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NURA 308 EXAM 3 PRACTICE QUESTIONS AND ANSWERS
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NURA 308 EXAM 3 PRACTICE QUESTIONSAND ANSWERS
The nurse has provided education to a client diagnosed with a pleural
effusion who is scheduled for a thoracentesis. Which client statement
indicates an understanding of the teaching?
A. "I will have a tube left in my chest to drain the fluid."
B. "The fluid removed during the procedure can be examined to
determine what caused the pleural effusion."
C. "I will be under general anesthesia during the procedure."
D. "During the procedure, an antibiotic will be put into the needle to
prevent a lung infection." - ANSWER B. "The fluid removed during the
procedure can be examined to determine what caused the pleural
effusion."
When caring for a client diagnosed with pleural effusion, the nurse
should begin by explaining that pleural effusion is an accumulation of
fluid around the outside of the lungs that makes breathing harder for
them. The nurse should let clients know that the extra fluid will be
drained during a thoracentesis and analyzed to confirm the cause of the
effusion. After this procedure, nurses should reassure clients that they
will be monitored closely for ongoing respiratory problems, pain,
bleeding, or infection.
The nurse in the post-anesthesia care unit (PACU) is caring for a client
who underwent a thoracentesis to treat pleural effusion. The client's lung
sounds are clear, oxygen saturation is 96% on room air, and respiratory
rate is 20/min. Which is the nurse's priority intervention?
A. Place the client's head on the bed at 30°
B. Obtain a respiratory therapist consultation
C. Instruct the client on how to use an incentive spirometer.
D. Administer supplemental oxygen - ANSWER A. Place the client's
head on the bed at 30°
,The nurse should place the client's head on the bed at 30° to facilitate
lung expansion, oxygenation, ventilation, and decrease the work of
breathing before performing other interventions.
The nurse is caring for a client diagnosed with a large pleural effusion
who is experiencing pain upon inhalation and a dry cough. For which
procedure should the nurse prepare the client?
A. Chemical pleurodesis
B. Pneumonectomy
C. Bronchoscopy
D. Thoracentesis - ANSWER D. Thoracentesis
A thoracentesis is when a needle is inserted through the chest wall into
the pleural space to remove the fluid. This is a treatment for large pleural
effusions.
While reviewing the electronic health record (EHR) of a client diagnosed
with pleural effusion, the nurse notes the client's condition is caused by
transudate fluid accumulation. Which condition should the nurse
associate with this finding?
A. Cataracts
B. Gout
C. Nephrotic syndrome
D. Type 2 diabetes mellitus (DM) - ANSWER C. Nephrotic syndrome
Nephrotic syndrome occurs when there is damage to small blood
vessels in the kidney, adversely affecting the renal filtration system and
resulting in protein loss. Nephrotic syndrome is associated with the
development of pleural effusion caused by transudate fluid build-up.
The nurse assesses a client diagnosed with a pleural effusion. Which
clinical finding should the nurse anticipate?
A. Sharp pain upon expiration
B. Resonance on the affected side during percussion
C. Stridor
D. Dry cough - ANSWER D. Dry cough
,A small pleural effusion typically causes no clinical manifestations. With
more significant pleural effusions, clients may present with dyspnea, dry
cough, and sharp pain that comes with inspiration. During auscultation,
the affected side has reduced or absent breath sounds. On percussion,
there is dullness due to the presence of fluid within the pleural space.
The nurse is caring for a client suspected of having a pleural effusion.
For which diagnostic testing should the nurse prepare the client?
A. Chest x-ray
B. Spirometry
C. Gas diffusion test
D. Echocardiogram - ANSWER A. Chest x-ray
The diagnosis of pleural effusion starts with the client's history and
physical assessment, followed by a chest X-ray or computed
tomography (CT) scan to visualize the flow. A large effusion might also
show a collapsed lung. Diagnostic thoracentesis is also frequently done.
Thoracentesis is a procedure involving collecting fluid from the pleural
space to determine its composition, which helps to find out the cause.
When examining pleural fluid, the main difference is that exudative
effusions are rich in protein or lactate dehydrogenase (LDH), while
transudative effusions are not.
The nurse is reviewing the physiology of the pleural space with a newly
graduated nurse. Which statement should the nurse include in the
teaching?
A. "The fluid in the pleural space provides lubrication for the pleural
layers during breathing."
B. "The pleural fluid is replaced during inspiration, preventing the
collapse of the lungs."
C. "The lymphatic vessels hold a reserve of fluid which is used by the
cells in the pleural space."
D. "The type I pneumocyte cells in the lungs secrete the fluid into the
pleural space." - ANSWER A. "The fluid in the pleural space provides
lubrication for the pleural layers during breathing."
, The pleural space contains 20 to 25 milliliters of fluid that provides
lubrication, allowing the two pleural layers to slide over each other during
breathing.
A nurse in the intensive care unit (ICU) is caring for a client with an
endotracheal tube who is receiving mechanical ventilation. The nurse
should recognize that the client is at risk for which complication(s)?
Select all that apply.
A. Hospital-acquired pressure injury
B. Deep vein thrombosis
C. Respiratory barotrauma
D. Malnutrition
E. Community-acquired pneumonia (CAP) - ANSWER A, B, C, D
When a client undergoes intubation and is placed on mechanical
ventilation, the client is at an increased risk of developing complications
such as infection, airway trauma, pressure injury, deep vein thrombosis,
and malnutrition. One of the main risks of mechanical ventilation is a
particular type of infection called ventilator-associated pneumonia, or
VAP. This occurs when bacteria invade the lungs through the ETT.
Intubated clients can also develop barotrauma and ventilator-induced
lung injuries, which occur when the pressure of ventilation is so high that
it causes the alveoli to rupture. In addition, intubated clients are
generally sedated and paralyzed temporarily with IV medications to
provide comfort and to ensure they don't resist the ETT and damage
their airway. However, this immobility can increase the risk of developing
pressure injuries and deep vein thrombosis. Lastly, malnutrition can
result since intubation means the client can't ingest food or fluids by
mouth since their swallowing ability is compromised. Awareness of these
potential complications is important since the nurse plays an important
role in prevention.
A nurse in the intensive care unit (ICU) is caring for a client who has
been intubated for 24 hours. What steps should the nurse take to
prevent ventilator-associated pneumonia (VAP) in this client?
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