EXAM 1 - MED SURG 3 QUESTIONS AND
CORRECT ANSWERS
WhileA2assessingA2aA2clientA2whoA2isA212A2hoursA2postoperativeA2afterA2aA2thoracotomyA2f
orA2lungA2cancer,A2aA2nurseA2noticesA2thatA2theA2lowerA2chestA2tubeA2isA2dislodged.A2Whic
hA2actionA2shouldA2theA2nurseA2takeA2first?A2
a.A2AssessA2forA2drainageA2fromA2theA2site.A2
b.A2CoverA2theA2insertionA2siteA2withA2sterileA2gauze.A2
c.A2ContactA2theA2providerA2andA2obtainA2aA2sutureA2kit.A2
d.A2ReinsertA2theA2tubeA2usingA2sterileA2techniqueA2-A2Ans--
ANS:A2BA2ImmediatelyA2coveringA2theA2insertionA2siteA2helpsA2preventA2airA2fromA2enterin
gA2theA2pleuralA2spaceA2andA2causingA2aA2pneumothorax.A2TheA2areaA2willA2notA2resealA2
quicklyA2enoughA2toA2preventA2airA2fromA2enteringA2theA2chest.A2TheA2nurseA2shouldA2notA
2leaveA2theA2clientA2toA2obtainA2aA2sutureA2kit.A2AnA2occlusiveA2dressingA2mayA2causeA2aA2
tensionA2pneumothorax.A2TheA2siteA2shouldA2onlyA2beA2assessedA2afterA2theA2insertionA2s
iteA2isA2covered.A2TheA2providerA2shouldA2beA2calledA2toA2reinsertA2theA2chestA2tubeA2orA2p
rescribeA2otherA2treatmentA2options.
AA2nurseA2caresA2forA2aA2clientA2whoA2hadA2aA2chestA2tubeA2placedA26A2hoursA2agoA2andA2
refusesA2toA2takeA2deepA2breathsA2becauseA2ofA2theA2pain.A2WhichA2actionA2shouldA2theA2
nurseA2take?A2
a.A2AmbulateA2theA2clientA2inA2theA2hallwayA2toA2promoteA2deepA2breathing.A2
b.A2AuscultateA2theA2clientsA2anteriorA2andA2posteriorA2lungA2fields.A2
c.A2EncourageA2theA2clientA2toA2takeA2shallowA2breathsA2toA2helpA2withA2theA2pain.A2
d.A2AdministerA2painA2medicationA2andA2encourageA2theA2clientA2toA2takeA2deepA2breaths.
A2-A2Ans--
ANS:A2DA2AA2chestA2tubeA2isA2placedA2inA2theA2pleuralA2spaceA2andA2mayA2beA2uncomfort
ableA2forA2aA2client.A2TheA2nurseA2shouldA2provideA2painA2medicationA2toA2minimizeA2disc
omfortA2andA2encourageA2theA2clientA2toA2takeA2deepA2breaths.A2TheA2otherA2responsesA2
doA2notA2addressA2theA2clientsA2discomfortA2andA2needA2toA2takeA2deepA2breathsA2toA2pre
ventA2complications.
AA2nurseA2caresA2forA2aA2clientA2whoA2hasA2aA2chestA2tube.A2WhenA2wouldA2thisA2clientA2b
eA2atA2highestA2riskA2forA2developingA2aA2pneumothorax?A2
a.A2WhenA2theA2insertionA2siteA2becomesA2redA2andA2warmA2toA2theA2touchA2
b.A2WhenA2theA2tubeA2drainageA2decreasesA2andA2becomesA2sanguineousA2
c.A2WhenA2theA2clientA2experiencesA2painA2atA2theA2insertionA2siteA2
d.A2WhenA2theA2tubeA2becomesA2disconnectedA2fromA2theA2drainageA2systemA2-A2Ans--
ANS:A2DA2IntrathoracicA2pressuresA2areA2lessA2thanA2atmosphericA2pressures;A2therefore,
A2ifA2theA2chestA2tubeA2becomesA2disconnectedA2fromA2theA2drainageA2system,A2airA2canA2
beA2suckedA2intoA2theA2pleuralA2spaceA2andA2causeA2aA2pneumothorax.A2AA2red,A2warm,A2
andA2painfulA2insertionA2siteA2doesA2notA2increaseA2theA2clientsA2riskA2forA2aA2pneumothor
ax.A2TubeA2drainageA2shouldA2decreaseA2andA2becomeA2serousA2asA2theA2clientA2heals.A2
,SanguineousA2drainageA2isA2aA2signA2ofA2bleedingA2butA2doesA2notA2increaseA2theA2clients
A2riskA2forA2aA2pneumothorax.
