NSG 4100 (AH III) Exam 3|Questions With Correct A pt is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest
tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of
Answers|Verified this chest tube?
The nurse caring for a pt w/ and endotracheal tube recognizes several disadvantages of an
endotracheal tube. What would the nurse recognize as a disadvantage? a. to remove air from the pleural space
a. cognition is decreased b. to drain copious sputum secretions
b. Daily ABGs are necessary c. to monitor bleeding around the lungs
c. slight tracheal bleeding is anticipated d. to assist with mechanical ventilation - ✔A
d. the cough reflex is depressed - ✔D
A pt's plan of care specifies postural drainage. What action should the nurse perform when
providing this noninvasive therapy?
What would the critical care nurse recognize as a condition that may indicate a pt's need to
have a tracheotomy? a. administer the tx w/ the pt in a high Fowler's or semi-fowlers position
a. a pt has a respiratory rate of 10 breaths/min b. perform the procedure immediately following the pt's meals
b. a pt required permanent ventilation c. apply percussion firmly to bare skin to facilitate drainage
c. a pt exhibits sx of dyspnea d. assist the pt into a position that will allow gravity to move secretions - ✔D
d. a pt has respiratory acidosis - ✔B
While assessing the pt, the nurse observes constant bubbling in the water-seal chamber of the
pt's closed chest-drinagae system. What should the Nurs conclude?
The nurse is caring for a pt who is scheduled to have a thoracotomy. When planning
preoperative teaching, what info should the nurse communicate to the pt? a. the system is functioning normally
a. how to milk the chest tubing b. pt has a pneumothorax
b. how to splint the incision when coughing c. system has a leak
c. how to take prophylactic antibiotics correctly d. chest tube is obstructed - ✔C
d. how to manage the need for fluid restriction - ✔B
The nurse has admitted a pt who is scheduled for a thoracic resection. The nurse is providing
preoperative teaching and is discussing several diagnostic studies that will be required prior to
A nurse is educating a pt in anticipation of a procedure that will require a water-sealed chest surgery. Which study will be performed to determine whether the panned resection will leave
drainage system. What should the nurse tell the pt and the family that this drainage system is sufficient functioning lung tissue?
used for?
a. pulmonary function studies
a. maintaining a positive chest-wall pressure
b. exercise tolerance tests
b. monitoring pleural fluid osmolarity
c. arterial blood gas values
c. providing passive intrathoracic pressure
d. chest x-ray - ✔A
d. removing excess air and fluid - ✔D
,The nurse is discussing activity management w/ a pt who is postoperative following The home care nurse is visiting a pt newly discharged home after a lobectomy. What would be
thoracotomy. What instructions should the nurse give to the pt regarding activity immediately most important for the home care nurse to assess?
following discharge?
a. resumption of the pt's ADLs
a. walk 1 mile 3-4x a week
b. the family's willingness to care for the pt
b. use wights daily to increase arm strength
c. nutritional status and fluid balance
c. walk on a treadmill 30min daily
d. s/s of respiratory complications - ✔D
d. perform shoulder exercises 5x daily - ✔D
A pt is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching
The OR nurse is setting up a water-seal chest drainage system for a pt who has just had a includes what?
thoracotomy. The nurse knows that the amount of suction in the system is determined by the
a. correct use of a ventilator
water level. At what suction level should the nurse set the system?
b. correct use of incentive spirometry
a. 20 cm H2O
c. correct use of a mini-nebulizer
b. 15 cm H2O
c. 10 cm H2O c. correct technique for rhythmic breathing - ✔B
d. 5 cm H2O - ✔A
A nurse is teaching a pt how to perform flow type incentive spirometry prior to his scheduled
thoracic surgery. What instruction should the nurse provide to the pt?
The nurse is caring for a client w/ and endotracheal tube who is on a ventilator. When assessing
a. hold the spirometer at your lips and breathe in and out like you normally would
the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on
the tracheal wall? b. when you're ready, blow hard into the spirometer for as long as you can
a. between 10-15 mm Hg c. take a deep breath and then blow short, forceful breaths into the spirometer
b. between 15-20 mm Hg d. breathe in deeply through the spirometer, hold your breath briefly, and then exhale - ✔D
c. between 20-25 mm Hg
d. between 25-30 mm Hg - ✔B The nurse is assessing a pt who has a chest tube in place for the treatment of a pneumothorax.
The nurse observes that the water level in the water seal rises and falls in rhythm w/ the pt's
respiration's. How should the nurse best respond to this assessment finding?
A nurse educator is reviewing the indications for chest drainage systems w/ a group of medical
a. gently reinsert the chest tube 1-2cm and observe if the water level stabilizes
nurses. What indications should the nurses identify? Select all that apply.
b. inform the physician property that there is an imminent leak in the drainage system
a. post thoracotomy
c. encourage pt to do deep breathing and coughing exercises
b. spontaneous pneumothorax
c. need for postural drainage d. document that the chest drainage is operating as it is intended - ✔D
d. chest trauma resulting in pneumothorax
e. pleurisy - ✔A, B, D The home care nurse is assessing the home environment of a pt who will be discharged from
the hospital shortly after his laryngectomy. The nurse should inform the pt that he may need to
arrange for the installation of which system in his home?
