1. A client has chest tubes due to a pneumothorax. The nurse recognizes that chest tubes may be used to: a. Regain positive intrapleural pressure b. Prevent pleural irritation c. Remove air and fluid from the intra-pleural space d. Establish negative pressure in the intra-alveolar space 2. Nursing care of the client with closed chest drainage should include : a. Clamping chest tube every 2 hours b. Elevating the chest tube higher then the client’s chest c. Milking chest tube only if obstructed by clots d. Clamping chest tube when moving the patient 3. While bathing a client with chest tubes the nurse notices that there is continuous bubbling in the water seal chamber. This means that: a. There is a leak in the system b. The system is functioning properly c. The client is exhaling d. The client needs to be turned to the left 4. A physician asks you to assist him with the removal of his chest tube. You would instruct the client to: a. Continuously breathe normally during the removal of the chest tube b. Take a deep breathe , exhale and bear down c. Exhale upon actual removal of the chest tube d. Hold breath until the chest tube is pulled out 5. Chest tube diameter is measured or expressed in a. French
b. Closed c. Decreased breath sounds on the affected side d. Clamp tubing to prevent a rapid decline in pressure 9. Disconnected b. Millimeters c. Placed lower than the patient’s chest d. Observe for fluid fluctuations in the water seal chamber c. In a client with new rib fractures which assessment finding would best alert the nurse to the possible development of a pneumothorax? a. Pneumonia d. The most important purpose of this is to prevent which of the following complications? a. Dullness to percussion on the unaffected side 8. He was attached to a 3 way water seal drainage system. Observe for fluid fluctuations in the suction control bottle d. Mediastinal shifting
. the system should be: a. Pain c. Hoarseness c. Which is an appropriate nursing priority? a. A chest tube is inserted to decompress the lung. Inches 6. Pink frothy sputum b. Placed between the legs of the client to prevent accidental breakage 7. Gauge d. When transporting a client with a chest tube. The nurse is caring for a client post thoracotomy after having been stabbed in the chest. Hypoventilation b. Apply a thoracic binder to prevent tension in the chest wall b.
3 consecutive months in 2 consecutive years c. Which finding will reinforce your assessment? a. Associated diseases include PTB and Lung CA b. Stridor 13. a. Polycythemia vera b. Diminished breath sounds d. Increased tactile fremitus 11.The following statements are generally considered accurate for clients with pleural effusion EXCEPT.A client is having a severe asthmatic attack.A client with chronic bronchitis has unresolved bronchial infection in: a. Signs and symptoms generally manifest with fluids greater than 100cc 12. Hyperresonance on percussion of the affected lung c. Whispered pectoriloquy d. Cor pulmonale c. Wheezing c. Primary management is through the use of antibiotics d.A client with COPD complains of w 10 pound weight gain in a week. 1 full year
. The complication that may have precipitated this weight gain is a.10.A client is admitted with severe dyspnea related to Pneumothorax. Left ventricular hypertrophy d. Bronchial breath sounds over affected area b. Compensated acidosis 14. Chest Xray generally turns positive with fluids of more than 250 cc c. 2 consecutive months in 3 consecutive years b. Bilateral crackles b. The nurse would expect to hear a.
CO2 19. Cyanosis 17. Lethargy d. edema and visual impairment 16.After the aminophylline drip is started the patients breathing improves. This occurs because aminophylline: a. Increases respiratory rate and depth 18. Decreases respiratory rate and depth c.A physician prescribes O2 at 2 LPM via nasal cannula for a patient with COPD. Helps the patient cough up thick secretions d. Calcium d.d. Prolonged exposure to high O2 causes structural damage to the lung b. Increased O2 can eliminate the stimulus for breathing in a patient with COPD d. Tracheal deviation to the unaffected side b. Inspiratory stridor and respiratory distress
.The physician orders aminophylline IV drip for the patient.A significant assessment finding in a client with a tension pneumothorax is: a. Lactic acid c. The nurse should be alert for which sign of drug toxicity? a. Tachycardia c. Depression b. a clients respiratory center is stimulated by: a. Allows more air to enter the lungs b.The nurse understands that in the absence of pathology. O2 b. Which statement best describes why the patients O2 therapy is maintained at this relatively low level? a. 6 consecutive months within a year 15. O2 may affect the eyes causing tearing. Increased o2 concentration of inspired air can cause alveoli to collapse c.
Chest tube diameter is measured or expressed in a. Hyper resonant percussion sound over the affected side 20.When transporting a client with a chest tube the system should be: a.Which of the following is the emergency treatment for tension pneumothorax? a. Closed c. French b.What is the primary purpose for instructing a client with COPD to use purse lip breathing? a. Placement of a chest tube a chest tube through the mid sternum to reduce cardiac tamponade c. Gauge c. Millimeters d. Attaching the chest tube to a continuous gravity drainage bag d.c. The clients O2 is running at 6LPM. It improves the delivery of oral and nasal medications
. Put the client in Fowlers position 24. Placed lower than the patient’s chest d. Inserting a large bore needle into the 2nd intercostal space on the affected side 21. Placed between the legs of the client to prevent breakage 23. what is the best initial action? a. Take vital signs b. Diminished breath sounds over the affected side d. Inches 22. Prolonged exhalation helps prevent air trapping b. Call the physician c. Inserting a large bore needle into the intercostal space on the unaffected side b. This trains the diaphragm to aid inspiration c. Disconnected b.The nurse enters the room of a client with COPD. his color is pink and his respirations are 9/min. Lower the O2 rate d.
