NCLEX Practice Exam for Reduction of Risk Potential

Text Mode – Text version of the exam

Questions

1. Nurse Emily is in the pediatric cardiac unit, attending to a young patient who has just undergone surgery to correct a ventricular septal defect. As she plans her immediate post-operative care, she knows that certain assessments are crucial at this stage. Which of the following nursing assessments should Nurse Emily prioritize?

A. Listening for signs of pulmonary congestion.
B. Checking the nail beds for color and refill by blanching them.
C. Evaluating the child for post-operative arrhythmias.
D. Observing the equality of peripheral pulses.

2. Nurse James is preparing to insert a chest tube for a patient diagnosed with a spontaneous pneumothorax. The anxious patient inquires about the purpose of the tube. What is the best explanation Nurse James can provide for the insertion of the chest tube?

A. “The tube is designed to remove the excess air that’s trapped in your chest.”
B. “The tube’s purpose is to drain any accumulated fluid from inside your chest.”
C. “The tube will regulate and control the amount of air that enters into your chest.”
D. “The tube is meant to seal up the hole present in your lung.”

3. Nurse Olivia is caring for a four-year-old child who has been in the hospital for 24 hours, receiving skeletal traction for a fractured right femur. During her rounds, she discovers the child crying, and the right foot appears pale with no detectable pulse. What is the FIRST action Nurse Olivia should take?

A. Make adjustments to the traction setup.
B. Plan to reassess the foot in another fifteen minutes.
C. Give the child the prescribed as-needed medication.
D. Immediately notify the attending physician.

4. Nurse Thomas is caring for a client who has recently undergone a right thoracotomy and an upper lobectomy. As he focuses on managing the patient’s post-operative pain, he knows that effective pain control is essential for a specific aspect of recovery. What is the primary reason for Nurse Thomas to concentrate on pain management in this client?

A. Facilitating deep breathing and encouraging coughing.
B. Enabling the client to perform a range of motion exercises.
C. Promoting the healing of the surgical incision.
D. Ensuring relaxation and aiding in restful sleep.

5. Nurse Amelia is assessing a client who is two hours postoperative following a femoral popliteal bypass. She notices that the upper leg dressing has become saturated with blood. What should be Nurse Amelia’s FIRST action in this situation?

A. Take off the dressings and re-dress the incision with fresh materials.
B. Apply direct pressure at the site where the bleeding appears to be coming from.
C. Add more dressing to reinforce the existing one and elevate the affected leg.
D. Encase the leg with elastic bandages to control the bleeding.

6. Nurse William is caring for a client who is dependent on a mechanical ventilator for breathing. Suddenly, the high-pressure alarm on the ventilator sounds. What is the FIRST action Nurse William should perform in this urgent situation?

A. Reach out to the respiratory therapist for assistance.
B. Conduct a rapid assessment of the client’s overall condition.
C. Hit the alarm reset button on the ventilator to silence it.
D. Detach the client from the ventilator and utilize a manual resuscitation bag.

7. Nurse Sophia is reviewing laboratory results for a client with acute renal failure. She knows that certain abnormalities in the lab results may require immediate attention. Which one of the following findings should be reported IMMEDIATELY?

A. Serum potassium level at 6 mEq/L.
B. Hemoglobin level of 10.3 mg/dl.
C. Blood urea nitrogen (BUN) at 50 mg/dl.
D. Venous blood pH reading of 7.30.

8. Nurse Benjamin is caring for a client with a chest tube in place, following a left lower lobectomy due to a stab wound to the chest. While repositioning the client, he observes 200 cc of dark, red fluid flowing into the collection chamber of the chest drain. What is the MOST appropriate nursing action for Nurse Benjamin to take?

A. Get ready to administer a blood transfusion.
B. Increase the height of the drainage system to slow down the fluid flow.
C. Apply a clamp to the chest tube.
D. Keep a close watch on the rate of drainage and continue regular monitoring.

9. Nurse Thomas is caring for a client who has recently undergone a right thoracotomy and an upper lobectomy. In the postoperative phase, he is concentrating on managing the patient’s pain. What is the primary reason for Nurse Thomas to focus on pain management in this client?

A. To promote the healing of the surgical incision.
B. To facilitate coughing and encourage deep breathing.
C. To ensure relaxation and aid in restful sleep.
D. To enable the client to perform a range of motion exercises.

10. Nurse Thompson is caring for a client who has undergone a right thoracotomy and an upper lobectomy. The priority in postoperative care is respiratory toilet, as inadequate gas exchange can lead to profound atelectasis and eventually pneumonia. Proper pain management is essential to achieve this. Without appropriate pain management, what symptom might the client quickly develop?

A. Involuntary muscle spasms.
B. Dyspnea (difficulty breathing).
C. Increased body temperature.
D. Pallor (paleness).

11. Nurse Hannah is performing a physical assessment on a client who has just had an endotracheal tube inserted. She knows that certain findings may require immediate intervention. Which of the following findings would call for IMMEDIATE action by Nurse Hannah?

A. Pulse oximetry reading of 88.
B. Client’s inability to speak.
C. Visible mist in the T-Piece of the breathing circuit.
D. Breath sounds that can be heard equally on both sides of the chest.

12. Nurse Martin is caring for a client receiving external beam radiation to the mediastinum for the treatment of bronchial cancer. In planning the care for this client, he must consider various side effects of the treatment. Which of the following should take PRIORITY in Nurse Martin’s care planning?

A. Managing fatigue related to the treatment.
B. Addressing esophagitis caused by radiation.
C. Treating skin irritation at the radiation site.
D. Monitoring and managing leukopenia (low white blood cell count).

13. Nurse Emily is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Upon entering the client’s room, she observes that the oxygen is running at 6 L/min, the client’s color is flushed, and his respirations are 8/min. What should Nurse Emily do FIRST in this situation?

A. Record the baseline vital signs.
B. Position the client in a high Fowler’s position.
C. Reduce the oxygen flow rate.
D. Obtain a 12-lead EKG to assess cardiac function.

14. Nurse James is preparing to insert a chest tube for a patient diagnosed with a spontaneous pneumothorax. The anxious patient inquires about the purpose of the tube. What is the BEST explanation Nurse James can provide for the insertion of the chest tube?

