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NSG 4100 (AH III) Exam 3 With Complete Questions and Answers
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NSG 4100 (AH III) Exam 3 With Complete Questionsand Answers
The nurse caring for a pt w/ and endotracheal tube recognizes several
disadvantages of an endotracheal tube. What would the nurse recognize as a
disadvantage?
a. cognition is decreased
b. Daily ABGs are necessary
c. slight tracheal bleeding is anticipated
d. the cough reflex is depressed - ANSWER D
What would the critical care nurse recognize as a condition that may indicate a pt's
need to have a tracheotomy?
a. a pt has a respiratory rate of 10 breaths/min
b. a pt required permanent ventilation
c. a pt exhibits sx of dyspnea
d. a pt has respiratory acidosis - ANSWER B
The nurse is caring for a pt who is scheduled to have a thoracotomy. When
planning preoperative teaching, what info should the nurse communicate to the
pt?
a. how to milk the chest tubing
b. how to splint the incision when coughing
c. how to take prophylactic antibiotics correctly
d. how to manage the need for fluid restriction - ANSWER B
A nurse is educating a pt in anticipation of a procedure that will require a
water-sealed chest drainage system. What should the nurse tell the pt and the
family that this drainage system is used for?
a. maintaining a positive chest-wall pressure
,b. monitoring pleural fluid osmolarity
c. providing passive intrathoracic pressure
d. removing excess air and fluid - ANSWER D
A pt is exhibiting signs of a pneumothorax following tracheostomy. The surgeon
inserts a chest tube into the anterior chest wall. What should the nurse tell the
family is the primary purpose of this chest tube?
a. to remove air from the pleural space
b. to drain copious sputum secretions
c. to monitor bleeding around the lungs
d. to assist with mechanical ventilation - ANSWER A
A pt's plan of care specifies postural drainage. What action should the nurse
perform when providing this noninvasive therapy?
a. administer the tx w/ the pt in a high Fowler's or semi-fowlers position
b. perform the procedure immediately following the pt's meals
c. apply percussion firmly to bare skin to facilitate drainage
d. assist the pt into a position that will allow gravity to move secretions - ANSWER
D
While assessing the pt, the nurse observes constant bubbling in the water-seal
chamber of the pt's closed chest-drinagae system. What should the Nurs conclude?
a. the system is functioning normally
b. pt has a pneumothorax
c. system has a leak
d. chest tube is obstructed - ANSWER C
The nurse has admitted a pt who is scheduled for a thoracic resection. The nurse is
providing preoperative teaching and is discussing several diagnostic studies that
will be required prior to surgery. Which study will be performed to determine
whether the panned resection will leave sufficient functioning lung tissue?
a. pulmonary function studies
,b. exercise tolerance tests
c. arterial blood gas values
d. chest x-ray - ANSWER A
The nurse is discussing activity management w/ a pt who is postoperative
following thoracotomy. What instructions should the nurse give to the pt
regarding activity immediately following discharge?
a. walk 1 mile 3-4x a week
b. use wights daily to increase arm strength
c. walk on a treadmill 30min daily
d. perform shoulder exercises 5x daily - ANSWER D
The OR nurse is setting up a water-seal chest drainage system for a pt who has just
had a thoracotomy. The nurse knows that the amount of suction in the system is
determined by the water level. At what suction level should the nurse set the
system?
a. 20 cm H2O
b. 15 cm H2O
c. 10 cm H2O
d. 5 cm H2O - ANSWER A
The nurse is caring for a client w/ and endotracheal tube who is on a ventilator.
When assessing the client, the nurse knows to maintain what cuff pressure to
maintain appropriate pressure on the tracheal wall?
a. between 10-15 mm Hg
b. between 15-20 mm Hg
c. between 20-25 mm Hg
d. between 25-30 mm Hg - ANSWER B
A nurse educator is reviewing the indications for chest drainage systems w/ a
group of medical nurses. What indications should the nurses identify? Select all
that apply.
, a. post thoracotomy
b. spontaneous pneumothorax
c. need for postural drainage
d. chest trauma resulting in pneumothorax
e. pleurisy - ANSWER A, B, D
The home care nurse is visiting a pt newly discharged home after a lobectomy.
What would be most important for the home care nurse to assess?
a. resumption of the pt's ADLs
b. the family's willingness to care for the pt
c. nutritional status and fluid balance
d. s/s of respiratory complications - ANSWER D
A pt is being admitted to the preoperative holding area for a thoracotomy.
Preoperative teaching includes what?
a. correct use of a ventilator
b. correct use of incentive spirometry
c. correct use of a mini-nebulizer
c. correct technique for rhythmic breathing - ANSWER B
A nurse is teaching a pt how to perform flow type incentive spirometry prior to his
scheduled thoracic surgery. What instruction should the nurse provide to the pt?
a. hold the spirometer at your lips and breathe in and out like you normally would
b. when you're ready, blow hard into the spirometer for as long as you can
c. take a deep breath and then blow short, forceful breaths into the spirometer
d. breathe in deeply through the spirometer, hold your breath briefly, and then
exhale - ANSWER D
The nurse is assessing a pt who has a chest tube in place for the treatment of a
pneumothorax. The nurse observes that the water level in the water seal rises and
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