Final Exam Sample Questions Flashcards
Yesterday Hemoglobin was 13, today hemoglobin is 11. What part of the chest tube system should be monitored related to these lab values?
Monitor collection chamber output
Based on a decreased hemoglobin the nurse should review a chest tube patient’s medication record for which class of medications that can increase procedure related blood loss?
anticoagulants, aspirin, anti platelets
How often should the nurse note the chest tube drainage based on decreasing hemoglobin?
every hour
The nurse would notify the physician if there is more than how may mL of bloody drainage in an hour.
70 mL per hour is considered hemorrhage
The purpose of a patient’s chest tube is to:
remove air or blood from the pleura space so the lung can re inflate
Is the chest tube drainage system emptied when full?
No, dispose of the whole system in the bio hazard area to prevent contact with blood.
What supplied would the nurse bring to the bedside to assist with removal of a chest tube?
sterile gloves, face shield, pulse oximeter, sterile petrolatum gauze, sterile scissors
Teach a patient to perform the Valsalva maneuver during chest tube insertion
True
Never clamp the chest tube catheter
True
Keep the chest tube drainage system below the level of the lung
True
The surgeon will remove the chest tube when there is an increase or decrease in drainage?
decrease
The surgeon will remove the chest tube when the nurse auscultated lung resonance or lung hyper resonance
resonance
The surgeon will remove the chest tube when water seal tidaling is observed or when water seal is bubbling
water seal tidaling is normal, continuous bubbling is not normal
The surgeon will remove the chest tube when respiratory rate is 24 or when SaO2 is 89%
respiratory rate 24
The surgeon will remove the chest tube when bright red drainage is observed or when serous drainage is observed
serous drainage
A nurse is caring for a client with acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?
a. auscultate the lungs
b. assist the client to a side lying position
c. provide oral hygiene
d. withhold oral fluids and foods
d. withhold oral fluids and foods
A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?
a. decrease fluid intake
b. increase saturated fat intake
c. increase sodium intake
d. decrease carbohydrate intake
a. decrease fluid intake
A nurse is reviewing the labs of a patient with liver failure with ascites and is receiving spironolactone. Which of the following findings should the nurse expect?
a. decrease sodium level
b. decreased phosphate level
c. decreased potassium level
d. decreased chloride level
a. decreased sodium level
A nurse is caring for a patient with liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following lab findings as indicating the client GI tract is digesting and absorbing blood?
a. elevated BUN
b. elevated a1c
c. decreased chloride
d. decreased bilirubin
a. elevated BUN
A nurse is caring for a client with active upper GI bleed. After inserting a NG tub into the client, which of the following findings should the nurse anticipate?
a. frothy pink drainage
b. dark amber drainage
c. coffee ground drainage
d. greenish yellow drainage
c. coffee ground drainage
A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition at home. Which of the following instructions should the nurse include? Select all that apply
a. Keep the TPN refrigerated when not in use
b. infuse 10 percent dextrose and water is the solution runs out
c. shake the TPN bag with fat emulsion if precipitate is present
d. stop using TPN once weight gain is achieved
e. maintain TPN infusion rate when behind schedule
a. keep the TPN refrigerated when not in use
b. infuse 10 percent dextrose in water if the solution runs out
e. maintain TPN infusion rate when behind schedule
A nurse is assessing a client who is receiving TPN. Which of the following finding should the nurse recognize as a complications of therapy?
a. hyperglycemia
b. aspiration
c. diarrhea
d. stomatitis
a. hyperglycemia, check blood glucose level every 4 hours
A nurse is caring for a client who is receiving TPN. The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives?
a. dextrose 5% in water
b. 0.9% sodium chloride
c. dextrose 10% in water
d. lactated ringer’s solution
c. dextrose 10% in water
A nurse is teaching a client who is about to undergo the insertion of a non-tunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
a. I will have to stay in bed for several hours after the procedure.
b. I will turn my head in the opposite direction during insertion
c. I will need to hold my breath when they first put the needle in.
d. I will call the clinic if I have persistent hiccups.
b. I will turn my head in the opposite direction during insertion.
The patient should perform the Valsalva maneuver when the provider detaches the syringe from the needle after insertion to prevent air embolus.
Always use a 10mL syringe to flush the CVAD.
True
Use sterile technique when accessing a implanted CVAD with the Huber needle
True
A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?
a. They are going to examine my gallbladder and ducts.
b. Soon those shock waves will get rid of my gallstones.
c. I’ll have a camera put down my throat so they can see my gallbladder.
d. They will put medication into my gallbladder to dissolve the stones.
a. They are going to examine my gallbladder and ducts.
lithotripsy dissolves stones with shock waves.
A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for the procedure?
a. high Fowler’s
b. side lying
c. leaning forward
d. supine
a. high Fowler’s
A nurse is planning care for a client who has end stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client’s ammonia level?
a. administer diuretics
b. restrict the client’s intake of fluids
c. reduce the client’s intake of protein
d. administer vitamin K
c. reduce the client’s intake of protein
In evaluating an HIV positive patient’s response to antiviral therapy, which data indicates a positive response?
a. increased viral load
b. increased BUN
c. increased DC4 count
d. increased creatinine
c. increased CD4 count
Zidovudine, used to treat HIV/AIDS, most concerning side effect is
bone marrow suppression, leading to anemia, neuropenia, and thrombocytopenia. Also watch for hepatomegaly, pancreatitis, and liver toxicity