A. “The tube is specifically designed to remove the excess air that’s trapped in your chest cavity.”
B. “The tube’s purpose is to seal up the hole present in your lung.”
C. “The tube will be used to drain any accumulated fluid from inside your chest.”
D. “The tube will regulate and control the amount of air that enters into your chest cavity.”

15. Nurse Emily is in the pediatric cardiac unit, attending to a young patient who has just undergone surgery to correct a ventricular septal defect. As she plans her immediate post-operative care, she knows that certain assessments are crucial at this stage. What nursing assessment should be her PRIORITY?

A. Keep an eye on the equality of peripheral pulses.
B. Listen attentively for any signs of pulmonary congestion.
C. Vigilantly assess the child for post-operative arrhythmias.
D. Check the nail beds for color and refill by blanching them.

16. Nurse Sarah is caring for a client in the postoperative phase and is aware that preventing atelectasis is crucial for a smooth recovery. What is the MOST effective nursing intervention to prevent atelectasis from developing in this postoperative client?

A. Ensure the client is ambulated within the first 12 hours post-surgery.
B. Assist the client to turn, cough, and take deep breaths regularly.
C. Splint the surgical incision to minimize discomfort during movement.
D. Maintain adequate hydration to keep secretions thin.

17. Nurse Sophia is reviewing laboratory results for a client with acute renal failure. She knows that certain abnormalities in the lab results may require immediate attention. Which one of the following findings should Nurse Sophia report IMMEDIATELY?

A. Serum potassium level at 6 mEq/L.
B. Blood urea nitrogen (BUN) at 50 mg/dl.
C. Hemoglobin level of 10.3 mg/dl.
D. Venous blood pH reading of 7.30.

18. Nurse Karen is in the process of preparing a client who is scheduled to undergo a myelogram, a specialized imaging test that involves the injection of contrast material into the spinal column. During her pre-procedure assessment, which of the client’s statements would indicate a contraindication for this particular test?

A. “I have a known allergy to shellfish like shrimp.”
B. “I had a really severe headache the last time I got a spinal tap.”
C. “It’s challenging for me to remain in a single position for more than half an hour.”
D. “I struggle with claustrophobia and enclosed spaces.”

19. Nurse Alex is monitoring a client who has just returned from undergoing a cardiac catheterization. He is vigilant about identifying any complications that may arise from the procedure. Which one of the following assessments would indicate that the client is experiencing a complication related to the cardiac catheterization?

A. Absence of pulse in the extremity where the catheter was inserted.
B. Elevated heart rate post-procedure.
C. Increased blood pressure levels.
D. Reduced urine output following the procedure.

20. Nurse Benjamin is caring for a client with a chest tube in place, following a left lower lobectomy due to a stab wound to the chest. While repositioning the client, he observes 200 cc of dark, red fluid flowing into the collection chamber of the chest drain. What is the most appropriate nursing action for Nurse Benjamin to take in this situation?

A. Elevate the client’s legs to improve venous return.
B. Immediately contact the surgeon to report the finding.
C. Get ready to administer a blood transfusion as a precaution.
D. Apply a clamp to the chest tube to stop the drainage.

Answers and Rationales

1. Correct answer:

C. Evaluating the child for post-operative arrhythmias. Nurse Emily is in a pediatric cardiac unit, and her patient has just undergone surgery for a ventricular septal defect. In the immediate post-operative period, cardiac assessments are of the utmost priority. Arrhythmias are common after cardiac surgery and can be life-threatening if not promptly identified and managed. The heart’s electrical system may be irritated or disrupted during surgery, making the patient susceptible to abnormal heart rhythms. Therefore, continuous cardiac monitoring is essential to detect any arrhythmias and initiate immediate treatment.

Think of the heart as an orchestra, with each part playing a specific role to produce a harmonious rhythm. After surgery, it’s like the orchestra has just finished a complex performance and is at risk of going out of tune. The conductor (Nurse Emily) must pay close attention to ensure that every instrument (part of the heart) is still playing correctly. If one instrument is out of tune (arrhythmia), it can disrupt the entire performance (cardiac function), leading to severe complications.

Incorrect answer options:

A. Listening for signs of pulmonary congestion. While pulmonary congestion is a concern in cardiac patients, it is not the immediate priority post-operatively for a ventricular septal defect correction. Pulmonary issues are generally secondary to cardiac issues in this context and would be addressed after ensuring cardiac stability.

B. Checking the nail beds for color and refill by blanching them. Capillary refill and nail bed color are general indicators of peripheral perfusion and are important but not the immediate priority in the post-operative cardiac setting. These assessments are more relevant for generalized circulatory issues rather than specific cardiac complications that are likely in this case.

D. Observing the equality of peripheral pulses. While peripheral pulses can provide information about circulatory status, they are not the most immediate concern following cardiac surgery for a ventricular septal defect. The focus should be on direct cardiac assessments like monitoring for arrhythmias.

2. Correct answer:

A. “The tube is designed to remove the excess air that’s trapped in your chest.” In the case of a spontaneous pneumothorax, air leaks into the space between the lung and the chest wall, causing the lung to collapse partially or completely. The chest tube serves as a conduit to remove this trapped air, allowing the lung to re-expand and resume its normal function. By doing so, the tube helps to restore normal intrathoracic pressure, which is crucial for effective lung expansion and oxygenation. Nurse James would prioritize this explanation because it directly addresses the primary issue at hand: the trapped air that is causing the lung to collapse.

Imagine your lung as a balloon inside a sealed box (your chest). If a small hole appears in the box, air will leak in and compress the balloon, making it difficult for the balloon to inflate fully. The chest tube acts like a small vacuum cleaner, sucking out the extra air that has leaked into the box, allowing the balloon (your lung) to inflate fully again. This helps everything return to normal inside the “box,” enabling you to breathe more comfortably.

By understanding the specific purpose and function of a chest tube in the context of a spontaneous pneumothorax, Nurse James can provide accurate and reassuring information to anxious patients, thereby improving their overall care experience.

Incorrect answer options:

B. “The tube’s purpose is to drain any accumulated fluid from inside your chest.” While it’s true that chest tubes can be used to drain fluid in conditions like pleural effusion or hemothorax, that’s not the primary concern in a spontaneous pneumothorax. In this case, the issue is trapped air, not fluid. Therefore, this explanation would not be the most accurate or relevant for the patient’s current condition.