AA2nurseA2caresA2forA2aA2clientA2whoA2hasA2aA2pleuralA2chestA2tube.A2WhichA2actionA2shou
ldA2theA2nurseA2takeA2toA2ensureA2safeA2useA2ofA2thisA2equipment?
a.A2StripA2theA2tubingA2toA2minimizeA2clotA2formationA2andA2ensureA2patency.A2
b.A2SecureA2tubingA2junctionsA2withA2clampsA2toA2preventA2accidentalA2disconnections.A2
c.A2ConnectA2theA2chestA2tubeA2toA2wallA2suctionA2atA2theA2levelA2prescribedA2byA2theA2pro
vider.A2
d.A2KeepA2paddedA2clampsA2atA2theA2bedsideA2forA2useA2ifA2theA2drainageA2systemA2isA2int
errupted.A2-A2Ans--
ANS:A2DA2PaddedA2clampsA2shouldA2beA2keptA2atA2theA2bedsideA2forA2useA2ifA2theA2draina
geA2systemA2becomesA2dislodgedA2orA2isA2interrupted.A2TheA2nurseA2shouldA2neverA2strip
A2theA2tubing.A2TubingA2junctionsA2shouldA2beA2taped,A2notA2clamped.A2WallA2suctionA2sho
uldA2beA2setA2atA2theA2levelA2indicatedA2byA2theA2devicesA2manufacturer,A2notA2theA2provid
er.
AA2nurseA2evaluatesA2theA2followingA2arterialA2bloodA2gasA2andA2vitalA2signA2resultsA2forA2
aA2clientA2withA2chronicA2obstructiveA2pulmonaryA2diseaseA2(COPD).
ArterialA2BloodA2GasA2Results:A2
pHA2=A27.32A2PaCO2A2=A262A2mmA2HgA2PaO2A2=A246A2mmA2HgA2HCO3A2=A228A2mEq/LA2
VitalA2Signs:A2
HeartA2rateA2=A2110A2beats/minA2RespiratoryA2rateA2=A212A2breaths/
minA2BloodA2pressureA2=A2145/65A2mmA2HgA2OxygenA2saturationA2=A276%A2
WhichA2actionA2shouldA2theA2nurseA2takeA2first?A2
a.A2AdministerA2aA2short-actingA2beta2A2agonistA2inhaler.A2
b.A2DocumentA2theA2findingsA2asA2normalA2forA2aA2clientA2withA2COPD.A2
c.A2TeachA2theA2clientA2diaphragmaticA2breathingA2techniques.A2
d.A2InitiateA2oxygenationA2therapyA2toA2increaseA2saturationA2toA292%A2-A2Ans--
ANS:A2DA2OxygenA2shouldA2beA2administeredA2toA2aA2clientA2whoA2isA2hypoxicA2evenA2ifA2t
heA2clientA2hasA2COPDA2andA2isA2aA2carbonA2dioxideA2retainer.A2TheA2otherA2intervention
sA2doA2notA2addressA2theA2clientsA2hypoxia,A2whichA2isA2theA2priority.
