Exam (elaborations)
NURS 480 MED SURGE
- Course
- Institution
- Book
Exam study book Medical-Surgical Nursing - E-Book of Susan C. deWit, Holly K. Stromberg, Carol Dallred - ISBN: 9780323328913 (NURS 480 MED SURGE)
[Show more]
Connected book
Book Title:
Author(s):
- Edition:
- ISBN:
- Edition:
More summaries for
-
Test Bank For Medical Surgical Nursing 5th Edition By Holly K. Stromberg, All Chapters 1-49 2024
-
Test Bank for Medical Surgical Nursing Concepts and Practice 5TH Edition Stromberg Dewits / All Chapters 1-49. Complete Guide with Rationales LATEST EDITION GRADED A+
-
Test Bank For Medical Surgical Nursing 5th Edition By Holly K. Stromberg Chapter 1-49 | 2024 Questions and Answers Graded A+
Seller
Follow
maxmaxwellmm254
Content preview
NURS 480 MED SURGE FINAL EXAM NEWEST 2024ACTUAL EXAM COMPLETE 100 QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |
ALREADY GRADED A+
A client with unresolved hemothorax is febrile, with chills and sweating. He has a
nonproductive cough and chest pain. His chest tube drainage is turbid. What should
the nurse request in SBAR communication with the health care provider?
Portable chest X-ray
Antibiotic therapy
Intubation and mechanical ventilation
Arterial blood gasses - ANSWER: Antibiotic therapy
Any condition that produces fluid accumulation or sequestration of fluid with
infective properties can lead to empyema, an accumulation of pus in a body cavity,
especially the pleural space, as a result of bacterial infection. An infected chest tube
site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and
sweating associated with infection. With the symptoms of infection, antibiotic
therapy would be recommended. Nothing in the question demonstrates a need for
chest X-ray, intubation, or ABGs.
A client has a chest tube inserted for the treatment of a pneumothorax. While
turning in the bed, the client dislodges the tube and it is found in the bed. As the
registered nurse is directing the health care team, place the actions of the registered
nurse in the correct order. All options must be used. - ANSWER: Apply an occlusive
dressing over the puncture site
Tape the dressing on three sides
Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care
provider.
Assess the client's respiratory status.
Assess vital signs and await further medical orders
A chest tube is a flexible, hollow tube placed through the chest wall and in to the
pleural space. The chest tube is able to relieve trapped air and fluid. If a chest tube is
dislodged and comes out, the nurse would immediately apply an occlusive dressing
such as Vaseline gauze (many times kept in the client's room). The dressing is taped
on three sides. The first action always focuses on the client. The nurse would direct
another licensed nurse to immediately notify the health care provider. The nurse
would then assess the respiratory status. The nurse would obtain vital signs and
await further orders.
After having a lobectomy for lung cancer, a client receives a chest tube connected to
a three-chamber chest drainage system. The nurse observes that the drainage
,system is functioning correctly when noting which of the following? Select all that
apply.
Fluctuations in the water-seal chamber occur when the client breathes.
Crepitus forms at the chest tube insertion site.
Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in
the suction control chamber. Drainage is collecting in the drainage chamber. -
ANSWER: Fluctuations in the water-seal chamber occur when the client breathes.
Intermittent bubbling occurs in the water-seal chamber.
Gentle bubbling occurs in the suction control chamber.
Drainage is collecting in the drainage chamber.
Fluctuations in the water-seal compartment (or tidal movements) indicate normal
function of the system as the pressure in the tubing changes with the client's
respirations. There also should be intermittent bubbling in the water-seal chamber,
indicating that air is being removed from the pleural cavity by the system. Gentle
bubbling in the suction control chamber indicates that the proper suction level has
been reached. Drainage is expected to collect in the drainage chamber after a
lobectomy. Crepitus indicates that air is leaking into the subcutaneous tissues. The
physician should be notified of this finding.
The nurse is planning care for a child with a pneumothorax. The nurse adds the
nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube" to
the care plan. When writing the care plan, what should the nurse be sure to include
as interventions?
Keep dry gauze at the bedside
Ensure a pair of hemostats are at the bedside
Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's condition warrants
Maintain chest tube bottle in an upright position and below the level of the chest -
ANSWER: Ensure a pair of hemostats are at the bedside
Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's condition warrants
Maintain chest tube bottle in an upright position and below the level of the chest
If the tube becomes dislodged from the child's chest, the nurse must apply Vaseline
gauze and an occlusive dressing to prevent air leakage into the pleural space. A pair
of hemostats should be kept at the bedside to clamp the tube should it become
dislodged from the drainage container. Pulse oximetry and lung assessments help
ensure proper placement of the chest tube. To maintain proper drainage, the bottle
must be kept upright and below the level of the chest.