C. “The tube will regulate and control the amount of air that enters into your chest.” This statement could be misleading. A chest tube doesn’t regulate the amount of air that enters the chest; rather, it removes excess air that has already entered the pleural space due to the pneumothorax. The tube is not a mechanism for controlling airflow into the chest but serves to correct an existing problem.

D. “The tube is meant to seal up the hole present in your lung.” This is incorrect because the chest tube itself does not seal the hole in the lung. Its primary function is to remove the trapped air, allowing the lung to re-expand. The body often seals small lung perforations naturally over time, or surgical intervention may be required for larger tears. The tube facilitates the conditions under which this natural or surgical healing can occur more effectively.

3. Correct answer:

D. Immediately notify the attending physician. When Nurse Olivia discovers that the child’s right foot appears pale and lacks a detectable pulse, this is a critical sign of compromised circulation, possibly leading to ischemia or tissue necrosis. Immediate intervention is required to prevent irreversible damage. The first action should be to notify the attending physician as this is a medical emergency that may require immediate surgical intervention or adjustment of the traction by a qualified healthcare provider.

Imagine you’re driving a car and suddenly see the engine light come on, accompanied by smoke coming out of the hood. You wouldn’t just adjust the air conditioning or plan to check it later; you’d pull over and call for immediate assistance. Similarly, in a medical setting, certain signs like a pale foot with no pulse are “emergency lights” that require immediate professional intervention.

Incorrect answer options:

A. Make adjustments to the traction setup. Making adjustments to the traction setup without physician guidance could worsen the situation. This is a critical condition that requires immediate medical evaluation and intervention. Adjusting the traction is not within the nurse’s scope of practice in this situation.

B. Plan to reassess the foot in another fifteen minutes. Time is of the essence in situations involving compromised circulation. Waiting another fifteen minutes could lead to irreversible tissue damage and worsen the child’s condition.

C. Give the child the prescribed as-needed medication. While medication might alleviate pain, it does not address the underlying issue of compromised circulation. Administering medication without resolving the root cause could lead to severe complications.

4. Correct answer:

A. Facilitating deep breathing and encouraging coughing. Effective pain management is crucial for patients who have undergone thoracotomy and lobectomy primarily to facilitate deep breathing and encourage coughing. These actions are essential for preventing postoperative complications such as atelectasis (lung collapse) and pneumonia. The surgical procedure involves the chest cavity, which can make deep breathing and coughing painful. If the pain is not adequately managed, the patient may engage in shallow breathing to avoid discomfort, leading to inadequate lung expansion and mucus accumulation. This sets the stage for respiratory complications, which can significantly hamper recovery and even become life-threatening.

Imagine you’ve just fixed a flat tire on your bicycle. To ensure the repair is effective, you need to inflate the tire fully and check for any leaks. If you only partially inflate it, you risk damaging the tire further and making your ride inefficient. Similarly, after a thoracotomy and lobectomy, the “tire” (in this case, the lung) needs to be “fully inflated” (deep breathing) and “checked for leaks” (coughing to clear mucus), and pain management is the “air pump” that makes this possible.

Effective pain management in this context is not just about the patient’s comfort but is a therapeutic intervention aimed at optimizing lung function post-surgery. By controlling pain, Nurse Thomas enables the patient to participate more willingly in respiratory exercises, thereby accelerating recovery and reducing the risk of complications.

Incorrect answer options:

B. Enabling the client to perform a range of motion exercises. While a range of motion exercises are generally beneficial for postoperative patients, they are not the primary focus following a thoracotomy and lobectomy. The immediate concern is respiratory function, as the surgery directly impacts the lungs and chest cavity. Focusing on a range of motion exercises could divert attention from more urgent respiratory needs.

C. Promoting the healing of the surgical incision. Although pain management can contribute to overall well-being and potentially aid in the healing process, the primary reason for focusing on pain control in this specific case is to facilitate respiratory function. Surgical incision healing is important but secondary to ensuring that the patient can breathe deeply and cough effectively to prevent respiratory complications.

D. Ensuring relaxation and aiding in restful sleep. While adequate sleep and relaxation are important for general recovery, they are not the primary reasons for concentrating on pain management in a patient who has undergone a thoracotomy and lobectomy. The urgent need is to ensure that the patient can engage in deep breathing and coughing to maintain optimal lung function and prevent complications.

5. Correct answer:

B. Apply direct pressure at the site where the bleeding appears to be coming from. In a postoperative situation where the dressing has become saturated with blood, the immediate concern is to control the bleeding. Applying direct pressure to the site of bleeding is the most effective first-line intervention to achieve hemostasis (cessation of bleeding). This action minimizes blood loss and prevents further complications such as hypovolemia, which could lead to shock. Direct pressure will compress the blood vessels at the site, facilitating clot formation and stopping the bleed.

Think of a leaking water hose; if you find a spot where water is gushing out, you would immediately place your thumb over the hole to stop the leak. You wouldn’t start by wrapping more tape around it or changing the hose entirely; you’d first stop the water from escaping. Similarly, in a medical setting, stopping the “leak” (bleeding) is the immediate priority, and direct pressure is the “thumb” that stops it.

Once the bleeding is controlled, Nurse Amelia can then proceed to assess the situation further, possibly changing the dressing and notifying the physician for further evaluation and orders. It’s crucial to remember that while direct pressure is a temporary measure, it buys time for more definitive interventions to be planned and executed.

Incorrect answer options:

A. Take off the dressings and re-dress the incision with fresh materials. Removing the saturated dressing without first controlling the bleeding could exacerbate the situation. The existing dressing may be providing some degree of pressure that is minimizing the bleed. Removing it could lead to increased blood loss and potential complications.

C. Add more dressing to reinforce the existing one and elevate the affected leg. While adding more dressing and elevating the leg may seem like a logical step, it does not directly address the immediate need to stop the bleeding. Additional dressings might absorb the blood, but they won’t necessarily control an active bleed. Elevation alone is also insufficient for this purpose.

