during delivery
d. Is less traumatic to the respirator tract
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\u2019t 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. "My family was angry when I told them they could not smoke in my room."
a. Anticipate the need for humidification
b. Notify the physician that this order is contraindicated
c. Place client in high Fowler's position
d. Schedule nursing care to allow frequent observations of the client
Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol abuse
for the past 15 years. His wife brings him to the emergency department because he is
increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the
a. Decreased serum creatinine
b. Decreased sodium
c. Increased ammonia
d. Restricted sodium
a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium
a. Deflate the esophageal balloon
b. Encourage him to take the deep breath
c. Monitor his vital signs
d. Notify the physician
Situation 4 - Rape is one of the most tragic things that could happen to anyone especially with young girls. Incidence such as these could develop into a crisis situation involving not only the rape victims but also their families.
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