AA2nurseA2assessesA2aA2clientA2whoA2hasA2aA2mediastinalA2chestA2tube.A2WhichA2sympto
msA2requireA2theA2nursesA2immediateA2intervention?A2(SelectA2allA2thatA2apply.)A2
a.A2ProductionA2ofA2pinkA2sputumA2
b.A2TrachealA2deviationA2
c.A2PainA2atA2insertionA2siteA2
d.A2SuddenA2onsetA2ofA2shortnessA2ofA2breathA2
e.A2DrainageA2greaterA2thanA270A2mL/hrA2
f.A2DisconnectionA2atA2YA2siteA2-A2Ans--
ANS:A2B,A2D,A2E,A2FA2ImmediateA2interventionA2isA2warrantedA2ifA2theA2clientA2hasA2trache
alA2deviationA2becauseA2thisA2couldA2indicateA2aA2tensionA2pneumothorax.A2SuddenA2shor
tnessA2ofA2breathA2couldA2indicateA2dislodgmentA2ofA2theA2tube,A2occlusionA2ofA2theA2tube,
A2orA2pneumothorax.A2DrainageA2greaterA2thanA270A2mL/
hrA2couldA2indicateA2hemorrhage.A2DisconnectionA2atA2theA2YA2siteA2couldA2resultA2inA2airA
,2enteringA2theA2tubing.A2ProductionA2ofA2pinkA2sputum,A2oxygenA2saturationA2lessA2thanA2
95%,A2andA2painA2atA2theA2insertionA2siteA2areA2notA2signs/
symptomsA2thatA2wouldA2requireA2immediateA2intervention.
AA2nurseA2assessesA2aA2clientA2whoA2hasA2aA2chestA2tube.A2ForA2whichA2manifestationsA2
shouldA2theA2nurseA2immediatelyA2intervene?A2(SelectA2allA2thatA2apply.)A2
a.A2ProductionA2ofA2pinkA2sputumA2
b.A2TrachealA2deviationA2
c.A2SuddenA2onsetA2ofA2shortnessA2ofA2breathA2
d.A2PainA2atA2insertionA2siteA2
e.A2DrainageA2ofA275A2mL/hrA2-A2Ans--
ANS:A2B,A2CA2TrachealA2deviationA2andA2suddenA2onsetA2ofA2shortnessA2ofA2breathA2areA2
manifestationsA2ofA2aA2tensionA2pneumothorax.A2TheA2nurseA2mustA2interveneA2immediat
elyA2forA2thisA2emergencyA2situation.A2PinkA2sputumA2isA2associatedA2withA2pulmonaryA2e
demaA2andA2isA2notA2aA2complicationA2ofA2aA2chestA2tube.A2PainA2atA2theA2insertionA2siteA2
andA2drainageA2ofA275A2mL/hrA2areA2normalA2findingsA2withA2aA2chestA2tube.
TheA2peakA2pressureA2alarmA2isA2soundingA2onA2theA2ventilatorA2ofA2theA2clientA2withA2aA2r
ecentA2tracheostomy.A2WhatA2interventionA2shouldA2beA2doneA2first?
A.A2AssessA2theA2client'sA2respiratoryA2status
B.A2DecreaseA2theA2sensitivityA2ofA2theA2alarm
C.A2EnsureA2thatA2theA2connectingA2tubingA2isA2notA2kinked
D.A2SuctionA2theA2clientA2-A2Ans--A
TheA2clientA2mustA2alwaysA2beA2assessedA2beforeA2attentionA2isA2turnedA2toA2equipment.
TheA2clientA2withA2respiratoryA2failureA2hasA2beenA2intubatedA2andA2placedA2onA2aA2ventila
torA2andA2isA2requiringA2100%A2oxygenA2deliveryA2toA2maintainA2adequateA2oxygenation.A2
Twenty-fourA2hoursA2later,A2theA2nurseA2notesA2new-
onsetA2cracklesA2andA2decreasedA2breathA2sounds,A2andA2theA2mostA2recentA2ABGsA2sho
wA2aA2PaO2A2levelA2ofA295A2mmA2Hg.A2TheA2ventilatorA2isA2notA2setA2toA2provideA2positiveA
2end-expiratory A2pressureA2(PEEP).A2WhyA2isA2theA2nurseA2concerned?
A.A2TheA2lowA2PaO2A2levelA2mayA2resultA2inA2oxygenA2toxicity
B.A2TheA2100%A2oxygenA2deliveryA2requirementA2indicatesA2immediateA2extubation
C.A2LungA2soundsA2mayA2indicateA2absorptionA2atelectasis
D.A2TheA2levelA2ofA2oxygenA2deliveryA2mayA2indicateA2absorptionA2atelectasisA2-A2Ans--C
HighA2levelsA2ofA2oxygenA2deliveryA2canA2resultA2inA2collapsedA2alveoliA2andA2absorptionA2
atelectasis.A2PEEPA2canA2helpA2alveoliA2remainA2properlyA2inflated.
