NU 214 exam 2 Questions With Complete Solutions
A nurse is caring for a patient who has had a total laryngectomy
and radical neck dissection. During the first 24 hours after
surgery what is a priority nursing action?
a. Monitor for bleeding
b. Maintain adequate IV fluids
c. Suction tracheostomy q8h
d. Keep the patient in semi fowlers position Correct Answers
d. Keep the patient in semi fowlers position
A patient is admitted to the emergency department was in open
stabbing to the left chest. What is the first action that the nurse
should take?
a. Position the pt so that the left chest is dependent
b. Tape a non-porous dressing on three sides over the chest
wound
c. Cover the sucking wound firmly with occlusive dressing
d. Keep the HOB at no more than 30 degrees elevation Correct
Answers b. Tape a non-porous dressing on three sides over the
chest wound
A patient's total laryngectomy has created a need for a laryngeal
speech which will be achieved through the use of
tracheoesophageal puncture. What action should the nurse
describe to the patient when teaching him about this process?
Correct Answers Fitting for a voice prosthesis
, After change of shift report, which patient should the nurse
assess first?
a. A 72 year old with cot pulmonary who has 4+ bilateral edema
in his legs and feet
b. A 28 year old with a history of lung transplant and a temp of
101F
c. A 40 year old with a pleural effusion who is complaining of
severe stabbing chest pain
d. A 64 year old with lung cancer and tracheal deviation after
subclavian catheter insertion Correct Answers d. A 64 year old
with lung cancer and tracheal deviation after subclavian catheter
insertion
An hour after a thoracotomy, a patient complains of incisional
pain at a level seven based on a 0 to 10 scale and has decreased
left-sided rust sounds. The pleural drainage system has 100 mL
of bloody drainage and a large air leak. Which action is best for
the nurse to take next?
a. Milk the chest tube gently to remove clots
b. Clamp the chest tube momentarily to check for origin of leak
c. Assist the pt to deep breathe, cough, and use incentive
spirometer
d. Set up the patient controlled analgesia (PCA) and administer
the loading dose of morphine Correct Answers d. Set up the
patient controlled analgesia (PCA) and administer the loading
dose of morphine
A nurse is caring for a patient who has had a total laryngectomy
and radical neck dissection. During the first 24 hours after
surgery what is a priority nursing action?
a. Monitor for bleeding
b. Maintain adequate IV fluids
c. Suction tracheostomy q8h
d. Keep the patient in semi fowlers position Correct Answers
d. Keep the patient in semi fowlers position
A patient is admitted to the emergency department was in open
stabbing to the left chest. What is the first action that the nurse
should take?
a. Position the pt so that the left chest is dependent
b. Tape a non-porous dressing on three sides over the chest
wound
c. Cover the sucking wound firmly with occlusive dressing
d. Keep the HOB at no more than 30 degrees elevation Correct
Answers b. Tape a non-porous dressing on three sides over the
chest wound
A patient's total laryngectomy has created a need for a laryngeal
speech which will be achieved through the use of
tracheoesophageal puncture. What action should the nurse
describe to the patient when teaching him about this process?
Correct Answers Fitting for a voice prosthesis
, After change of shift report, which patient should the nurse
assess first?
a. A 72 year old with cot pulmonary who has 4+ bilateral edema
in his legs and feet
b. A 28 year old with a history of lung transplant and a temp of
101F
c. A 40 year old with a pleural effusion who is complaining of
severe stabbing chest pain
d. A 64 year old with lung cancer and tracheal deviation after
subclavian catheter insertion Correct Answers d. A 64 year old
with lung cancer and tracheal deviation after subclavian catheter
insertion
An hour after a thoracotomy, a patient complains of incisional
pain at a level seven based on a 0 to 10 scale and has decreased
left-sided rust sounds. The pleural drainage system has 100 mL
of bloody drainage and a large air leak. Which action is best for
the nurse to take next?
a. Milk the chest tube gently to remove clots
b. Clamp the chest tube momentarily to check for origin of leak
c. Assist the pt to deep breathe, cough, and use incentive
spirometer
d. Set up the patient controlled analgesia (PCA) and administer
the loading dose of morphine Correct Answers d. Set up the
patient controlled analgesia (PCA) and administer the loading
dose of morphine
