exam 3

Question 1

The ICU nurse is caring for a patient who has a chest tube inserted for management of pneumothorax. Which of the following observations would prompt the nurse to contact the physician following assessment?

Answer 1

Continuous bubbling in the water seal compartment

Question 2

The nurse is educating a client with ascites about an upcoming paracentesis. Which statement by the client indicates that client understands the procedure.

Answer 2

The doctor will insert a needle in my abdomen to drain fluid

Question 3

The nurse is caring for a pt on a ventilator. The pt develops restlessness, tachycardia, tachypnea, brief episodes of hypertension, cyanosis, diaphoresis, and urinary output. The nurse recognizes that the pt is experiencing which of the following complications of mechanical ventilation?

Answer 3

Pneumothorax
Barotrauma

Question 4

The client dx with portal hypertension and ascites is prescribed a 2-gram sodium diet. Which of the following statements by the pt. would indicate that the patient understands this dietary restriction?

Answer 4

I will season my food w/ oregano or thyme

Question 4

A patient diagnosed with bladder cancer is to receive intravesical chemotherapy. Which of the following pre procedure instructions should the nurse give to the patient?

Answer 4

Hold the solution in the bladder for two hours

Question 5

The HCP is preparing to insert a chest tube in an alert and oriented client. Which intervention should the nurse implement first?

Answer 5

Participate in obtaining informed consent for the procedure

Question 6

The patient diagnosed with end stage liver failure is admitted to the ICU w/ bleeding esophageal varices. The doctor initiates balloon tamponade therapy. Which intervention would the nurse implement?

Answer 6

Stay with the client at all times

Question 7

A patient diagnosed with esophageal cancer is recovering from an esophageal resection and has had the nasogastric tube removed. Which of the following nursing interventions would be important to implement to prevent complications? SATA

Answer 7

Watch cardiac monitor closely
Encourage use of incentive spirometry every hr.
Monitor patient temp. every 4 hr.
Assist the patient to sit up in the chair

Question 8

A pt. admitted with severe exacerbation of COPD and needs assisted ventilation. The client refuses to be intubated. Which type of ventilation would the nurse expect to be ordered for this client?

Answer 8

Non-invasive positive pressure

Question 9

The nurse is reviewing the chart of 66 yr old male patient who has been dx. With bladder cancer. The nurse notes the following data in the chart: family hx of bladder cancer, employment in a paint manufacturing company for 15 yrs. And smokes 1 pack of cigarettes a day. Which of the following modifiable risk factors would the nurse address when educating the client on his condition?

Answer 9

Tobacco use

Question 10

The nurse is assessing a pt w/ a water seal chest drainage system. The nurse notes a rise in water level to 20 cm and it has not returned to baseline. What should the nurse do?

Answer 10

Document that the water level in the drainage system is correct.

Question 11

Which of the following meds would the nurse expect to be ordered for a pt following esophageal resection to promote gastrointestinal motility?

Answer 11

Metoclopramide

Question 12

The nurse is caring for a pt who was in a motor vehicle accident and has a renal contusion with hematuria. Which of the following nursing dx takes priority in the patient’s plan of care?

Answer 12

ineffective renal tissue perfusion

Question 13

The nurse is assessing a newly admitted patient with cirrhosis and ascites what specific interventions should be included in the pt’s plan of care select all.

Answer 13

*Abdominal Girth increase (4cm)
Increase Bilirubin level (monitor cmp and cbc)
Increase of ammonia
weigh pt

Question 14

A pt is recovering from an endoscopy to verify esophageal varices. The pt is complaining of thirst and wants water. What is the appropriate initial nursing action?

Answer 14

Check the client gag reflex

Question 15

The nurse is providing a pt w/ discharge instructions after a transurethral resection of the prostate for prostate cancer. The nurse should inform the pt to call the hcp immediately for which of the following?

Answer 15

hematuria and bladder spasms

Question 16

A pt presents to the ED w/ an enlarged abdomen, distended abdominal veins, striae, SOB and abdominal discomfort, and a sodium level of 126. The nurse recognizes these symptoms as being consistent with which of the following diagnoses?