D. Encase the leg with elastic bandages to control the bleeding. Using elastic bandages might apply some pressure but it’s not targeted, and there’s a risk of applying too much pressure, which could lead to complications like compartment syndrome. Direct pressure is more effective for immediate control of a localized bleed.

6. Correct answer:

B. Conduct a rapid assessment of the client’s overall condition. When a high-pressure alarm sounds on a mechanical ventilator, the immediate priority is to assess the client’s condition. This involves checking vital signs, oxygen saturation, and the client’s level of consciousness. The alarm could indicate a variety of issues, such as a kink in the tubing, mucus plug, or a worsening of the patient’s respiratory status. A rapid assessment will provide immediate information on the client’s condition and guide subsequent interventions. Ignoring the alarm or delaying the assessment could lead to severe hypoxia and other life-threatening complications.

Imagine you’re driving a car and suddenly the “Check Engine” light comes on. You wouldn’t just call a mechanic without first pulling over to assess the situation. You’d check if the car is overheating, listen for strange noises, and maybe even check under the hood. Similarly, when a high-pressure alarm sounds on a ventilator, the first step is to “check under the hood” by rapidly assessing the patient’s condition to understand what triggered the alarm.

After the rapid assessment, Nurse William can then proceed to troubleshoot the ventilator issue, consult with the respiratory therapist, or escalate to medical intervention as needed. The assessment is crucial because it informs the healthcare team about the urgency and type of intervention required, whether it’s a simple fix like adjusting the tubing or a more complex medical intervention.

Incorrect answer options:

A. Reach out to the respiratory therapist for assistance. While consulting a respiratory therapist is important, it should not be the first action. The immediate priority is to assess the client’s condition to determine the severity of the situation and guide further interventions.

C. Hit the alarm reset button on the ventilator to silence it. Simply silencing the alarm without assessing the patient could lead to a delay in identifying and resolving a potentially life-threatening issue. The alarm is a warning sign that something is wrong and needs immediate attention.

D. Detach the client from the ventilator and utilize a manual resuscitation bag. Disconnecting the patient from the ventilator is a drastic step that should only be taken if it’s confirmed that the ventilator is malfunctioning and compromising the patient’s breathing. Doing this without a rapid assessment could lead to unnecessary complications.

7. Correct answer:

A. Serum potassium level at 6 mEq/L. A serum potassium level of 6 mEq/L is a critical finding that requires immediate attention. Elevated potassium levels, known as hyperkalemia, can lead to life-threatening cardiac arrhythmias and even cardiac arrest. The heart relies on a delicate balance of electrolytes, including potassium, to regulate its electrical activity. When potassium levels are too high, it can disrupt this electrical balance, leading to irregular heart rhythms and potentially fatal outcomes. Immediate intervention, such as administering medications to lower potassium levels or initiating hemodialysis, may be necessary to prevent severe complications.

Imagine you’re baking a cake and the recipe calls for a specific amount of baking powder. If you accidentally add too much, the cake could overflow and create a mess in the oven. Similarly, the heart needs just the right amount of potassium for optimal function. Too much potassium is like adding too much baking powder; it can lead to a “mess,” but in this case, the consequences can be life-threatening.

Nurse Sophia should immediately report this finding to the healthcare provider for prompt intervention. This could include administering medications that help to lower potassium levels, adjusting the patient’s diet, or even initiating emergency dialysis. The goal is to bring the potassium levels back to a safe range as quickly as possible to prevent cardiac complications.

Incorrect answer options:

B. Hemoglobin level of 10.3 mg/dl. While a hemoglobin level of 10.3 mg/dl is low and warrants attention, it is not as immediately life-threatening as a serum potassium level of 6 mEq/L. Low hemoglobin levels could indicate anemia, which needs to be addressed but usually not on an emergency basis.

C. Blood urea nitrogen (BUN) at 50 mg/dl. A BUN level of 50 mg/dl is elevated and indicates poor kidney function, which is expected in a patient with acute renal failure. However, it is not an immediate life-threatening situation like hyperkalemia and can be managed with ongoing renal supportive care.

D. Venous blood pH reading of 7.30. A venous blood pH of 7.30 indicates acidemia, which is a concern but not as immediately life-threatening as a serum potassium level of 6 mEq/L. Acidemia can often be managed with medications and adjustments to ventilation settings if the patient is mechanically ventilated.

8. Correct answer:

D. Keep a close watch on the rate of drainage and continue regular monitoring. In the case of a chest tube following a left lower lobectomy due to a stab wound, observing 200 cc of dark, red fluid in the collection chamber is concerning but not necessarily an immediate emergency. The color and amount of drainage can vary depending on the nature of the injury and the surgery. Dark, red fluid may indicate older blood, and 200 cc may not be an excessive amount depending on the time frame and the specific clinical context. The most appropriate initial nursing action is to closely monitor the rate of drainage and the patient’s vital signs to assess for any signs of hemodynamic instability, such as changes in blood pressure, heart rate, or oxygen saturation.

Imagine you’re a lifeguard at a pool, and you notice the water level dropping more quickly than usual. You wouldn’t immediately evacuate the pool or call for emergency repairs. First, you’d closely monitor the water level, check for any visible leaks, and observe if anyone in the pool seems to be in distress. Similarly, Nurse Benjamin should closely monitor the drainage and the patient’s condition to determine the next steps.

After closely monitoring the patient, Nurse Benjamin should report the findings to the healthcare provider for further evaluation. Depending on the rate of drainage and the patient’s condition, additional interventions such as diagnostic tests or surgical exploration may be necessary. Immediate action like clamping the tube or preparing for a transfusion may not be warranted without a comprehensive assessment.

Incorrect answer options:

A. Get ready to administer a blood transfusion. While a blood transfusion may eventually be necessary, it is not the immediate action to take. The first step is to closely monitor the patient’s condition and consult with the healthcare provider for further evaluation and orders.

B. Increase the height of the drainage system to slow down the fluid flow. Raising the height of the drainage system is not recommended as it could lead to backflow of fluid into the pleural space, potentially causing complications such as infection or impaired lung expansion.

C. Apply a clamp to the chest tube. Clamping the chest tube without a healthcare provider’s order can be dangerous. It could lead to complications like tension pneumothorax, as the tube is in place to allow for drainage and air escape. Clamping it would prevent this and could exacerbate the problem.