TheA2medicalA2nurseA2isA2creatingA2theA2careA2planA2ofA2anA2adultA2patientA2requiringA2me
chanicalA2ventilation.A2WhatA2nursingA2actionA2isA2mostA2appropriate?
A)A2KeepA2theA2patientA2inA2aA2lowA2FowlersA2position.
B)A2PerformA2tracheostomyA2careA2atA2leastA2onceA2perA2day.
C)A2MaintainA2continuousA2bedrest.
, D)A2MonitorA2cuffA2pressureA2everyA28A2hours.A2-A2Ans--D
TheA2acuteA2medicalA2nurseA2isA2preparingA2toA2weanA2aA2patientA2fromA2theA2ventilator.A2
WhichA2assessmentA2parameterA2isA2mostA2importantA2forA2theA2nurseA2toA2assess?
A)A2FluidA2intakeA2forA2theA2lastA224A2hours
B)A2BaselineA2arterialA2bloodA2gasA2(ABG)A2levels
C)A2PriorA2outcomesA2ofA2weaning
D)A2ElectrocardiogramA2(ECG)A2resultsA2-A2Ans--B
AA2patientA2recoveringA2fromA2thoracicA2surgeryA2isA2onA2long-
termA2mechanicalA2ventilationA2andA2becomesA2veryA2frustratedA2whenA2heA2triesA2toA2co
mmunicate.A2WhatA2interventionA2shouldA2theA2nurseA2performA2toA2assistA2theA2patient?
A)A2AssureA2theA2patientA2thatA2everythingA2willA2beA2allA2rightA2andA2thatA2remainingA2cal
mA2isA2theA2bestA2strategy.
B)A2AskA2aA2familyA2memberA2toA2interpretA2whatA2theA2patientA2isA2tryingA2toA2communica
te.
C)A2AskA2theA2physicianA2toA2weanA2theA2patientA2offA2theA2mechanicalA2ventilatorA2toA2all
owA2theA2patientA2toA2speakA2freely.
D)A2ExpressA2empathyA2andA2thenA2encourageA2theA2patientA2toA2write,A2useA2aA2pictureA2
board,A2orA2spellA2wordsA2withA2anA2alphabetA2board.A2-A2Ans--D
TheA2physicianA2hasA2orderedA2continuousA2positiveA2airwayA2pressureA2(CPAP)A2withA2t
heA2deliveryA2ofA2aA2patientsA2high-
flowA2oxygenA2therapy.A2TheA2patientA2asksA2theA2nurseA2whatA2theA2benefitA2ofA2CPAPA2i
s.A2WhatA2wouldA2beA2theA2nursesA2bestA2response?
A)A2CPAPA2allowsA2aA2higherA2percentageA2ofA2oxygenA2toA2beA2safelyA2used.
B)A2CPAPA2allowsA2aA2lowerA2percentageA2ofA2oxygenA2toA2beA2usedA2withA2aA2similarA2eff
ect.
C)A2CPAPA2allowsA2forA2greaterA2humidificationA2ofA2theA2oxygenA2thatA2isA2administered.
D)A2CPAPA2allowsA2forA2theA2eliminationA2ofA2bacterialA2growthA2inA2oxygenA2deliveryA2sy
stems.A2-A2Ans--B
TheA2nurseA2isA2caringA2forA2aA2patientA2whoA2isA2readyA2toA2beA2weanedA2fromA2theA2vent
ilator.A2InA2preparingA2toA2assistA2inA2theA2collaborativeA2processA2ofA2weaningA2theA2patie
ntA2fromA2aA2ventilator,A2theA2nurseA2isA2awareA2thatA2theA2weaningA2ofA2theA2patientA2willA
2progressA2inA2whatA2order?
