Nursing Comprehensive Exit exam
A nurse within the put up-anesthesia care unit is caring for a purchaser who's postoperative
following a thoracotomy and lobectomy. Which of the following postoperative tests need to the
nurse deliver highest priority to? - ANS-Arterial blood gases.
The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.
A nurse is assessing a client following a bronchoscopy. Which of the subsequent findings ought
to the nurse report to the provider? - ANS-Bronchospasms
Bronchospasms can suggest the purchaser is having problem keeping a patent airway.
Blood-tinged sputum, a dry, nonproductive cough, and a sore throat are expected findings
following a bronchoscopy.
A nurse is assessing a purchaser following a thoracentesis. Which of the subsequent findings
ought to the nurse report? - ANS-Dyspnea
Fever
Hypotension
Dyspnea can imply a pneumothorax or a re-accumulation of fluid, fever can imply an infection,
and hypotension can imply intrathoracic bleeding.
A nurse is assessing a client who has a chest tube and drainage device in area. The following
are anticipated findings:
- Gentle constant bubbling only in the suction manipulate chamber; air is being removed. A
suction strain of -20 cm H2O is usually prescribed.
- Rise and fall inside the degree of water in the water seal chamber with idea and expiration
(Tidaling); the drainage machine is functioning well.
- keep the chamber upright and beneath the chest tube insertion site always
- Position the consumer in the semi- to excessive-Fowler's position.
- Ensure that the tubing is straight to promote drainage via gravity. - ANS-Unexpected findings:
- Continuous bubbling within the water seal chamber shows an air leak within the system;
tighten the relationship, replace drainage system. Check all connections.
- Do now not clamp, strip, or milk tubing; simplest perform this movement when prescribed.
- Report excessive drainage (extra than 70 mL/hr) or drainage that is cloudy or purple to the
provider.
- If there is not bubbling inside the suction control chamber, check for leaks and make sure the
suction is on.
, A nurse is assessing a customer who will go through stomach surgical treatment in 2 hr. The
client reviews being anxious approximately the surgery, last had food and fluids at 2330 the
previous evening, and signed the surgical consent 2 days ago. Which of the subsequent is the
appropriate nursing action concerning these findings? - ANS-Document the findings within the
patron's clinical file.
A nurse is caring for a 62-12 months-antique patron who has been recognized with
emphysema. The nurse is aware that the purchaser is at high-danger for pulmonary
contamination. Which of the subsequent conditions predisposes the consumer to
contamination? - ANS-Pooling of respiration secretions.
A nurse is caring for a consumer in the emergency department who complains of epigastric pain
and feeling lightheaded. The consumer has a blood pressure of one hundred forty/80 mmHg
with a heart price of seventy five/min even as supine and a hundred and ten/sixty five mmHg
sitting with a coronary heart charge of 100/min. Which of the subsequent duties ought to the
nurse perform next? - ANS-Anticipate management of intravenous crystalloid solution.
A nurse is worrying for a purchaser who has a chest tube and drainage device in place. The
nurse observes that the chest tube changed into accidentally eliminated. In what order have to
the nurse carry out the following actions? - ANS-1. Apply sterile gauze to the insertion website
online.
2. Place tape around the insertion web page.
3. Assess breathing reputation.
Four. Obtain a chest x-ray.
Also, If the chest tube drainage gadget is compromised, immerse the stop of the chest tube in
sterile water to offer a transient water seal.
A nurse is being concerned for a customer who has a chest tube connected to a closed
drainage gadget and needs to be transported to the x-ray branch. Which of the following actions
should the nurse take? - ANS-Keep the drainage device underneath the extent of the client's
chest always.
A nurse is being concerned for a consumer who has a three- chamber closed chest tube
gadget. Which of the subsequent moves should the nurse take after noticing a rise inside the
water seal chamber with client thought? - ANS-keep to screen the client
A nurse is caring for a customer who is experiencing respiratory distress. Sort the following
manifestations of hypoxemia via whether or not it is an early or past due manifestation of
hypoxemia (insufficient degree of oxygen inside the blood).- ANS-Early manifestation:
Tachypnea
Tachycardia
Anxiety and restlessness
A nurse within the put up-anesthesia care unit is caring for a purchaser who's postoperative
following a thoracotomy and lobectomy. Which of the following postoperative tests need to the
nurse deliver highest priority to? - ANS-Arterial blood gases.
