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NCLEX Practice Exam for Reduction of Risk Potential (PM)
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Question 1
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?
A
Disconnect the client from the ventilator and use a manual resuscitation bag
B
Perform a quick assessment of the client’s condition
C
Call the respiratory therapist for help
D
Press the alarm re-set button on the ventilator
Question 1 Explanation:
A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
Question 2
The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:
A
Apply pressure at the bleeding site
B
Wrap the leg with elastic bandages
C
Reinforce the dressing and elevate the leg
D
Remove the dressings and re-dress the incision
Question 2 Explanation:
Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.
Question 3
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?
A
Blood urea nitrogen 50 mg/dl
B
Serum potassium 6 mEq/L
C
Venous blood pH 7.30
D
Hemoglobin of 10.3 mg/dl
Question 3 Explanation:
Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
Question 4
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?
A
Take baseline vital signs
B
Lower the oxygen rate
C
Place client in high Fowler’s position
D
Obtain a 12-lead EKG
Question 4 Explanation:
A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.
Question 5
A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?
A
Reassess the foot in fifteen minutes
B
Administer the ordered prn medication
C
Readjust the traction
D
Notify the physician
Question 5 Explanation:
The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.
Question 6
A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?
A
Prepare for blood transfusion
B
Continue to monitor the rate of drainage
C
Call the surgeon immediately
D
Clamp the chest tube
Question 6 Explanation:
Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
Question 7
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
A
“The tube controls the amount of air that enters your chest.”
B
“The tube will seal the hole in your lung.”
C
“The tube will drain fluid from your chest.”
D
“The tube will remove excess air from your chest.”
Question 7 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 8
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
A
Blanch nail beds for color and refill
B
Auscultate for pulmonary congestion
C
Assess for post operative arrhythmias
D
Monitor equality of peripheral pulses
Question 8 Explanation:
The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
Question 9
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
A
Increased temperature
B
Pallor
C
Involuntary muscle spasms
D
Dyspnea
Question 9 Explanation:
Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
Question 10
The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
A
“I developed a severe headache after a spinal tap.”
B
“I suffer from claustrophobia.”
C
“I am allergic to shrimp.”
D
“I can’t lie in one position for more than thirty minutes.”
Question 10 Explanation:
A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.
Question 11
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
A
Clamp the chest tube
B
Call the surgeon immediately
C
Prepare for blood transfusion
D
Continue to monitor the rate of drainage
Question 11 Explanation:
Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest
Question 12
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
A
“The tube will remove excess air from your chest.”
B
“The tube controls the amount of air that enters your chest.”
C
“The tube will seal the hole in your lung.”
D
“The tube will drain fluid from your chest.”
Question 12 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 13
The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?
A
Client is unable to speak
B
Pulse oximetery of 88
C
Breath sounds can be heard bilaterally
D
Mist is visible in the T-Piece
Question 13 Explanation:
Pulse oximetry should not be lower than 90.
Question 14
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
A
Range of motion exercises
B
Incisional healing
C
Coughing and deep breathing
D
Relaxation and sleep
Question 14 Explanation:
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Question 15
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
A
Blood urea nitrogen 50 mg/dl
B
Serum potassium 6 mEq/L
C
Hemoglobin of 10.3 mg/dl
D
Venous blood pH 7.30
Question 15 Explanation:
Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
Question 16
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
A
Incisional healing
B
Incisional healing
C
Deep breathing and coughing
D
Relaxation and sleep
Question 16 Explanation:
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Question 17
The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:
A
Maintain adequate hydration
B
Ambulate client within 12 hours
C
Splint incision
D
Assist client to turn, cough and deep breathe
Question 17 Explanation:
Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
Question 18
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
A
Esophagitis
B
Leukopenia
C
Fatigue
D
Skin irritation
Question 18 Explanation:
Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
Question 19
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?