A)A2RemovalA2fromA2theA2ventilator,A2tube,A2andA2thenA2oxygen
B)A2RemovalA2fromA2oxygen,A2ventilator,A2andA2thenA2tube
C)A2RemovalA2ofA2theA2tube,A2oxygen,A2andA2thenA2ventilator
D)A2RemovalA2fromA2oxygen,A2tube,A2andA2thenA2ventilatorA2-A2Ans--A
CORRECT ANSWERS
WhileA2assessingA2aA2clientA2whoA2isA212A2hoursA2postoperativeA2afterA2aA2thoracotomyA2f
orA2lungA2cancer,A2aA2nurseA2noticesA2thatA2theA2lowerA2chestA2tubeA2isA2dislodged.A2Whic
hA2actionA2shouldA2theA2nurseA2takeA2first?A2
a.A2AssessA2forA2drainageA2fromA2theA2site.A2
b.A2CoverA2theA2insertionA2siteA2withA2sterileA2gauze.A2
c.A2ContactA2theA2providerA2andA2obtainA2aA2sutureA2kit.A2
d.A2ReinsertA2theA2tubeA2usingA2sterileA2techniqueA2-A2Ans--
ANS:A2BA2ImmediatelyA2coveringA2theA2insertionA2siteA2helpsA2preventA2airA2fromA2enterin
gA2theA2pleuralA2spaceA2andA2causingA2aA2pneumothorax.A2TheA2areaA2willA2notA2resealA2
quicklyA2enoughA2toA2preventA2airA2fromA2enteringA2theA2chest.A2TheA2nurseA2shouldA2notA
2leaveA2theA2clientA2toA2obtainA2aA2sutureA2kit.A2AnA2occlusiveA2dressingA2mayA2causeA2aA2
tensionA2pneumothorax.A2TheA2siteA2shouldA2onlyA2beA2assessedA2afterA2theA2insertionA2s
iteA2isA2covered.A2TheA2providerA2shouldA2beA2calledA2toA2reinsertA2theA2chestA2tubeA2orA2p
rescribeA2otherA2treatmentA2options.
AA2nurseA2caresA2forA2aA2clientA2whoA2hadA2aA2chestA2tubeA2placedA26A2hoursA2agoA2andA2
refusesA2toA2takeA2deepA2breathsA2becauseA2ofA2theA2pain.A2WhichA2actionA2shouldA2theA2
nurseA2take?A2
a.A2AmbulateA2theA2clientA2inA2theA2hallwayA2toA2promoteA2deepA2breathing.A2
b.A2AuscultateA2theA2clientsA2anteriorA2andA2posteriorA2lungA2fields.A2
c.A2EncourageA2theA2clientA2toA2takeA2shallowA2breathsA2toA2helpA2withA2theA2pain.A2
d.A2AdministerA2painA2medicationA2andA2encourageA2theA2clientA2toA2takeA2deepA2breaths.
A2-A2Ans--
ANS:A2DA2AA2chestA2tubeA2isA2placedA2inA2theA2pleuralA2spaceA2andA2mayA2beA2uncomfort
ableA2forA2aA2client.A2TheA2nurseA2shouldA2provideA2painA2medicationA2toA2minimizeA2disc
omfortA2andA2encourageA2theA2clientA2toA2takeA2deepA2breaths.A2TheA2otherA2responsesA2
doA2notA2addressA2theA2clientsA2discomfortA2andA2needA2toA2takeA2deepA2breathsA2toA2pre
ventA2complications.
AA2nurseA2caresA2forA2aA2clientA2whoA2hasA2aA2chestA2tube.A2WhenA2wouldA2thisA2clientA2b
eA2atA2highestA2riskA2forA2developingA2aA2pneumothorax?A2
a.A2WhenA2theA2insertionA2siteA2becomesA2redA2andA2warmA2toA2theA2touchA2
b.A2WhenA2theA2tubeA2drainageA2decreasesA2andA2becomesA2sanguineousA2
c.A2WhenA2theA2clientA2experiencesA2painA2atA2theA2insertionA2siteA2
d.A2WhenA2theA2tubeA2becomesA2disconnectedA2fromA2theA2drainageA2systemA2-A2Ans--
ANS:A2DA2IntrathoracicA2pressuresA2areA2lessA2thanA2atmosphericA2pressures;A2therefore,
A2ifA2theA2chestA2tubeA2becomesA2disconnectedA2fromA2theA2drainageA2system,A2airA2canA2
beA2suckedA2intoA2theA2pleuralA2spaceA2andA2causeA2aA2pneumothorax.A2AA2red,A2warm,A2
andA2painfulA2insertionA2siteA2doesA2notA2increaseA2theA2clientsA2riskA2forA2aA2pneumothor
ax.A2TubeA2drainageA2shouldA2decreaseA2andA2becomeA2serousA2asA2theA2clientA2heals.A2
,SanguineousA2drainageA2isA2aA2signA2ofA2bleedingA2butA2doesA2notA2increaseA2theA2clients
A2riskA2forA2aA2pneumothorax.