Answer 16

Portal hypertension

Question 17

What specific intervention should the nurse perform on a pt admitted w/ hepatic encephalopathy?

Answer 17

assess neurological status

Question 18

Which of the following interventions would be included in the plan of care for a pt on a ventilator w/ a tracheostomy?

Answer 18

Maintain tracheostomy cuff pressure between 20 and 25 mm Hg

Question 19

The nurse is called to the pt room by the UAP when the clients chest tube is accidentally disconnected from the drainage system. Which intervention by the nurse would be appropriate?

Answer 19

Immerse the chest tube open end into sterile water

Question 20

A hospitalized pt w/ terminal prostate cancer is cachexic and refuses to eat b/c of anorexia. Which nursing action would implement?

Answer 20

consults the family and the dietician about foods the client will eat

Question 21

A nurse is caring for pt on mechanical ventilation who is receiving an infusion of propofol. Which of the following findings would indicate to the nurse that the pt is developing propofol infusion syndrome?

Answer 21

Elevation of lactic acid and ck levels

*Rhabdomyolysis, Metabolic Acidosis, Elevate Lactic acid *Skeletal Muscle Relaxant

Question 22

A 55 yr old pt undergoes a TRUP and biopsy procedure for prostate cancer and receives a gleason score of 3 w/ localization to the prostate. The nurse anticipates which of the following treatment modalities as a follow up?

Answer 22

External beam radiation therapy

Question 22

The nurse is caring for a pt on mechanical vent. who has previously been resting quietly. The pt suddenly begins thrashing and becomes diaphoretic and tachycardic, w/ wide open eyes and a look of fear. What should be the nurse’s first action?

Answer 22

Assess the pt respiratory status

Question 23

The nurse is conducting a wellness class for a group for a African American pt. when addressing the topic of health screening, the nurse informs the group about which recommendations by the American cancer society for early detection of prostate cancer?

Answer 23

Digital rectal exam by age 45

Question 24

Nursing actions important to prevent a ventilated pt from developing pneumonia include which of the following? sata

Answer 24

Decrease sedative doses periodically
Implement measures to prevent DVT
Provide frequent oral care w/ hydrogen peroxide
Begin peptic ulcer disease prophylaxis

Question 25

The pt w/ hepatic encephalopathy is having difficulty with handwriting and cannot draw a star figure when asked to do so. The nurse documents that the patient is experiencing which of the following phenomenon?

Answer 25

Constructional apraxia

Question 26

Which of the following statements by a client w/ a ureter sigmoid ostomy would indicated understanding of this procedure?

Answer 26

I Will not have to wear an appliance

Question 27

A pt w/ a drug overdose is placed on a ventilator. Which of the following situations would require the nurse to intervene?

Answer 27

The client’s pulse oximetry is 86%

Question 28

Which of the following would indicate to the nurse the effective cough technique had been taught to a thoracotomy pt successfully?

Answer 28

clear lungs after

Question 29

The pt w/ ascites has not been compliant w/ a low sodium diet alone and the HCP decides to add a diuretic to the treatment regimen. The provider prescribes acetazolamide to taken daily in addition to the diet restriction. What should the nurse’s next action be?

Answer 29

Question the order for potential side effects

Question 30

The nurse is preparing to assist w/ a paracentesis. The HCP orders an infusion of low sodium albumin. The nurse knows that the purpose of an albumin infusion with a paracentesis is which of the following?

Answer 30

Prevent reaccumulating of fluid by increasing blood volume

Question 30

A preceptor and a student nurse are making rounds on the pt assignments for the day. After leaving the room of a patient with ascites, the student asks the preceptor how the fluid accumulates. How should the preceptor explain the pathophysiology of ascites?

Answer 30

Increased pressure in the portal system and resulting vasodilation causes leakage into the abdominal cavity

Question 31

The nursing is caring for a pt admitted w/ cirrhosis and ascites. Which manifestation would indicate to the nurse that the pt. conditions is getting worse?

Answer 31

Increase in abdominal girth of 4 centimeters

Question 32

The nurse is caring for a pt after thoracotomy for lung cancer. Which of the following assessment findings would prompt the nurse to notify HCP immediately?

Answer 32

The patient is coughing up pink, frothy sputum.

