NSG 4100 (AH III) Exam 3- actual questions
and answers highly graded a+
A nurse is educating a pt in anticipation of a procedure that will require a water-sealed
chest drainage system. What should the nurse tell the pt and the family that this
drainage system is used for?
a. maintaining a positive chest-wall pressure
b. monitoring pleural fluid osmolarity
c. providing passive intrathoracic pressure
d. removing excess air and fluid - CORRECT ANSWERS--D
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 this chest tube?
a. to remove air from the pleural space
b. to drain copious sputum secretions
c. to monitor bleeding around the lungs
d. to assist with mechanical ventilation - CORRECT ANSWERS--A
A pt's plan of care specifies postural drainage. What action should the nurse perform
when providing this noninvasive therapy?
a. administer the tx w/ the pt in a high Fowler's or semi-fowlers position
b. perform the procedure immediately following the pt's meals
c. apply percussion firmly to bare skin to facilitate drainage
d. assist the pt into a position that will allow gravity to move secretions - CORRECT
ANSWERS--D
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?
a. the system is functioning normally
b. pt has a pneumothorax
c. system has a leak
d. chest tube is obstructed - CORRECT ANSWERS--C
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 surgery. Which study will be performed to determine whether the
panned resection will leave sufficient functioning lung tissue?
a. pulmonary function studies
b. exercise tolerance tests
c. arterial blood gas values
d. chest x-ray - CORRECT ANSWERS--A
,The nurse is discussing activity management w/ a pt who is postoperative following
thoracotomy. What instructions should the nurse give to the pt regarding activity
immediately following discharge?
a. walk 1 mile 3-4x a week
b. use wights daily to increase arm strength
c. walk on a treadmill 30min daily
d. perform shoulder exercises 5x daily - CORRECT ANSWERS--D
The OR nurse is setting up a water-seal chest drainage system for a pt who has just
had a thoracotomy. The nurse knows that the amount of suction in the system is
determined by the water level. At what suction level should the nurse set the system?
a. 20 cm H2O
b. 15 cm H2O
c. 10 cm H2O
d. 5 cm H2O - CORRECT ANSWERS--A
The nurse is caring for a client w/ and endotracheal tube who is on a ventilator. When
assessing the client, the nurse knows to maintain what cuff pressure to maintain
appropriate pressure on the tracheal wall?
a. between 10-15 mm Hg
b. between 15-20 mm Hg
c. between 20-25 mm Hg
d. between 25-30 mm Hg - CORRECT ANSWERS--B
A nurse educator is reviewing the indications for chest drainage systems w/ a group of
medical nurses. What indications should the nurses identify? Select all that apply.
a. post thoracotomy
b. spontaneous pneumothorax
c. need for postural drainage
d. chest trauma resulting in pneumothorax
e. pleurisy - CORRECT ANSWERS--A, B, D
The home care nurse is visiting a pt newly discharged home after a lobectomy. What
would be most important for the home care nurse to assess?
a. resumption of the pt's ADLs
b. the family's willingness to care for the pt
c. nutritional status and fluid balance
d. s/s of respiratory complications - CORRECT ANSWERS--D
A pt is being admitted to the preoperative holding area for a thoracotomy. Preoperative
teaching includes what?
a. correct use of a ventilator
b. correct use of incentive spirometry
c. correct use of a mini-nebulizer
c. correct technique for rhythmic breathing - CORRECT ANSWERS--B
, 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?
a. hold the spirometer at your lips and breathe in and out like you normally would
b. when you're ready, blow hard into the spirometer for as long as you can
c. take a deep breath and then blow short, forceful breaths into the spirometer
d. breathe in deeply through the spirometer, hold your breath briefly, and then exhale -
CORRECT ANSWERS--D
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. gently reinsert the chest tube 1-2cm and observe if the water level stabilizes
b. inform the physician property that there is an imminent leak in the drainage system
c. encourage pt to do deep breathing and coughing exercises
d. document that the chest drainage is operating as it is intended - CORRECT
ANSWERS--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. an air conditioning system
c. a water purification system
d. a radiant heating system - CORRECT ANSWERS--A
The nurse is caring for a pt whose recent unexplained weight loss and hx of smoking
have prompted diagnostic testing for cancer. What sx is most closely associated w/ the
early stages of laryngeal caner?
a. hoarseness
b. dyspnea
c. dysphagia
d. frequent nosebleeds - CORRECT ANSWERS--A
The nurse is conducting a presurgical interview for a pt w/ laryngeal cancer. The pt
states that he drinks approx 6-8 shots of vodka per day. it is imperative that the nurse
inform the surgical team so the pt can be assessed for what?
a. increased risk for infection
b. delirium tremens
c. depression
d. non-adherence to postop care - CORRECT ANSWERS--B
The nurse is caring for a pt who is post-op day 2 following a total laryngectomy for
supraglottic cancer. The nurse should prioritize what assessment?