AA2nurseA2caresA2forA2aA2clientA2whoA2hasA2aA2pleuralA2chestA2tube.A2WhichA2actionA2shou
ldA2theA2nurseA2takeA2toA2ensureA2safeA2useA2ofA2thisA2equipment?
a.A2StripA2theA2tubingA2toA2minimizeA2clotA2formationA2andA2ensureA2patency.A2
b.A2SecureA2tubingA2junctionsA2withA2clampsA2toA2preventA2accidentalA2disconnections.A2
c.A2ConnectA2theA2chestA2tubeA2toA2wallA2suctionA2atA2theA2levelA2prescribedA2byA2theA2pro
vider.A2
d.A2KeepA2paddedA2clampsA2atA2theA2bedsideA2forA2useA2ifA2theA2drainageA2systemA2isA2int
errupted.A2-A2Ans--
ANS:A2DA2PaddedA2clampsA2shouldA2beA2keptA2atA2theA2bedsideA2forA2useA2ifA2theA2draina
geA2systemA2becomesA2dislodgedA2orA2isA2interrupted.A2TheA2nurseA2shouldA2neverA2strip
A2theA2tubing.A2TubingA2junctionsA2shouldA2beA2taped,A2notA2clamped.A2WallA2suctionA2sho
uldA2beA2setA2atA2theA2levelA2indicatedA2byA2theA2devicesA2manufacturer,A2notA2theA2provid
er.
AA2nurseA2evaluatesA2theA2followingA2arterialA2bloodA2gasA2andA2vitalA2signA2resultsA2forA2
aA2clientA2withA2chronicA2obstructiveA2pulmonaryA2diseaseA2(COPD).
ArterialA2BloodA2GasA2Results:A2
pHA2=A27.32A2PaCO2A2=A262A2mmA2HgA2PaO2A2=A246A2mmA2HgA2HCO3A2=A228A2mEq/LA2
VitalA2Signs:A2
HeartA2rateA2=A2110A2beats/minA2RespiratoryA2rateA2=A212A2breaths/
minA2BloodA2pressureA2=A2145/65A2mmA2HgA2OxygenA2saturationA2=A276%A2
WhichA2actionA2shouldA2theA2nurseA2takeA2first?A2
a.A2AdministerA2aA2short-actingA2beta2A2agonistA2inhaler.A2
b.A2DocumentA2theA2findingsA2asA2normalA2forA2aA2clientA2withA2COPD.A2
c.A2TeachA2theA2clientA2diaphragmaticA2breathingA2techniques.A2
d.A2InitiateA2oxygenationA2therapyA2toA2increaseA2saturationA2toA292%A2-A2Ans--
ANS:A2DA2OxygenA2shouldA2beA2administeredA2toA2aA2clientA2whoA2isA2hypoxicA2evenA2ifA2t
heA2clientA2hasA2COPDA2andA2isA2aA2carbonA2dioxideA2retainer.A2TheA2otherA2intervention
sA2doA2notA2addressA2theA2clientsA2hypoxia,A2whichA2isA2theA2priority.