Question 33

The nurse has identified the nursing dx, “disturbed body image” for a client with bladder cancer who has just undergone an ileal conduit procedure. Which of the following goal statements would be appropriate for the client?

Answer 33

client will successfully perform stoma care
client will initiate the process of changing the pouch
client will openly discuss feelings about the procedure

Question 34

Which of the following pt data would indicate to the nurse that a 68 kg patient may be ready for ventilator weaning?

Answer 34

Minute ventilation of 6L/min

Question 35

The nurse is caring for a pt on mechanical ventilation. The nurse hears a ventilator alarm go off and enters the patient’s room. The patient does not seem to be in distress. What should the nurse do first?

Answer 35

Check Ventilator to determine cause

Question 36

The nurse is providing medication education to a client diagnosed with hepatic encephalopathy. When reviewing the client’s prescription for Lactulose, the nurse informs the client that the primary purpose of taking Lactulose is which of the following?

Answer 36

Lower ammonia levels

Question 37

An ICU nurse precepting a newly licensed nurse caring for a pt with Adult Respiratory Distress Syndrome (ARDS) who is on a high frequency oscillatory support ventilator. Which statement by the new nurse indicates an understanding of this type of ventilator?

Answer 37

It delivers rapid small pulses of air

Question 38

The nurse is assessing a client with hepatic encephalopathy. The patient is drowsy, disoriented, agitated, and displays asterixis and fetor hepaticus. The nurse would document these findings as being constant with which stage of encephalopathy?

Answer 38

Stage 2

Question 39

A pt on mechanical ventilation is prescribed pantoprazole. The nurse knows the indication for this prescription is which of the following?

Answer 39

Prevent stress ulcers

Question 40

A pt is prescribed goserelin (Zoladex) as a hormonal treatment for prostate cancer. Which of the following actions should the nurse direct the patient to do related to this medication?

Answer 40

Monitor blood glucose levels regularly

Question 41

A patient with liver disease and jaundice is experiencing intense pruritus. The UAP is assisting the client with morning care. Which action by the UAP would prompt the nurse to intervene?

Answer 41

Taking a hot and soapy shower

Question 42

The wound care nurse is providing education to a client who has had cutaneous urinary diversion procedure for bladder cancer. Which of the following points should be included when discussing care of the stoma and appliance with client? Sata

Answer 42

Monitor the stoma for infection.
Shower with non-moisturizer soap and body wash
Limit asparagus, egg and cheeses
Take vitamin C

Question 43

An 78- yr old pt who has had a thoracotomy w/ a chest tube placed is initially prescribed tramadol for pain. Prior to starting the tramadol, the nurse reviews the client’s chart. The client has a hx of hypertension, osteoarthritis, and neuropathic pain form diabetes. The client is also prescribed and antihypertensive, an SSRI, aspirin 81 mg and metformin. Which of the elements of the pt hx would cause concern for the nurse?

Answer 43

SSRI

Question 44

A student nurse is caring for a pt. w/ cirrhosis. The nurse preceptor is explaining to the student that the patient has hepatocellular jaundice. The instructor knows that the student understands the concept of hepatocellular jaundice when the student says which of the following?

Answer 44

Damage liver cell are unable to get rid of bilirubin causing it to build up

Question 45

A pt dx with esophageal cancer is recovering from esophageal resection and has a nasal gastric tube removed which of the following nursing interventions would be important to implement to prevent complications?

Answer 45

Encourage use o fIncentive Spirometry Monitor
Temperature every 4 hour
Watch Cardiac monitoring closely
Assist Patient to sit up in chair

Question 46

The nurse is conducting education with a client DX with esophageal varices. Which of the following will the nurse tell the client to avoid?

Answer 46

Do Not Take Aspirin
Do Not drink Tomato Juice (acidic drinks)
Do Not Drink Alcohol
Do Not Strain at Stooling
Do Not Lift Heavy Object

Question 47

The nurse is prepared to assist a provider with chest tube removal. Which of the following will the nurse perform to select all that apply.

Answer 47

Pre-mediate prior to removal per doctor order
Gather supplies needed including guaze
Place patient in semi-fowler position