, a. a humidification system b. protein level
b. an air conditioning system c. albumin level
c. a water purification system d. platelet count
d. a radiant heating system - ✔A e. glucose level - ✔B, C, E
The nurse is caring for a pt whose recent unexplained weight loss and hx of smoking have The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should
prompted diagnostic testing for cancer. What sx is most closely associated w/ the early stages the nurse best manage this risk?
of laryngeal caner?
a. facilitate total parenteral nutrition (TPN)
a. hoarseness
b. keep a complete suction setup at the bedside
b. dyspnea
c. feed the pt several small meals daily
c. dysphagia
d. refer the pt for occupational therapy - ✔B
d. frequent nosebleeds - ✔A
The nurse is providing care for a pt who has just been admitted to the post surgical unit
The nurse is conducting a presurgical interview for a pt w/ laryngeal cancer. The pt states that following a laryngecotomy. What assessment should the nurse prioritize?
he drinks approx 6-8 shots of vodka per day. it is imperative that the nurse inform the surgical
a. the pt's swallowing ability
team so the pt can be assessed for what?
b. the pt's airway patency
a. increased risk for infection
c. the pt's carotid pulses
b. delirium tremens
c. depression d. s/s of infection - ✔B
d. non-adherence to postop care - ✔B
The nurse has noted the emergency of a significant amount of fresh blood at the drain site of a
pt who is postoperative day 1 following total laryngecomy. How should the nurse respond to this
The nurse is caring for a pt who is post-op day 2 following a total laryngectomy for supraglottic development?
cancer. The nurse should prioritize what assessment?
a. remove the pt's drain and apply pressure w/ a sterile gauze
a. assessment of body image
b. assess the pt, reposition the pt supine, and apply wall suction to the drain
b. assessment of jugular venous pressure
c. rapidly assess the pt and notify the surgeon about the pt's bleeding
c. assessment of carotid pulse
d. administer a STAT dose of vitamin K to aid coagulation - ✔C
d. assessment of swallowing ability - ✔D
The nurse is creating a care plan for a pt who is status post-total laryngectomy. Much of the
The nurse is performing an assessment on a pt who has been diagnosed w/ cancer of the plan consists of a ling-term postoperative communication plan for alaryngeal communication.
larynx. Part of the nurses assessment addresses the pt's general state of nutrition. Which lab What form of alaryngeal communication will likely be chosen?
values would be assessed when determine the nutritional status of the pt? Select all that apply.
a. esophageal speech
a. WBC count
b. electric larynx
tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of
Answers|Verified this chest tube?
The nurse caring for a pt w/ and endotracheal tube recognizes several disadvantages of an
endotracheal tube. What would the nurse recognize as a disadvantage? a. to remove air from the pleural space
a. cognition is decreased b. to drain copious sputum secretions
b. Daily ABGs are necessary c. to monitor bleeding around the lungs
c. slight tracheal bleeding is anticipated d. to assist with mechanical ventilation - ✔A
d. the cough reflex is depressed - ✔D
A pt's plan of care specifies postural drainage. What action should the nurse perform when
providing this noninvasive therapy?
What would the critical care nurse recognize as a condition that may indicate a pt's need to
have a tracheotomy? a. administer the tx w/ the pt in a high Fowler's or semi-fowlers position
a. a pt has a respiratory rate of 10 breaths/min b. perform the procedure immediately following the pt's meals
b. a pt required permanent ventilation c. apply percussion firmly to bare skin to facilitate drainage
c. a pt exhibits sx of dyspnea d. assist the pt into a position that will allow gravity to move secretions - ✔D
d. a pt has respiratory acidosis - ✔B
While assessing the pt, the nurse observes constant bubbling in the water-seal chamber of the
pt's closed chest-drinagae system. What should the Nurs conclude?
The nurse is caring for a pt who is scheduled to have a thoracotomy. When planning
preoperative teaching, what info should the nurse communicate to the pt? a. the system is functioning normally
a. how to milk the chest tubing b. pt has a pneumothorax
b. how to splint the incision when coughing c. system has a leak
c. how to take prophylactic antibiotics correctly d. chest tube is obstructed - ✔C
d. how to manage the need for fluid restriction - ✔B
The nurse has admitted a pt who is scheduled for a thoracic resection. The nurse is providing
preoperative teaching and is discussing several diagnostic studies that will be required prior to
A nurse is educating a pt in anticipation of a procedure that will require a water-sealed chest surgery. Which study will be performed to determine whether the panned resection will leave
drainage system. What should the nurse tell the pt and the family that this drainage system is sufficient functioning lung tissue?
used for?
a. pulmonary function studies
a. maintaining a positive chest-wall pressure
b. exercise tolerance tests
b. monitoring pleural fluid osmolarity
c. arterial blood gas values
c. providing passive intrathoracic pressure
d. chest x-ray - ✔A
d. removing excess air and fluid - ✔D
,The nurse is discussing activity management w/ a pt who is postoperative following The home care nurse is visiting a pt newly discharged home after a lobectomy. What would be
thoracotomy. What instructions should the nurse give to the pt regarding activity immediately most important for the home care nurse to assess?