AA2nurseA2assessesA2aA2clientA2whoA2hasA2aA2mediastinalA2chestA2tube.A2WhichA2sympto
msA2requireA2theA2nursesA2immediateA2intervention?A2(SelectA2allA2thatA2apply.)A2
a.A2ProductionA2ofA2pinkA2sputumA2
b.A2TrachealA2deviationA2
c.A2PainA2atA2insertionA2siteA2
d.A2SuddenA2onsetA2ofA2shortnessA2ofA2breathA2
e.A2DrainageA2greaterA2thanA270A2mL/hrA2
f.A2DisconnectionA2atA2YA2siteA2-A2Ans--
ANS:A2B,A2D,A2E,A2FA2ImmediateA2interventionA2isA2warrantedA2ifA2theA2clientA2hasA2trache
alA2deviationA2becauseA2thisA2couldA2indicateA2aA2tensionA2pneumothorax.A2SuddenA2shor
tnessA2ofA2breathA2couldA2indicateA2dislodgmentA2ofA2theA2tube,A2occlusionA2ofA2theA2tube,
A2orA2pneumothorax.A2DrainageA2greaterA2thanA270A2mL/
hrA2couldA2indicateA2hemorrhage.A2DisconnectionA2atA2theA2YA2siteA2couldA2resultA2inA2airA
,2enteringA2theA2tubing.A2ProductionA2ofA2pinkA2sputum,A2oxygenA2saturationA2lessA2thanA2
95%,A2andA2painA2atA2theA2insertionA2siteA2areA2notA2signs/
symptomsA2thatA2wouldA2requireA2immediateA2intervention.
AA2nurseA2assessesA2aA2clientA2whoA2hasA2aA2chestA2tube.A2ForA2whichA2manifestationsA2
shouldA2theA2nurseA2immediatelyA2intervene?A2(SelectA2allA2thatA2apply.)A2
a.A2ProductionA2ofA2pinkA2sputumA2
b.A2TrachealA2deviationA2
c.A2SuddenA2onsetA2ofA2shortnessA2ofA2breathA2
d.A2PainA2atA2insertionA2siteA2
e.A2DrainageA2ofA275A2mL/hrA2-A2Ans--
ANS:A2B,A2CA2TrachealA2deviationA2andA2suddenA2onsetA2ofA2shortnessA2ofA2breathA2areA2
manifestationsA2ofA2aA2tensionA2pneumothorax.A2TheA2nurseA2mustA2interveneA2immediat
elyA2forA2thisA2emergencyA2situation.A2PinkA2sputumA2isA2associatedA2withA2pulmonaryA2e
demaA2andA2isA2notA2aA2complicationA2ofA2aA2chestA2tube.A2PainA2atA2theA2insertionA2siteA2
andA2drainageA2ofA275A2mL/hrA2areA2normalA2findingsA2withA2aA2chestA2tube.
TheA2peakA2pressureA2alarmA2isA2soundingA2onA2theA2ventilatorA2ofA2theA2clientA2withA2aA2r
ecentA2tracheostomy.A2WhatA2interventionA2shouldA2beA2doneA2first?
A.A2AssessA2theA2client'sA2respiratoryA2status
B.A2DecreaseA2theA2sensitivityA2ofA2theA2alarm
C.A2EnsureA2thatA2theA2connectingA2tubingA2isA2notA2kinked
D.A2SuctionA2theA2clientA2-A2Ans--A
TheA2clientA2mustA2alwaysA2beA2assessedA2beforeA2attentionA2isA2turnedA2toA2equipment.
TheA2clientA2withA2respiratoryA2failureA2hasA2beenA2intubatedA2andA2placedA2onA2aA2ventila
torA2andA2isA2requiringA2100%A2oxygenA2deliveryA2toA2maintainA2adequateA2oxygenation.A2
Twenty-fourA2hoursA2later,A2theA2nurseA2notesA2new-
onsetA2cracklesA2andA2decreasedA2breathA2sounds,A2andA2theA2mostA2recentA2ABGsA2sho
wA2aA2PaO2A2levelA2ofA295A2mmA2Hg.A2TheA2ventilatorA2isA2notA2setA2toA2provideA2positiveA
2end-expiratory A2pressureA2(PEEP).A2WhyA2isA2theA2nurseA2concerned?
A.A2TheA2lowA2PaO2A2levelA2mayA2resultA2inA2oxygenA2toxicity
B.A2TheA2100%A2oxygenA2deliveryA2requirementA2indicatesA2immediateA2extubation
C.A2LungA2soundsA2mayA2indicateA2absorptionA2atelectasis
D.A2TheA2levelA2ofA2oxygenA2deliveryA2mayA2indicateA2absorptionA2atelectasisA2-A2Ans--C
HighA2levelsA2ofA2oxygenA2deliveryA2canA2resultA2inA2collapsedA2alveoliA2andA2absorptionA2
atelectasis.A2PEEPA2canA2helpA2alveoliA2remainA2properlyA2inflated.
