NURS 3725: Clinical Integration – Midterm
Exam With Complete Solutions
What is the LEARNS model - ANSWER Listen, Establish, Adopt, Reinforce,
Name, Strengthen
What learning theory is the LEARNS model based on - ANSWER social
constructivism learning theory
What are four steps to motivational interviewing - ANSWER ask permission,
listen, summarize, invite
What are the "My Diabetes Vital Signs" - ANSWER ABCDESSS
A1C 7% or less
Blood pressure less than 130/80
Cholesterol less than 2.0 mmol/L
Drugs for decreasing heart disease
Exercise goals and healthy eating
Self management support
Screening for complications
Smoking cessation
How long is a chest tube - ANSWER 20 inches
When would small-bore chest tubes be used - ANSWER also called pigtail,
curled end is less traumatic, can be irrigated by physician, used for chemical
pleurodesis, not for trauma or drainage of blood
more easily kinked or dislodged
What should be done prior to insertion of a chest tube - ANSWER baseline vital
signs, O2 sats, resp assessment, pain management, support for patient
What should be done immediately post chest tube insertion - ANSWER apply air
occlusive dressing, send for xray to confirm placement and efficacy
monitor Q15 for 2 hours then every hour or as needed
What is a water seal chamber - ANSWER Tube from patient is placed 2 cm under
water to prevent air and fluid from returning back up tube to the pleural space
-if tube resurfaces, 250 mL sterile saline should be at bedside to create seal
What does vigorous bubbling in the chest tube water seal chamber mean -
ANSWER air leak
, what should a nurse assess for in patient with chest tube - ANSWER CV, resp,
neuro
vitals, ABGs
pain
dressing, occlusiveness
subcutaneous emphysema
check tubing, chamber
note volume of fluid
should chest tubes be milked? - ANSWER no, can cause excessive negative
pressure
can chest tubes be clamped - ANSWER briefly to allow for changing the unit,
assessing for air leak, to assess if ready for removal (physician order)
when should chest tube dressings be changed - ANSWER q 3 days
sterile
what should be done with chest tube system when transporting patient -
ANSWER keep unit below chest, disconnect system from suction and keep air
vent open, give pain meds prior
what are possible complications of chest tube - ANSWER malposition, subq
emphysema, air leak, blockage, infection, tension pneumo, frozen shoulder
what should you do if the chest tube becomes disconnected from the system -
ANSWER do not clamp, put in 2.5 cm of sterile water or saline
what should you do if chest tube gets pulled out - ANSWER apply pressure with
sterile occlusive dressing and dress with gauze/abdo tape on 3 sides (allow air
to escape)
tracheostomy vs laryngectomy - ANSWER laryngectomy: larynx removed
completely, trachea redirected, permanent
tracheostomy: hole in neck to treat airway obstruction, person can also breathe
via nose/mouth, speech through valve, reversible
why would we use a fenestrated tracheostomy tube - ANSWER allows passage
of air through vocal cords, patient is able to speak
what are some things nurses should manage with trachs - ANSWER vitals, O2
sats
secretions
skin breakdown
Exam With Complete Solutions
What is the LEARNS model - ANSWER Listen, Establish, Adopt, Reinforce,
Name, Strengthen
What learning theory is the LEARNS model based on - ANSWER social
constructivism learning theory
What are four steps to motivational interviewing - ANSWER ask permission,
listen, summarize, invite
What are the "My Diabetes Vital Signs" - ANSWER ABCDESSS
A1C 7% or less
Blood pressure less than 130/80
Cholesterol less than 2.0 mmol/L
Drugs for decreasing heart disease
Exercise goals and healthy eating
Self management support
Screening for complications
Smoking cessation
How long is a chest tube - ANSWER 20 inches
When would small-bore chest tubes be used - ANSWER also called pigtail,
curled end is less traumatic, can be irrigated by physician, used for chemical
pleurodesis, not for trauma or drainage of blood
more easily kinked or dislodged
What should be done prior to insertion of a chest tube - ANSWER baseline vital
signs, O2 sats, resp assessment, pain management, support for patient
What should be done immediately post chest tube insertion - ANSWER apply air
occlusive dressing, send for xray to confirm placement and efficacy
monitor Q15 for 2 hours then every hour or as needed
What is a water seal chamber - ANSWER Tube from patient is placed 2 cm under
water to prevent air and fluid from returning back up tube to the pleural space
-if tube resurfaces, 250 mL sterile saline should be at bedside to create seal
What does vigorous bubbling in the chest tube water seal chamber mean -
ANSWER air leak
, what should a nurse assess for in patient with chest tube - ANSWER CV, resp,
neuro
vitals, ABGs
pain
dressing, occlusiveness
subcutaneous emphysema
check tubing, chamber
note volume of fluid
should chest tubes be milked? - ANSWER no, can cause excessive negative
pressure
can chest tubes be clamped - ANSWER briefly to allow for changing the unit,
assessing for air leak, to assess if ready for removal (physician order)
when should chest tube dressings be changed - ANSWER q 3 days
sterile
what should be done with chest tube system when transporting patient -
ANSWER keep unit below chest, disconnect system from suction and keep air
vent open, give pain meds prior
what are possible complications of chest tube - ANSWER malposition, subq
emphysema, air leak, blockage, infection, tension pneumo, frozen shoulder
what should you do if the chest tube becomes disconnected from the system -
ANSWER do not clamp, put in 2.5 cm of sterile water or saline
what should you do if chest tube gets pulled out - ANSWER apply pressure with
sterile occlusive dressing and dress with gauze/abdo tape on 3 sides (allow air
to escape)
tracheostomy vs laryngectomy - ANSWER laryngectomy: larynx removed
completely, trachea redirected, permanent
tracheostomy: hole in neck to treat airway obstruction, person can also breathe
via nose/mouth, speech through valve, reversible
why would we use a fenestrated tracheostomy tube - ANSWER allows passage
of air through vocal cords, patient is able to speak
what are some things nurses should manage with trachs - ANSWER vitals, O2
sats
secretions
skin breakdown