A
Monitor equality of peripheral pulses
B
Assess for post operative arrhythmias
C
Blanch nail beds for color and refill
D
Auscultate for pulmonary congestion
Question 19 Explanation:
The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
Question 20
A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
A
Increased heart rate
B
Loss of pulse in the extremity
C
Increased blood pressure
D
Decreased urine output
Question 20 Explanation:
Loss of the pulse in the extremity would indicate impaired circulation.
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NCLEX Practice Exam for Reduction of Risk Potential (EM)
Choose the letter of the correct answer. You got 20 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed NCLEX Practice Exam for Reduction of Risk Potential (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?
A
Notify the physician
B
Reassess the foot in fifteen minutes
C
Administer the ordered prn medication
D
Readjust the traction
Question 1 Explanation:
The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.
Question 2
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?
A
Press the alarm re-set button on the ventilator
B
Perform a quick assessment of the client’s condition
C
Call the respiratory therapist for help
D
Disconnect the client from the ventilator and use a manual resuscitation bag
Question 2 Explanation:
A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
Question 3
The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
A
“I developed a severe headache after a spinal tap.”
B
“I can’t lie in one position for more than thirty minutes.”
C
“I am allergic to shrimp.”
D
“I suffer from claustrophobia.”
Question 3 Explanation:
A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.
Question 4
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
A
Pallor
B
Increased temperature
C
Dyspnea
D
Involuntary muscle spasms
Question 4 Explanation:
Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
Question 5
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?
A
Place client in high Fowler’s position
B
Lower the oxygen rate
C
Take baseline vital signs
D
Obtain a 12-lead EKG
Question 5 Explanation:
A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.
Question 6
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
A
Deep breathing and coughing
B
Relaxation and sleep
C
Incisional healing
D
Incisional healing
Question 6 Explanation:
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Question 7
A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?
A
Call the surgeon immediately
B
Prepare for blood transfusion
C
Continue to monitor the rate of drainage
D
Clamp the chest tube
Question 7 Explanation:
Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
Question 8
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
A
“The tube will seal the hole in your lung.”
B
“The tube controls the amount of air that enters your chest.”
C
“The tube will remove excess air from your chest.”
D
“The tube will drain fluid from your chest.”
Question 8 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 9
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
A
“The tube will drain fluid from your chest.”
B
“The tube will remove excess air from your chest.”
C
“The tube controls the amount of air that enters your chest.”
D
“The tube will seal the hole in your lung.”
Question 9 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 10
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
A
Hemoglobin of 10.3 mg/dl
B
Blood urea nitrogen 50 mg/dl
C
Venous blood pH 7.30
D
Serum potassium 6 mEq/L
Question 10 Explanation:
Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
Question 11
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
A
Leukopenia
B
Skin irritation
C
Esophagitis
D
Fatigue
Question 11 Explanation:
Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
Question 12
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?
A
Venous blood pH 7.30
B
Serum potassium 6 mEq/L
C
Hemoglobin of 10.3 mg/dl
D
Blood urea nitrogen 50 mg/dl
Question 12 Explanation:
Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
Question 13
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
A
Call the surgeon immediately
B
Continue to monitor the rate of drainage
C
Prepare for blood transfusion
D
Clamp the chest tube
Question 13 Explanation:
Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest
Question 14
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
A
Relaxation and sleep
B
Incisional healing
C
Range of motion exercises
D
Coughing and deep breathing
Question 14 Explanation:
The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Question 15
A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
A
Decreased urine output
B
Loss of pulse in the extremity
C
Increased blood pressure
D
Increased heart rate
Question 15 Explanation:
Loss of the pulse in the extremity would indicate impaired circulation.
Question 16
The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:
A
Splint incision
B
Ambulate client within 12 hours
C
Maintain adequate hydration
D
Assist client to turn, cough and deep breathe
Question 16 Explanation:
Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
Question 17
The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:
A
Apply pressure at the bleeding site
B
Reinforce the dressing and elevate the leg
C
Wrap the leg with elastic bandages
D
Remove the dressings and re-dress the incision
Question 17 Explanation:
Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.