What is the purpose of the long glass tube that is immersed 3 cm below the water level in a water seal bottle? a. dissolve clots that he may have c. To monitor the respirations by visualizing the fluctuation d. To prevent atmospheric air from entering the chest tube Situation: A 60 year old male client is admitted to the emergency department with crushing substernal chest pain that radiates to the shoulder. administer the morphine b.If the client develops cardiogenic shock. a chest radiograph. obtain a 12-lead ECG c. blood work. and 2 mg of morphine sulfate given intravenously. bradycardia c. fever
. The admitting diagnosis is acute MI. treat potential cardiac dysrhythmias 28. order the chest radiograph 27. The nurse should first a. elevated blood pressure d. obtain the blood work d.When administering a thrombolytic drug to the client experiencing an MI. To humidify the air leaving the pleural space b. help keep him well-hydrated b. oliguria b. 26. which characteristic sign should the nurse expect to observe? a. prevent kidney failure d.d. To allow the drainage to mix with sterile water c. It facilitates the movement of thick mucus 25. and left arm. the nurse explains to him that the purpose of the drug is to a.Immediate admission orders include oxygen by nasal cannula at 4 L/minute. jaw. a 12-lead ECG.
antithrombotic action c. You have a fine doctor.Alteplase recombinant. control the dysrhythmias associated with MI d.The pain associated with MI is due to a. control chest pain b. antiplatelet action d. is administered during the first 3 hours after onset of MI to a. is that rehabilitation begins a. analgesic action 31.The client says to the nurse. Everything will be all right soon. antipyretic action b. I’m sure?
. on discharge form the cardiac care unit c. a thrombolytic enzyme. left ventricular overload b. on admission to the hospital d.A basic principle of any rehabilitation program including cardiac rehabilitation. impending circulatory collapse c. Tell me more about what you are feeling b. reduce coronary artery vasospasm c. extracellular electrolyte imbalances d. Are you thinking that you won’t recover from this illness? c. or tissue plasminogen activator (tPA). on discharge form the hospital b. revascularize the blocked coronary artery 33.Aspirin is administered to the client experiencing an MI because of its a.29. four weeks after the onset of illness 32. Which of the following responses by the nurse would be the most appropriate? a. insufficient oxygen reaching the heart muscle 30. my father died of a heart attack when he was 60. and I suppose I will too.
d. Would you agree that this would be very unlikely? 34. activity intolerance related to imbalance between oxygen supply and demand d. improve respiratory status c. primarily because the drug acts to
. the nurse notes eight premature ventricular contractions (PVC’s) in one minute on the cardiac monitor.While caring for client who sustained an MI.Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? a. The client is receiving an intravenous infusion of 5% dextrose in water and 2 liters/minute of oxygen. impaired skin integrity related to pressure c. bronchospasm c. constipation related to immobility 37. administer a prescribed analgesic 35. The nurse’s first course of action should be to a. high risk for infection related to stasis of secretions in alveoli b. increase cardiac output b. fluid-filled alveoli
36. pulmonary edema b. notify the physician promptly c. increase the intravenous infusion rate b. increase the oxygen concentration d.The major goal of therapy for this client would be to a. enhance comfort 38. airway narrowing d.Digoxin is administered intravenously to this client.Crackles heard on lung auscultation indicate a. decrease peripheral edema d.
peptic ulcer disease
. The primary reason for this is to help a.The nurse teaches a client with heart failure to take oral furosemide in the morning.a. excrete fluids accumulated during the night d. colored vision d. retard rapid drug absorption c.The nurse should teach the client that signs of digitalis toxicity include a.Long term complications of HPN include a. dilate coronary arteries b. valvular heart diasease c. high glucose level c. decrease cardiac dysrhythmias d. low sodium level b. renal insufficiency and failure b. decrease GI irritation b. decrease electrical conductivity in the 39. increased appetite c. endocariditis d. elevated BP 41. prevent sleep disturbances during the night 40. high calcium level d.The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a a. increase myocardial contractility c. skin rash over the chest and back b. low potassium level 42.
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital.Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to prevent what complication? a.43. Selects a low-cholesterol diet to control CAD b. The nurse explains to the client that this procedure is being used in this specific case to a. assess the functional adequacy of the valves and heart muscle 44. high blood pressure c. headache b. bypass obstructed vessels d. open and dilate blocked coronary arteries b.The nurse teaches a client with unstable angina for a cardiac catheterization. States a need for bed rest for one week after discharge c. Emesis d. Explains signs and symptoms of myocardial infarction 47. including a. Replace NTG every 6 months
. assess the extent of arterial blockage c. Rib fracture 46. Outcome criteria include that the client a.The nurses teaches the client with angina about the common expected side effects of nitroglycerin. GI bleeding b. Which is not an appropriate health teaching to a patient prescribed with nitroglycerine (NTG): a. shortness of breath d. stomach cramps 45. Verbalizes safety precautions needed to prevent pacemaker malfunction d. MI c.
except: a. Take only up to 3 tablets of NTG d. Check for bleeding b. Measure the blood pressure c. Norepinephrine c. Assess the apical pulse b.b. Avoid engaging in contract sports or using power tools 50.Which of the following drugs is not used for the treatment of cardiac arrest? a. the most important responsibility of the nurse to the patient is to: a. Count the respiratory rate
. Before administering digoxin (Lanoxin) to a cardiac patient. Eat green leafy vegetables once a week c. Dopamine hydrochloride b. Always carry one or 2 tablets of NTG in your pocket for emergency need c.A client with a prescription of sodium warfarin (Coumadin) should be given the following instructions. Verify the doctor’s order d. Do not expose NTG to sun or extreme heat 48. Sodium bicarbonate d. Nitroglycerin 49. Inject the drug subcutaneously only d.