9. Correct answer:

B. To facilitate coughing and encourage deep breathing. Effective pain management is crucial for patients who have undergone thoracotomy and lobectomy primarily to facilitate deep breathing and encourage coughing. These actions are essential for preventing postoperative complications such as atelectasis (lung collapse) and pneumonia. The surgical procedure involves the chest cavity, which can make deep breathing and coughing painful. If the pain is not adequately managed, the patient may engage in shallow breathing to avoid discomfort, leading to inadequate lung expansion and mucus accumulation. This sets the stage for respiratory complications, which can significantly hamper recovery and even become life-threatening.

Imagine you’ve just fixed a flat tire on your bicycle. To ensure the repair is effective, you need to inflate the tire fully and check for any leaks. If you only partially inflate it, you risk damaging the tire further and making your ride inefficient. Similarly, after a thoracotomy and lobectomy, the “tire” (in this case, the lung) needs to be “fully inflated” (deep breathing) and “checked for leaks” (coughing to clear mucus), and pain management is the “air pump” that makes this possible.

Effective pain management in this context is not just about the patient’s comfort but is a therapeutic intervention aimed at optimizing lung function post-surgery. By controlling pain, Nurse Thomas enables the patient to participate more willingly in respiratory exercises, thereby accelerating recovery and reducing the risk of complications.

Incorrect answer options:

A. To promote the healing of the surgical incision. Although pain management can contribute to overall well-being and potentially aid in the healing process, the primary reason for focusing on pain control in this specific case is to facilitate respiratory function. Surgical incision healing is important but secondary to ensuring that the patient can breathe deeply and cough effectively to prevent respiratory complications.

C. To ensure relaxation and aid in restful sleep. While adequate sleep and relaxation are important for general recovery, they are not the primary reasons for concentrating on pain management in a patient who has undergone a thoracotomy and lobectomy. The urgent need is to ensure that the patient can engage in deep breathing and coughing to maintain optimal lung function and prevent complications.

D. To enable the client to perform a range of motion exercises. While a range of motion exercises are generally beneficial for postoperative patients, they are not the primary focus following a thoracotomy and lobectomy. The immediate concern is respiratory function, as the surgery directly impacts the lungs and chest cavity. Focusing on a range of motion exercises could divert attention from more urgent respiratory needs.

10. Correct answer:

B. Dyspnea (difficulty breathing). Inadequate pain management following a thoracotomy and upper lobectomy can lead to dyspnea, or difficulty breathing. The surgery involves the chest and lungs, making deep breathing and coughing painful activities. If the pain is not well-managed, the patient is likely to engage in shallow breathing to avoid the discomfort. Shallow breathing doesn’t allow for full lung expansion and can lead to inadequate gas exchange. This, in turn, can cause hypoxia (low levels of oxygen in the blood), leading to dyspnea as the body struggles to meet its oxygen needs.

Imagine your lungs as two bellows used to stoke a fire. When the bellows are fully expanded and compressed, they effectively fuel the fire, keeping it bright and warm. Now, imagine you have a sprained wrist, making the action of using the bellows painful. You might not expand and compress them as much as you should, leading to a weaker fire that eventually smolders and dies out. Similarly, after a thoracotomy and lobectomy, if the pain isn’t well-managed, the “fire” (in this case, efficient gas exchange in the lungs) becomes weak. The patient engages in shallow breathing to avoid the “pain” (sprained wrist in the analogy), leading to inadequate oxygenation and causing difficulty in breathing, or dyspnea.

The symptom of dyspnea is a red flag that should prompt immediate intervention. It indicates that the patient is not achieving adequate gas exchange, which can lead to more severe complications like atelectasis (lung collapse) and pneumonia if not addressed promptly. Effective pain management is crucial to allow the patient to breathe deeply and cough, thereby improving lung function and preventing complications.

Incorrect answer options:

A. Involuntary muscle spasms. While muscle spasms can occur in various situations, they are not the primary concern or the most likely immediate symptom to develop due to inadequate pain management following thoracic surgery. The focus here is on respiratory function.

C. Increased body temperature. An elevated body temperature could indicate an infection or other systemic issue but is not the immediate symptom likely to develop from inadequate pain management in this context. The primary concern is respiratory function.

D. Pallor (paleness). Pallor could be a sign of anemia or reduced blood flow but is not the immediate symptom to expect due to inadequate pain management following a thoracotomy and upper lobectomy. The main concern is ensuring adequate respiratory function to prevent complications like atelectasis and pneumonia.

11. Correct answer:

A. Pulse oximetry reading of 88. A pulse oximetry reading of 88 is a critical finding that requires immediate intervention. Normal pulse oximetry readings usually range from 95 to 100 percent. A reading below 90 is considered hypoxemic and indicates that the patient is not receiving enough oxygen. This could lead to tissue hypoxia and, if not corrected promptly, could result in severe complications such as organ failure. In the context of a recently inserted endotracheal tube, this could indicate improper tube placement, mucus plug, or another obstruction affecting airflow.

Imagine you’re driving a car with a fuel gauge that suddenly drops to the red zone. You wouldn’t continue driving, hoping it will improve on its own. You’d pull over and address the issue immediately, knowing that running out of fuel could damage the engine and leave you stranded. Similarly, a pulse oximetry reading of 88 is like your “fuel gauge” dropping into the red zone; it’s a sign that your body is not getting the “fuel” (oxygen) it needs to function properly, and immediate action is required.

Nurse Hannah should immediately check the endotracheal tube placement, suction any secretions, and adjust ventilator settings as needed. She should also notify the healthcare provider for further evaluation and intervention, which may include diagnostic tests like a chest X-ray or arterial blood gases, to determine the cause of the low oxygen levels and correct it promptly.

Incorrect answer options:

B. Client’s inability to speak. While the inability to speak is expected when a client has an endotracheal tube in place, it is not an immediate concern requiring urgent intervention in this context. The tube bypasses the vocal cords, making speech impossible, but this is a known and expected outcome.

C. Visible mist in the T-Piece of the breathing circuit. Visible mist in the T-Piece of the breathing circuit is actually a positive sign, indicating that humidification is occurring. This is generally a desired outcome and does not require immediate intervention.