The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.
A nurse is assessing a client following a bronchoscopy. Which of the subsequent findings ought
to the nurse report to the provider? - ANS-Bronchospasms
Bronchospasms can suggest the purchaser is having problem keeping a patent airway.
Blood-tinged sputum, a dry, nonproductive cough, and a sore throat are expected findings
following a bronchoscopy.
A nurse is assessing a purchaser following a thoracentesis. Which of the subsequent findings
ought to the nurse report? - ANS-Dyspnea
Fever
Hypotension
Dyspnea can imply a pneumothorax or a re-accumulation of fluid, fever can imply an infection,
and hypotension can imply intrathoracic bleeding.
A nurse is assessing a client who has a chest tube and drainage device in area. The following
are anticipated findings:
- Gentle constant bubbling only in the suction manipulate chamber; air is being removed. A
suction strain of -20 cm H2O is usually prescribed.
- Rise and fall inside the degree of water in the water seal chamber with idea and expiration
(Tidaling); the drainage machine is functioning well.
- keep the chamber upright and beneath the chest tube insertion site always
- Position the consumer in the semi- to excessive-Fowler's position.
- Ensure that the tubing is straight to promote drainage via gravity. - ANS-Unexpected findings:
- Continuous bubbling within the water seal chamber shows an air leak within the system;
tighten the relationship, replace drainage system. Check all connections.
- Do now not clamp, strip, or milk tubing; simplest perform this movement when prescribed.
- Report excessive drainage (extra than 70 mL/hr) or drainage that is cloudy or purple to the
provider.
- If there is not bubbling inside the suction control chamber, check for leaks and make sure the
suction is on.
, A nurse is assessing a customer who will go through stomach surgical treatment in 2 hr. The
client reviews being anxious approximately the surgery, last had food and fluids at 2330 the
previous evening, and signed the surgical consent 2 days ago. Which of the subsequent is the
appropriate nursing action concerning these findings? - ANS-Document the findings within the
patron's clinical file.
A nurse is caring for a 62-12 months-antique patron who has been recognized with
emphysema. The nurse is aware that the purchaser is at high-danger for pulmonary
contamination. Which of the subsequent conditions predisposes the consumer to
contamination? - ANS-Pooling of respiration secretions.
A nurse is caring for a consumer in the emergency department who complains of epigastric pain
and feeling lightheaded. The consumer has a blood pressure of one hundred forty/80 mmHg
with a heart price of seventy five/min even as supine and a hundred and ten/sixty five mmHg
sitting with a coronary heart charge of 100/min. Which of the subsequent duties ought to the
nurse perform next? - ANS-Anticipate management of intravenous crystalloid solution.
A nurse is worrying for a purchaser who has a chest tube and drainage device in place. The
nurse observes that the chest tube changed into accidentally eliminated. In what order have to
the nurse carry out the following actions? - ANS-1. Apply sterile gauze to the insertion website
online.
2. Place tape around the insertion web page.
3. Assess breathing reputation.
Four. Obtain a chest x-ray.
Also, If the chest tube drainage gadget is compromised, immerse the stop of the chest tube in
sterile water to offer a transient water seal.
A nurse is being concerned for a customer who has a chest tube connected to a closed
drainage gadget and needs to be transported to the x-ray branch. Which of the following actions
should the nurse take? - ANS-Keep the drainage device underneath the extent of the client's
chest always.
A nurse is being concerned for a consumer who has a three- chamber closed chest tube
gadget. Which of the subsequent moves should the nurse take after noticing a rise inside the
water seal chamber with client thought? - ANS-keep to screen the client
A nurse is caring for a customer who is experiencing respiratory distress. Sort the following
manifestations of hypoxemia via whether or not it is an early or past due manifestation of
hypoxemia (insufficient degree of oxygen inside the blood).- ANS-Early manifestation:
Tachypnea
Tachycardia
Anxiety and restlessness