TheA2medicalA2nurseA2isA2creatingA2theA2careA2planA2ofA2anA2adultA2patientA2requiringA2me
chanicalA2ventilation.A2WhatA2nursingA2actionA2isA2mostA2appropriate?
A)A2KeepA2theA2patientA2inA2aA2lowA2FowlersA2position.
B)A2PerformA2tracheostomyA2careA2atA2leastA2onceA2perA2day.
C)A2MaintainA2continuousA2bedrest.
, D)A2MonitorA2cuffA2pressureA2everyA28A2hours.A2-A2Ans--D
TheA2acuteA2medicalA2nurseA2isA2preparingA2toA2weanA2aA2patientA2fromA2theA2ventilator.A2
WhichA2assessmentA2parameterA2isA2mostA2importantA2forA2theA2nurseA2toA2assess?
A)A2FluidA2intakeA2forA2theA2lastA224A2hours
B)A2BaselineA2arterialA2bloodA2gasA2(ABG)A2levels
C)A2PriorA2outcomesA2ofA2weaning
D)A2ElectrocardiogramA2(ECG)A2resultsA2-A2Ans--B
AA2patientA2recoveringA2fromA2thoracicA2surgeryA2isA2onA2long-
termA2mechanicalA2ventilationA2andA2becomesA2veryA2frustratedA2whenA2heA2triesA2toA2co
mmunicate.A2WhatA2interventionA2shouldA2theA2nurseA2performA2toA2assistA2theA2patient?
A)A2AssureA2theA2patientA2thatA2everythingA2willA2beA2allA2rightA2andA2thatA2remainingA2cal
mA2isA2theA2bestA2strategy.
B)A2AskA2aA2familyA2memberA2toA2interpretA2whatA2theA2patientA2isA2tryingA2toA2communica
te.
C)A2AskA2theA2physicianA2toA2weanA2theA2patientA2offA2theA2mechanicalA2ventilatorA2toA2all
owA2theA2patientA2toA2speakA2freely.
D)A2ExpressA2empathyA2andA2thenA2encourageA2theA2patientA2toA2write,A2useA2aA2pictureA2
board,A2orA2spellA2wordsA2withA2anA2alphabetA2board.A2-A2Ans--D
TheA2physicianA2hasA2orderedA2continuousA2positiveA2airwayA2pressureA2(CPAP)A2withA2t
heA2deliveryA2ofA2aA2patientsA2high-
flowA2oxygenA2therapy.A2TheA2patientA2asksA2theA2nurseA2whatA2theA2benefitA2ofA2CPAPA2i
s.A2WhatA2wouldA2beA2theA2nursesA2bestA2response?
A)A2CPAPA2allowsA2aA2higherA2percentageA2ofA2oxygenA2toA2beA2safelyA2used.
B)A2CPAPA2allowsA2aA2lowerA2percentageA2ofA2oxygenA2toA2beA2usedA2withA2aA2similarA2eff
ect.
C)A2CPAPA2allowsA2forA2greaterA2humidificationA2ofA2theA2oxygenA2thatA2isA2administered.
D)A2CPAPA2allowsA2forA2theA2eliminationA2ofA2bacterialA2growthA2inA2oxygenA2deliveryA2sy
stems.A2-A2Ans--B
TheA2nurseA2isA2caringA2forA2aA2patientA2whoA2isA2readyA2toA2beA2weanedA2fromA2theA2vent
ilator.A2InA2preparingA2toA2assistA2inA2theA2collaborativeA2processA2ofA2weaningA2theA2patie
ntA2fromA2aA2ventilator,A2theA2nurseA2isA2awareA2thatA2theA2weaningA2ofA2theA2patientA2willA
2progressA2inA2whatA2order?
A)A2RemovalA2fromA2theA2ventilator,A2tube,A2andA2thenA2oxygen
B)A2RemovalA2fromA2oxygen,A2ventilator,A2andA2thenA2tube
C)A2RemovalA2ofA2theA2tube,A2oxygen,A2andA2thenA2ventilator
D)A2RemovalA2fromA2oxygen,A2tube,A2andA2thenA2ventilatorA2-A2Ans--A
