3/4/23 EXAM #3 STUDY
Question 1
A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?
This is an expected finding.
The lung may have re-expanded or there is a kink in the system.
The system is broken and needs to be replaced.
There is an air leak in the tubing.
Question 2
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?
Stay with the patient and monitor their vital signs while another nurse notifies the physician.
Place a sterile dressing over the site and tape it on three sides and notify the physician.
Attempt to re-insert the tube.
Keep the site open to air and notify the physician.
Question 3
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?
Intermittent bubbling may be noted in the water seal chamber.
200 cc of drainage per hour is expected during recovery of a pneumothorax.
The chest tube is positioned at the patient's chest level to facilitate drainage.
All of these options are appropriate findings.
Question 4
[[1]] is air delivered with each inspiration that is preset
[[2]] terminates or controls inspiration after a preset time
[[3]] Delivers a flow of air during inspiration until it reaches a preset pressure, and then it cycles off to allow passive expiration
VOLUME-CYCLED
TIME-CYCLED
PRESSURE-CYCLED
Question 5
he physician prescribes the patient a potassium-sparing diuretic. Which statement below best describes how this medication works to cause diuresis?
These medications work to inhibit the sodium-chloride cotransporter in the early part of the distal convoluted tubule.
These medications work to inhibit the sodium-potassium-chloride cotransporter in the thick ascending limb of the loop of Henle.
These medications work to inhibit the sodium and potassium exchange within the sodium channels in the distal tubule and collecting duct.
These medications work to inhibit the sodium channels within the proximal convoluted tubule by decreasing sodium reabsorption.
Question 6
patient is scheduled for a diagnostic paracentesis, but when coagulation studies are reviewed, the nurse observes results outside of normal parameters. How does the nurse anticipate the healthcare provider will proceed with the paracentesis?
An ultrasound-guided paracentesis will be performed
The procedure will be canceled until the laboratory results are within normal parameters
The paracentesis will be performed at the bedside
The nurse will administer packed red blood cells (RBCs) prior to the paracentesis
Question 7
What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?
Administration of diuretic therapy
Assisting with a therapeutic paracentesis
Infusing platelets
Infusing albumin
Question 8
The nurse is educating a patient who has been treated for hepatic encephalopathy about dietary restrictions to prevent ammonia accumulation. What should the nurse include in the teaching?
Decrease the amount of fats in the diet
Increase the amount of potassium in the diet
Decrease the amount of protein in the diet
Increase the amount of magnesium in the diet
Question 9
A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing?
Riboflavin deficiency
Folic acid deficiency
Vitamin A deficiency
Vitamin K deficiency
Question 10
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
Teach the client to instill a few drops of vinegar into the pouch.
Tell the client the stoma should be slightly dusky colored.
Inform the client large clumps of mucus are expected.
Vinegar will act as a deodorizing agent in the pouch and help prevent a strong urine smell.
Question 11
You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient’s bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply:
Frothy light-colored urine
Dark brown urine
Yellowing of the sclera
Dark brown stool
Jaundice of the skin
Bluish mucous membranes
Question 12
A client is to undergo a TURP for BPH. Which statement is accurate with regard to a TURP?
There is no danger of retrograde ejaculation.
Urethral strictures are more frequent for TURP than for nontransurethral procedures.
A TURP causes erectile dysfunction.
It is done on an outpatient basis.
Question 13
Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin
Spironolactone
Cimetidine
Nitroglycerin
Question 14
Jam is under chemotherapy in which nausea is an expected side effect. Which of the following drugs is indicated to prevent such side effects?
metoclopramide
cimetidine
tagamet
famotidine
Question 15
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client’s understanding of the surgical procedure by explaining that an ileal conduit:
Is a temporary procedure that can be reversed later.
Diverts urine into the sigmoid colon, where it is expelled through the rectum.
Conveys urine from the ureters to a stoma opening in the abdomen.
Creates an opening in the bladder that allows urine to drain into an external pouch.
Question 16
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Ensuring that humidified oxygen is always introduced through the tube
Routinely deflating the cuff
Checking the cuff pressure every 6 to 8 hours
Deflating the cuff before removing the tube
Question 17
Which of the following conditions can you safely administer metoclopramide (Reglan)?
Patient with bowel obstruction
Patient with gastrointestinal hemorrhage
Patient undergoing radiation
Patients with pheochromocytoma
Question 18
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which problem?
Rupture of the bladder
The development of a vesicovaginal fistula
Extreme stress because of the diagnosis of cancer
Altered perineal sensation as a side effect of radiation therapy
Question 19
Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client?
Previous exposure to chemicals.
Pelvic radiation therapy.
Cigarette smoking.
Parasitic infections of the bladder.
Question 20
The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included?
Demonstrate turn, cough, and deep breathing.
Explain a bag will drain the urine from now on.
Instruct the client on the use of a PCA pump.
Take the client to the ICU to become familiar with it.
Question 21
The nurse is preparing to suction a client via a tracheostomy tube. The nurse would plan to limit the suctioning time to a maximum of which time period?
5 seconds
10 seconds
30 seconds
2 seconds
Question 22
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?
Muscle weakness in the arms and legs
A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C)
A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg
A heart rate of 80 beats/minute, decreased from 85 beats/minute
Question 23
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply.
Water or a kink in the tubing
Biting on the endotracheal tube
Increased secretions in the airway
Disconnection or leak in the system
The client ceasing spontaneous breathing
Question 24
The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse would perform which actions for this procedure? Select all that apply.
Keeping a supply of suction catheters at the bedside
Auscultating breath sounds to determine the need for suctioning
Hyperoxygenating the client before, during, and after suctioning
Intermittently suctioning during insertion of the suction catheter
Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
Question 25
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?
Excessive secretions
Kinks in the ventilator tubing
The presence of a mucous plug
Disconnection of the ventilator tube