D. Breath sounds that can be heard equally on both sides of the chest. Hearing breath sounds equally on both sides of the chest is a good sign, indicating that the endotracheal tube is likely well-placed and that both lungs are receiving ventilation. This is a normal finding and does not require immediate action.

12. Correct answer:

D. Monitoring and managing leukopenia (low white blood cell count). Leukopenia, or a low white blood cell count, should take priority in Nurse Martin’s care planning for a client receiving external beam radiation to the mediastinum for bronchial cancer. White blood cells are crucial for fighting off infections, and a low count makes the patient more susceptible to infections that can be severe or even life-threatening. Given that the patient is already dealing with bronchial cancer, an infection could significantly complicate the clinical picture and hamper treatment progress. Therefore, frequent monitoring of blood counts and implementation of infection control measures are essential.

Think of white blood cells as the security guards of a large, busy building. If suddenly the number of security guards is reduced, the building becomes more vulnerable to break-ins and other security issues. In the same way, a low white blood cell count leaves the body more vulnerable to infections, making it crucial to “increase security” by monitoring and managing leukopenia.

Nurse Martin should collaborate with the healthcare team to monitor the client’s white blood cell count regularly. If leukopenia is detected, interventions such as prophylactic antibiotics, growth factor administration, or even temporary cessation of radiation may be considered. Infection control measures like hand hygiene, sterile technique for invasive procedures, and isolation protocols may also be intensified to protect the patient.

Incorrect answer options:

A. Managing fatigue related to the treatment. While fatigue is a common side effect of radiation therapy, it is generally not life-threatening. Although important for quality of life, managing fatigue is secondary to monitoring and managing leukopenia, which has more immediate and potentially severe consequences.

B. Addressing esophagitis caused by radiation. Esophagitis can be a painful and uncomfortable side effect of radiation to the mediastinum, but it is generally not life-threatening. Symptomatic treatment can be provided, but this is not the priority when compared to the risk of severe infection due to leukopenia.

C. Treating skin irritation at the radiation site. Skin irritation is a common side effect of external beam radiation and, while it may cause discomfort, it is not the most critical issue to address. Topical treatments can manage the irritation, but the priority should be on monitoring and managing leukopenia to prevent severe infections.

13. Correct answer:

C. Reduce the oxygen flow rate. In a client with chronic obstructive pulmonary disease (COPD), administering oxygen at a high flow rate can lead to respiratory depression and hypercapnia (elevated levels of carbon dioxide in the blood). COPD patients often have a different respiratory drive that is more sensitive to oxygen levels rather than carbon dioxide levels. When given too much oxygen, their respiratory drive may be suppressed, leading to decreased respiratory rate and potential respiratory failure. The flushed color and low respiratory rate of 8/min are alarming signs that the client may be experiencing hypercapnia and respiratory depression.

Imagine driving a car that has a unique fuel system, one that can’t handle high-octane fuel. If you fill it up with high-octane fuel, the engine might stall or even get damaged. Similarly, a COPD patient’s respiratory system can’t handle high levels of oxygen (“high-octane fuel”), and giving too much can cause the “engine” (respiratory system) to stall (respiratory depression).

Nurse Emily should immediately reduce the oxygen flow rate to a safer level, typically 1-2 L/min for COPD patients, and closely monitor the client’s vital signs and oxygen saturation. She should also notify the healthcare provider for further evaluation and orders, which may include arterial blood gas analysis to assess the levels of oxygen and carbon dioxide in the blood.

Incorrect answer options:

A. Record the baseline vital signs. While recording vital signs is generally important, it is not the immediate priority in this situation. The client is showing signs of potential respiratory failure, and immediate intervention is needed to prevent life-threatening complications.

B. Position the client in a high Fowler’s position. Although positioning the client in a high Fowler’s position may facilitate better lung expansion and gas exchange, the immediate concern is the high oxygen flow rate that is likely causing respiratory depression. The oxygen flow rate needs to be adjusted first.

D. Obtain a 12-lead EKG to assess cardiac function. While cardiac function is important, the immediate concern is the respiratory status of the client. An EKG can be obtained later, once the immediate life-threatening issue of potential respiratory failure is addressed.

14. Correct answer:

A. “The tube is specifically designed to remove the excess air that’s trapped in your chest cavity.” In the case of a spontaneous pneumothorax, air leaks into the space between the lung and the chest wall, causing the lung to collapse. A chest tube is inserted to evacuate this trapped air, allowing the lung to re-expand and resume normal function. The tube is connected to a drainage system that uses suction to help remove the air, and it remains in place until the lung has fully re-expanded and the leak has sealed itself.

Imagine your lung as a beach ball at a pool party. Normally, the ball stays inflated and floats effortlessly on the water. However, if someone pokes a hole in the ball, air starts to escape, and the ball deflates. Now, imagine there’s a small, sealed chamber around the beach ball that also fills with air as the ball deflates. This extra air in the chamber prevents the beach ball from re-inflating even if you try to pump more air into it. The chest tube acts like a vacuum hose that removes the extra air from this chamber, allowing the beach ball (your lung) to inflate properly again.

Nurse James should explain to the patient that the chest tube will help remove the trapped air, allowing the lung to re-expand. This will alleviate the pressure on the lung and improve breathing. The tube will be connected to a drainage system that will collect the air, and healthcare providers will monitor the system to ensure it’s working effectively and to determine when the tube can be safely removed.

Incorrect answer options:

B. “The tube’s purpose is to seal up the hole present in your lung.” The chest tube does not directly seal the hole in the lung. Its primary function is to remove the trapped air, allowing the lung to re-expand. The body’s natural healing processes will work to seal the hole over time.

C. “The tube will be used to drain any accumulated fluid from inside your chest.” While chest tubes can be used to drain fluid in conditions like pleural effusion, the primary purpose in the case of a spontaneous pneumothorax is to remove trapped air, not fluid.

D. “The tube will regulate and control the amount of air that enters into your chest cavity.” The chest tube does not regulate the amount of air entering the chest cavity; rather, it removes excess air that has already entered the space between the lung and the chest wall.