following discharge?
a. resumption of the pt's ADLs
a. walk 1 mile 3-4x a week
b. the family's willingness to care for the pt
b. use wights daily to increase arm strength
c. nutritional status and fluid balance
c. walk on a treadmill 30min daily
d. s/s of respiratory complications - ✔D
d. perform shoulder exercises 5x daily - ✔D
A pt is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching
The OR nurse is setting up a water-seal chest drainage system for a pt who has just had a includes what?
thoracotomy. The nurse knows that the amount of suction in the system is determined by the
a. correct use of a ventilator
water level. At what suction level should the nurse set the system?
b. correct use of incentive spirometry
a. 20 cm H2O
c. correct use of a mini-nebulizer
b. 15 cm H2O
c. 10 cm H2O c. correct technique for rhythmic breathing - ✔B
d. 5 cm H2O - ✔A
A nurse is teaching a pt how to perform flow type incentive spirometry prior to his scheduled
thoracic surgery. What instruction should the nurse provide to the pt?
The nurse is caring for a client w/ and endotracheal tube who is on a ventilator. When assessing
a. hold the spirometer at your lips and breathe in and out like you normally would
the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on
the tracheal wall? b. when you're ready, blow hard into the spirometer for as long as you can
a. between 10-15 mm Hg c. take a deep breath and then blow short, forceful breaths into the spirometer
b. between 15-20 mm Hg d. breathe in deeply through the spirometer, hold your breath briefly, and then exhale - ✔D
c. between 20-25 mm Hg
d. between 25-30 mm Hg - ✔B The nurse is assessing a pt who has a chest tube in place for the treatment of a pneumothorax.
The nurse observes that the water level in the water seal rises and falls in rhythm w/ the pt's
respiration's. How should the nurse best respond to this assessment finding?
A nurse educator is reviewing the indications for chest drainage systems w/ a group of medical
a. gently reinsert the chest tube 1-2cm and observe if the water level stabilizes
nurses. What indications should the nurses identify? Select all that apply.
b. inform the physician property that there is an imminent leak in the drainage system
a. post thoracotomy
c. encourage pt to do deep breathing and coughing exercises
b. spontaneous pneumothorax
c. need for postural drainage d. document that the chest drainage is operating as it is intended - ✔D
d. chest trauma resulting in pneumothorax
e. pleurisy - ✔A, B, D The home care nurse is assessing the home environment of a pt who will be discharged from
the hospital shortly after his laryngectomy. The nurse should inform the pt that he may need to
arrange for the installation of which system in his home?
, a. a humidification system b. protein level
b. an air conditioning system c. albumin level
c. a water purification system d. platelet count
d. a radiant heating system - ✔A e. glucose level - ✔B, C, E
The nurse is caring for a pt whose recent unexplained weight loss and hx of smoking have The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should
prompted diagnostic testing for cancer. What sx is most closely associated w/ the early stages the nurse best manage this risk?
of laryngeal caner?
a. facilitate total parenteral nutrition (TPN)
a. hoarseness
b. keep a complete suction setup at the bedside
b. dyspnea
c. feed the pt several small meals daily
c. dysphagia
d. refer the pt for occupational therapy - ✔B
d. frequent nosebleeds - ✔A
The nurse is providing care for a pt who has just been admitted to the post surgical unit
The nurse is conducting a presurgical interview for a pt w/ laryngeal cancer. The pt states that following a laryngecotomy. What assessment should the nurse prioritize?
he drinks approx 6-8 shots of vodka per day. it is imperative that the nurse inform the surgical
a. the pt's swallowing ability
team so the pt can be assessed for what?
b. the pt's airway patency
a. increased risk for infection
c. the pt's carotid pulses
b. delirium tremens
c. depression d. s/s of infection - ✔B
d. non-adherence to postop care - ✔B
The nurse has noted the emergency of a significant amount of fresh blood at the drain site of a
pt who is postoperative day 1 following total laryngecomy. How should the nurse respond to this
The nurse is caring for a pt who is post-op day 2 following a total laryngectomy for supraglottic development?
cancer. The nurse should prioritize what assessment?
a. remove the pt's drain and apply pressure w/ a sterile gauze
a. assessment of body image
b. assess the pt, reposition the pt supine, and apply wall suction to the drain
b. assessment of jugular venous pressure
c. rapidly assess the pt and notify the surgeon about the pt's bleeding
c. assessment of carotid pulse
d. administer a STAT dose of vitamin K to aid coagulation - ✔C
d. assessment of swallowing ability - ✔D
The nurse is creating a care plan for a pt who is status post-total laryngectomy. Much of the
The nurse is performing an assessment on a pt who has been diagnosed w/ cancer of the plan consists of a ling-term postoperative communication plan for alaryngeal communication.
larynx. Part of the nurses assessment addresses the pt's general state of nutrition. Which lab What form of alaryngeal communication will likely be chosen?
values would be assessed when determine the nutritional status of the pt? Select all that apply.
a. esophageal speech
a. WBC count
b. electric larynx