The nurse has received a change-of-shift report. The nurse should assess which client
first?
a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08
,a 36-year-old with chest tube due to spontaneous pneumothorax with current
respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal
cannula a 28-year-old who is 2 days postappendectomy with discharge prescriptions
written and whose husband is waiting to take her home
a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose
hemoglobin is 13.8 g/dL (138 g/L) - ANSWER: a 72-year-old admitted 2 days ago with
a blood alcohol level of 0.08
The nurse should closely monitor the client admitted with an elevated blood alcohol
level for several hours for signs and symptoms of withdrawal, administering sedation
as needed; delirium tremens, the most severe form of withdrawal, usually peaks at
48 to 72 hours following the last drink. The client with the chest tube is not in any
distress and has no pressing needs. For an older client who has had GI bleeding, a
hemoglobin of 13.8 g/dL (138 g/L) is within normal limits. After assessing all clients'
needs, the nurse will prepare the client who had an appendectomy for discharge as
soon as possible.
The young child had a chest tube placed during cardiac surgery. Which findings may
indicate the development of cardiac tamponade? Select all that apply.
The chest tube drainage had been averaging 15 to 25 mL out per hour and now there
is no drainage from the chest tube.
The child's heart rate has increased from 88 beats per minute to 126 beats per
minute.
The child's right atrial filling pressure has decreased.
The child is resting quietly.
The child's apical heart rate is strong and easily auscultated. - ANSWER: The chest
tube drainage had been averaging 15 to 25 mL out per hour and now there is no
drainage from the chest tube.
The child's heart rate has increased from 88 beats per minute to 126 beats per
minute.
Abrupt cessation of chest tube output and an increased heart rate are indicators that
the child may have developed cardiac tamponade. The child's right atrial filling
pressure will increase. The child may be anxious and their apical heart rate may be
faint and difficult to auscultate.
The nurse has responsibility for several clients. Based on the information provided,
which of these clients would be a priority for the nurse to evaluate when assuming
responsibility for their care at the beginning of the evening shift?
the 70-year-old client who had a total laryngectomy the previous day
the 40-year-old client with diabetes who had a fasting blood sugar of 110 mg/dL (6.1
mmol/L)
an elderly client who has Alzheimer's disease and periods of confusion
, a 20-year-old with a spontaneous pneumothorax who had a chest tube inserted
earlier in the day whose vital signs are stable - ANSWER: the 70-year-old client who
had a total laryngectomy the previous day
Based on the information provided, the client who is on day 1 after a total
laryngectomy would be the priority client for the nurse to evaluate. This client is at
risk for swelling or pressure on the trachea and should be monitored closely. Clients
with acute conditions that can affect their respiratory status are a high priority for
nursing care.
The client with diabetes has a normal fasting blood sugar and will not require
immediate intervention.
The client with Alzheimer's disease is not in immediate danger and, therefore, does
not require immediate evaluation.
There is no evidence that the client with pneumothorax is in immediate need of
evaluation.
The nurse is caring for a client with a left chest tube to drain a pleural effusion. The
nurse notes that the water is below the required level in the water seal chamber of
the closed chest drainage system. What is the priority assessment that the nurse
needs to make?
Check for bloody drainage in the collection chamber. Ensure that the tubing is free of
any occlusions.
Evaluate the client for the presence of a pneumothorax. Determine whether there
has been an increase in suction. - ANSWER: Evaluate the client for the presence of a
pneumothorax.
Atmospheric pressure is greater than the pressure inside the pleural space. Without
the necessary amount of water in the water seal chamber, air would enter the
pleural space and collapse the lung, resulting in a pneumothorax. The water seal
does not affect the amount of suction used. The water seal is separate from the
drainage collection chamber. The tubing does not affect the level of water in the
water seal chamber.
While the nurse is providing morning hygiene for a patient who has a chest tube, the
patient has rolled over quickly and the chest tube has become disconnected from
the drainage unit. How should the nurse first respond to this event?
Submerge the end of the tube in sterile water
Clamp the tube near the end and also near the insertion point
Place the end of the tube on a sterile surface and seek help promptly
Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit
- ANSWER: Submerge the end of the tube in sterile water
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller maxmaxwellmm254. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $17.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
67474 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now