15. Correct answer:

C. Vigilantly assess the child for post-operative arrhythmias. After surgery to correct a ventricular septal defect, the heart has been manipulated, and the electrical conduction system may be disturbed. This makes the child at high risk for developing post-operative arrhythmias, which can be life-threatening if not promptly identified and treated. Arrhythmias can compromise cardiac output, leading to inadequate perfusion and potentially causing damage to vital organs. Therefore, continuous cardiac monitoring should be a priority to detect any abnormal rhythms.

Imagine the heart as a well-coordinated orchestra, with each section (strings, woodwinds, brass, percussion) playing in harmony. The surgery is like a major disruption in the middle of a performance—maybe the conductor had to step away briefly. When the performance resumes, it’s crucial to listen carefully for any instruments that are out of tune or out of sync, as they can throw off the entire orchestra. Similarly, after heart surgery, Nurse Emily needs to “listen” carefully via cardiac monitoring for any “out-of-tune” heart rhythms that could disrupt the whole system.

Nurse Emily should keep the child on continuous cardiac monitoring, frequently assess the heart rate and rhythm, and be prepared to administer anti-arrhythmic medications as ordered. She should also collaborate with the healthcare team, including the cardiologist, to interpret the findings and determine the appropriate course of action, which may include further diagnostic tests or interventions.

Incorrect answer options:

A. Keep an eye on the equality of peripheral pulses. While assessing peripheral pulses is important for evaluating perfusion, it is not the immediate priority in this case. A significant arrhythmia could lead to poor perfusion, making the root cause—arrhythmia—the priority.

B. Listen attentively for any signs of pulmonary congestion. While pulmonary congestion could be a concern in cardiac patients, it is generally not the immediate post-operative priority when compared to the risk of life-threatening arrhythmias.

D. Check the nail beds for color and refill by blanching them. Although assessing nail bed color and capillary refill can provide information about peripheral perfusion, it is not the most critical assessment in the immediate post-operative period for a child who has undergone cardiac surgery to correct a ventricular septal defect.

16. Correct answer:

B. Assist the client to turn, cough, and take deep breaths regularly. Atelectasis is the collapse of alveoli, the tiny air sacs in the lungs, and is a common postoperative complication. It can lead to decreased oxygenation and can be a precursor to more serious conditions like pneumonia. One of the most effective ways to prevent atelectasis is to encourage the client to turn, cough, and take deep breaths regularly. This helps to expand the lungs fully, promoting better gas exchange and preventing the alveoli from collapsing.

Imagine your lungs as two balloons inside a box (your chest). Normally, these balloons are fully inflated, taking up the entire space in the box. However, after surgery, it’s as if someone has let some air out of the balloons. They’re not as full as they should be, and they’re not filling the box as they usually do. Now, if you don’t do anything to re-inflate those balloons, they’ll stay partially deflated, making it harder for them to do their job, which is to help you breathe.

Turning, coughing, and taking deep breaths are like using a hand pump to put air back into those balloons. Each turn is like a pump of air, each cough is like a burst of air to shake off any dust or particles sticking to the balloon, and each deep breath is like holding the pump in place to make sure the balloon stays inflated. The more you turn, cough, and breathe deeply, the better you inflate your “lung balloons,” helping them to fill the “box” and do their job effectively.

Nurse Sarah should educate the client on the importance of these actions and assist as needed, especially if the client is experiencing postoperative pain that makes these movements uncomfortable. She can also use incentive spirometry as a tool to encourage deep breathing. Regular monitoring of respiratory rates, breath sounds, and oxygen saturation levels will provide valuable data on the effectiveness of these interventions.

Incorrect answer options:

A. Ensure the client is ambulated within the first 12 hours post-surgery. While early ambulation is important for overall postoperative recovery and can aid in lung expansion, it is not the most effective single intervention for preventing atelectasis. Turning, coughing, and deep breathing directly target lung expansion and are more immediately effective.

C. Splint the surgical incision to minimize discomfort during movement. While splinting the surgical incision can make coughing and deep breathing less painful, it is not the primary intervention for preventing atelectasis. The focus should be on the actions that directly expand the lungs.

D. Maintain adequate hydration to keep secretions thin. While hydration is important for keeping secretions thin and easier to cough up, it is not the most effective measure for preventing atelectasis. The direct action of expanding the lungs through turning, coughing, and deep breathing is more effective.

17. Correct answer:

A. Serum potassium level at 6 mEq/L. In acute renal failure, the kidneys lose their ability to filter out waste and regulate electrolytes, including potassium. A serum potassium level of 6 mEq/L is dangerously high and can lead to severe cardiac arrhythmias or even cardiac arrest. Elevated potassium affects the electrical conduction system of the heart, leading to abnormal heart rhythms. Immediate intervention is required to lower the potassium level, which may include medications, dialysis, or other treatments as ordered by the physician.

Imagine your heart as a finely tuned musical instrument, like a piano, and potassium as the piano tuner. Just the right amount of potassium keeps the heart “in tune,” allowing it to beat regularly. Too much potassium, however, is like a piano tuner who tightens the strings too much, causing the piano to play off-key notes. In the same way, high potassium levels can make your heart “play” irregular rhythms, which can be life-threatening.

Nurse Sophia should immediately report this finding to the healthcare provider for prompt intervention. She should also prepare for immediate treatments like administering calcium gluconate, sodium bicarbonate, or other medications that can stabilize the cardiac membrane and lower potassium levels. Continuous cardiac monitoring should also be initiated if not already in place.

Incorrect answer options:

B. Blood urea nitrogen (BUN) at 50 mg/dl. While a BUN level of 50 mg/dl is elevated and indicates poor kidney function, it is not immediately life-threatening like a high potassium level. Elevated BUN levels require treatment but not as urgently as hyperkalemia.

C. Hemoglobin level of 10.3 mg/dl. A hemoglobin level of 10.3 mg/dl is low and may indicate anemia, but it is not an immediate life-threatening situation in the context of acute renal failure. Treatment to raise hemoglobin levels can be planned but is not as urgent as addressing hyperkalemia.

D. Venous blood pH reading of 7.30. A venous blood pH of 7.30 indicates acidemia, which is a concern but not as immediately life-threatening as a potassium level of 6 mEq/L. Acid-base imbalances do require treatment but are generally not as urgently addressed as severe electrolyte imbalances like hyperkalemia.