Question 18
The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?
A
Breath sounds can be heard bilaterally
B
Mist is visible in the T-Piece
C
Pulse oximetery of 88
D
Client is unable to speak
Question 18 Explanation:
Pulse oximetry should not be lower than 90.
Question 19
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
A
Monitor equality of peripheral pulses
B
Auscultate for pulmonary congestion
C
Assess for post operative arrhythmias
D
Blanch nail beds for color and refill
Question 19 Explanation:
The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
Question 20
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?
A
Auscultate for pulmonary congestion
B
Monitor equality of peripheral pulses
C
Blanch nail beds for color and refill
D
Assess for post operative arrhythmias
Question 20 Explanation:
The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
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1. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
Relaxation and sleep
Deep breathing and coughing
Incisional healing
Range of motion exercises
2. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
Clamp the chest tube
Call the surgeon immediately
Prepare for blood transfusion
Continue to monitor the rate of drainage
3. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
Blood urea nitrogen 50 mg/dl
Hemoglobin of 10.3 mg/dl
Venous blood pH 7.30
Serum potassium 6 mEq/L
4. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
Blanch nail beds for color and refill
Assess for post operative arrhythmias
Auscultate for pulmonary congestion
Monitor equality of peripheral pulses
5. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
“The tube will drain fluid from your chest.”
“The tube will remove excess air from your chest.”
“The tube controls the amount of air that enters your chest.”
“The tube will seal the hole in your lung.”
6. A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?
Notify the physician
Readjust the traction
Administer the ordered prn medication
Reassess the foot in fifteen minutes
7. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?
Obtain a 12-lead EKG
Place client in high Fowler’s position
Lower the oxygen rate
Take baseline vital signs
8. The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:
Wrap the leg with elastic bandages
Apply pressure at the bleeding site
Reinforce the dressing and elevate the leg
Remove the dressings and re-dress the incision
9. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?
Disconnect the client from the ventilator and use a manual resuscitation bag
Perform a quick assessment of the client’s condition
Call the respiratory therapist for help
Press the alarm re-set button on the ventilator
10. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?
Blood urea nitrogen 50 mg/dl
Hemoglobin of 10.3 mg/dl
Venous blood pH 7.30
Serum potassium 6 mEq/L
11. A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?
Clamp the chest tube
Call the surgeon immediately
Prepare for blood transfusion
Continue to monitor the rate of drainage
12. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
Relaxation and sleep
Coughing and deep breathing
Incisional healing
Range of motion exercises
13. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Pallor
Increased temperature
Dyspnea
Involuntary muscle spasms
14. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?
Breath sounds can be heard bilaterally
Mist is visible in the T-Piece
Pulse oximetery of 88
Client is unable to speak
15. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
Esophagitis
Leukopenia
Fatigue
Skin irritation
16. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
“The tube will drain fluid from your chest.”
“The tube will remove excess air from your chest.”
“The tube controls the amount of air that enters your chest.”
“The tube will seal the hole in your lung.”
17. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?
Blanch nail beds for color and refill
Assess for post operative arrhythmias
Auscultate for pulmonary congestion
Monitor equality of peripheral pulses
18. The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:
Maintain adequate hydration
Assist client to turn, cough and deep breathe
Ambulate client within 12 hours
Splint incision
19. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
“I can’t lie in one position for more than thirty minutes.”
“I am allergic to shrimp.”
“I suffer from claustrophobia.”
“I developed a severe headache after a spinal tap.”
20. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
Increased blood pressure
Increased heart rate
Loss of pulse in the extremity
Decreased urine output
Answers and Rationales
Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest
Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Answer A. The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.
Answer C. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.
Answer C. Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.
Answer B. A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.
Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
Answer C. Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
Answer C. Pulse oximetry should not be lower than 90.
Answer B. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
Answer B. Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
Answer B. A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.
Answer C. Loss of the pulse in the extremity would indicate impaired circulation.