a. assessment of body image
b. assessment of jugular venous pressure
and answers highly graded a+
A nurse is educating a pt in anticipation of a procedure that will require a water-sealed
chest drainage system. What should the nurse tell the pt and the family that this
drainage system is used for?
a. maintaining a positive chest-wall pressure
b. monitoring pleural fluid osmolarity
c. providing passive intrathoracic pressure
d. removing excess air and fluid - CORRECT ANSWERS--D
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 this chest tube?
a. to remove air from the pleural space
b. to drain copious sputum secretions
c. to monitor bleeding around the lungs
d. to assist with mechanical ventilation - CORRECT ANSWERS--A
A pt's plan of care specifies postural drainage. What action should the nurse perform
when providing this noninvasive therapy?
a. administer the tx w/ the pt in a high Fowler's or semi-fowlers position
b. perform the procedure immediately following the pt's meals
c. apply percussion firmly to bare skin to facilitate drainage
d. assist the pt into a position that will allow gravity to move secretions - CORRECT
ANSWERS--D
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?
a. the system is functioning normally
b. pt has a pneumothorax
c. system has a leak
d. chest tube is obstructed - CORRECT ANSWERS--C
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 surgery. Which study will be performed to determine whether the
panned resection will leave sufficient functioning lung tissue?
a. pulmonary function studies
b. exercise tolerance tests
c. arterial blood gas values
d. chest x-ray - CORRECT ANSWERS--A
,The nurse is discussing activity management w/ a pt who is postoperative following
thoracotomy. What instructions should the nurse give to the pt regarding activity
immediately following discharge?
a. walk 1 mile 3-4x a week
b. use wights daily to increase arm strength
c. walk on a treadmill 30min daily
d. perform shoulder exercises 5x daily - CORRECT ANSWERS--D
The OR nurse is setting up a water-seal chest drainage system for a pt who has just
had a thoracotomy. The nurse knows that the amount of suction in the system is
determined by the water level. At what suction level should the nurse set the system?
a. 20 cm H2O
b. 15 cm H2O
c. 10 cm H2O
d. 5 cm H2O - CORRECT ANSWERS--A
The nurse is caring for a client w/ and endotracheal tube who is on a ventilator. When
assessing the client, the nurse knows to maintain what cuff pressure to maintain
appropriate pressure on the tracheal wall?
a. between 10-15 mm Hg
b. between 15-20 mm Hg
c. between 20-25 mm Hg
d. between 25-30 mm Hg - CORRECT ANSWERS--B
A nurse educator is reviewing the indications for chest drainage systems w/ a group of
medical nurses. What indications should the nurses identify? Select all that apply.
a. post thoracotomy
b. spontaneous pneumothorax
c. need for postural drainage
d. chest trauma resulting in pneumothorax
e. pleurisy - CORRECT ANSWERS--A, B, D
The home care nurse is visiting a pt newly discharged home after a lobectomy. What
would be most important for the home care nurse to assess?
a. resumption of the pt's ADLs
b. the family's willingness to care for the pt
c. nutritional status and fluid balance
d. s/s of respiratory complications - CORRECT ANSWERS--D
A pt is being admitted to the preoperative holding area for a thoracotomy. Preoperative
teaching includes what?
a. correct use of a ventilator
b. correct use of incentive spirometry
c. correct use of a mini-nebulizer
c. correct technique for rhythmic breathing - CORRECT ANSWERS--B
, 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?
a. hold the spirometer at your lips and breathe in and out like you normally would
b. when you're ready, blow hard into the spirometer for as long as you can
c. take a deep breath and then blow short, forceful breaths into the spirometer
d. breathe in deeply through the spirometer, hold your breath briefly, and then exhale -
CORRECT ANSWERS--D
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. gently reinsert the chest tube 1-2cm and observe if the water level stabilizes
b. inform the physician property that there is an imminent leak in the drainage system
c. encourage pt to do deep breathing and coughing exercises
d. document that the chest drainage is operating as it is intended - CORRECT
ANSWERS--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. an air conditioning system
c. a water purification system
d. a radiant heating system - CORRECT ANSWERS--A
The nurse is caring for a pt whose recent unexplained weight loss and hx of smoking
have prompted diagnostic testing for cancer. What sx is most closely associated w/ the
early stages of laryngeal caner?
a. hoarseness
b. dyspnea
c. dysphagia
d. frequent nosebleeds - CORRECT ANSWERS--A
The nurse is conducting a presurgical interview for a pt w/ laryngeal cancer. The pt
states that he drinks approx 6-8 shots of vodka per day. it is imperative that the nurse
inform the surgical team so the pt can be assessed for what?
a. increased risk for infection
b. delirium tremens
c. depression
d. non-adherence to postop care - CORRECT ANSWERS--B
The nurse is caring for a pt who is post-op day 2 following a total laryngectomy for
supraglottic cancer. The nurse should prioritize what assessment?
a. assessment of body image
b. assessment of jugular venous pressure