18. Correct answer:

A. “I have a known allergy to shellfish like shrimp.” A myelogram involves the injection of a contrast dye into the spinal column to visualize the spinal cord and surrounding structures. An allergy to shellfish like shrimp is a significant contraindication because the iodine-based contrast material used in a myelogram can trigger an allergic reaction in individuals who are allergic to shellfish. This could lead to anaphylaxis, a severe and potentially life-threatening allergic reaction that requires immediate medical intervention.

Imagine you’re baking a cake and you know one of your guests is allergic to nuts. You wouldn’t use a recipe that includes nuts, as it could cause a severe allergic reaction for that guest. Similarly, if a patient has a known allergy to shellfish, using an iodine-based contrast dye could be like adding nuts to the cake—it’s a risky ingredient that could cause a severe reaction.

Nurse Karen should immediately inform the healthcare provider about the client’s shellfish allergy so that alternative imaging methods can be considered. In some cases, a different type of contrast material may be used, or the provider may opt for a different diagnostic test altogether. Pre-procedure allergy testing may also be considered to confirm the allergy and assess the risk.

Incorrect answer options:

B. “I had a really severe headache the last time I got a spinal tap.” While a previous adverse reaction like a severe headache (post-dural puncture headache) is noteworthy, it is not a contraindication for a myelogram. Precautions can be taken to minimize the risk of a headache.

C. “It’s challenging for me to remain in a single position for more than half an hour.” While this could make the procedure more challenging, it is not a contraindication. The healthcare team can take measures to make the client as comfortable as possible during the procedure.

D. “I struggle with claustrophobia and enclosed spaces.” Claustrophobia is a concern, especially if the myelogram is followed by imaging tests like MRI or CT scans that involve enclosed spaces. However, it is not a contraindication for the myelogram itself. Anti-anxiety medication could be administered to help the client cope with the procedure.

19. Correct answer:

A. Absence of pulse in the extremity where the catheter was inserted. The absence of a pulse in the extremity where the catheter was inserted is a critical sign that could indicate a vascular complication, such as arterial occlusion or thrombosis. This is a serious issue that could lead to tissue ischemia and necrosis if not promptly addressed. Immediate intervention, which may include medications to dissolve the clot or surgical intervention, is essential to restore blood flow to the affected extremity.

Imagine a busy highway where traffic flows smoothly. If there’s a sudden roadblock, cars can’t move, leading to a traffic jam and potential chaos. Similarly, your blood vessels are like highways for blood flow. If a clot forms (the roadblock), blood can’t get through, leading to potential harm to the tissues that rely on that blood flow. Just as you’d urgently remove a roadblock on a highway, immediate action is needed to restore blood flow in the affected vessel.

Nurse Alex should immediately notify the healthcare provider and prepare for potential interventions, which may include diagnostic tests to confirm the issue, medications to dissolve the clot, or even surgical intervention. Time is of the essence in such situations, and prompt action is crucial to prevent irreversible damage to the tissues supplied by the affected artery.

Incorrect answer options:

B. Elevated heart rate post-procedure. An elevated heart rate post-procedure is not uncommon and could be related to stress, pain, or the body’s response to the procedure itself. While it should be monitored, it is not a definitive sign of a complication specifically related to cardiac catheterization.

C. Increased blood pressure levels. Like an elevated heart rate, increased blood pressure levels post-procedure could be due to various factors such as stress or pain. While it should be managed, it is not a direct indication of a complication from the cardiac catheterization.

D. Reduced urine output following the procedure. Reduced urine output could be concerning for kidney function, especially if contrast dye was used during the procedure. However, it is not a direct sign of a complication related to the site of catheter insertion and would require broader assessment and intervention.

20. Correct answer:

B. Immediately contact the surgeon to report the finding. When Nurse Benjamin observes 200 cc of dark, red fluid flowing into the collection chamber of the chest drain, it is a critical sign that could indicate active bleeding. This is a medical emergency that requires immediate intervention. The dark red color of the fluid suggests that the blood is fresh, indicating ongoing bleeding. If not addressed promptly, this could lead to hypovolemia, shock, and potentially life-threatening complications.

Imagine you’re filling a water balloon at a faucet, and you expect a slow, steady fill. Suddenly, water starts gushing out rapidly, and the balloon expands at an alarming rate. You wouldn’t just stand there and watch; you’d immediately turn off the faucet and check for any issues with the balloon or the faucet. Similarly, the chest tube is designed for a controlled drainage of air and fluids. When you see a sudden surge of dark, red fluid, it’s like that water balloon filling too quickly; it’s a sign that something is wrong and needs immediate attention.

In this case, Nurse Benjamin should act like you would with a rapidly filling water balloon: immediately call for professional help—in this case, the surgeon—to identify and fix the issue before it leads to severe complications.

Nurse Benjamin should immediately contact the surgeon to report the finding. He should also prepare for potential immediate interventions, which could include surgical exploration to identify and control the source of the bleeding, administering blood products, or other treatments as directed by the healthcare provider. Time is of the essence, and prompt action is crucial.

Incorrect answer options:

A. Elevate the client’s legs to improve venous return. Elevating the legs can indeed improve venous return to the heart, which might be useful in cases of shock or low blood pressure. However, in this specific situation, the primary concern is the sudden and significant drainage of dark, red fluid, indicative of active bleeding. Elevating the legs does not address this immediate, life-threatening issue and could potentially delay the necessary surgical intervention. It’s like trying to fix a burst pipe by adjusting the water pressure; it doesn’t solve the root problem.

C. Get ready to administer a blood transfusion as a precaution. Preparing for a blood transfusion might seem like a proactive step, but it’s not the immediate action needed here. The key is to identify the source of the bleeding, which only the surgeon can definitively do. Administering a blood transfusion without addressing the root cause is akin to refilling a leaking gas tank without fixing the leak; you might temporarily replace what’s lost, but you haven’t solved the problem.

D. Apply a clamp to the chest tube to stop the drainage. While it might seem logical to stop the flow of blood by clamping the chest tube, this action could lead to other severe complications, such as tension pneumothorax. Clamping the tube without a surgeon’s guidance is like putting a band-aid on a deep wound that requires stitches; it may stop the bleeding temporarily but doesn’t address the underlying issue and could make things worse.