NSG3160/ NSG 3160 Exam 1 (NEW 2026/ 2027 Update) Health Assessment Guide| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Galen

NSG3160/ NSG 3160 Exam 1 (NEW 2026/ 2027 Update) Health Assessment Guide| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Galen Q. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? (Select all that apply.) A. Patient reports dyspnea upon exertion B. Edema, +2, noted on left hand C. Rate of respirations 16 breaths per minute D. Nonproductive cough E. Inspiratory wheezes noted in left lower lobes F. Hypoactive bowel sounds ANSWER A. Patient reports dyspnea upon exertion C. Rate of respirations 16 breaths per minute D. Nonproductive cough E. Inspiratory wheezes noted in left lower lobes Q. The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take? A. Collect a follow-up database and then check the patient's blood pressure. B. Ask the patient to read her health record and indicate any changes since her last visit. C. Check the patient's blood pressure. D. Obtain a complete health history on the patient before checking her blood pressure. ANSWER A. Collect a follow-up database and then check the patient's blood pressure. A follow-up database is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. Asking the patient to read her health history and indicate any changes since her last visit is not appropriate. Just checking the patient's blood pressure without following up on or assessing for any changes in the patient's condition is inappropriate. It is not necessary to conduct a complete health history as one was conducted 2 months ago. Rather a follow-up assessment regarding the patient's blood pressure and factors associated with it are necessary. Q. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? A. Nurses are responsible for a patient's health state. B. Disease originates from the external environment. C. The individual human is a closed system. D. Holistic health views the mind, body, and spirit as interdependent. ANSWER D. Holistic health views the mind, body, and spirit as interdependent. Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent and functioning as a whole within the environment. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. The basis of disease originates from both the external environment and from within the person; the individual human is an open system, continually changing and adapting; and each person is responsible for his or her own personal health state (not the nurse). Q. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. Why is it important for the nurse to consider the basics of the patient's culture during the patient's health assessment? A. Identify the cause of his illness. Correct! B. Provide culturally relevant health care. C. The U.S. is becoming increasingly diverse. D. Make accurate disease diagnoses. ANSWER B. Provide culturally relevant health care. It is important for the nurse to consider the basics of the patient's culture in order to ask the right questions to gather data that is accurate and meaningful in order to provide culturally relevant health care. Considering the basics of a patient's culture does not ensure the identification of the cause of a patient's illness or an accurate disease diagnosis. Although the U.S. is becoming increasingly diverse, that is not a reason for considering the basics of the patient's culture during the patient's health assessment. Instead it is to provide culturally relevant health care to this patient. Q. The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." Based on this question, the nurse is at which phase of the interview process? A. Working B. Closing C. Opening or introduction D. Summary ANSWER C. Opening or introduction When gathering a complete history, the nurse should give the reason for the interview during the opening or introduction phase of the interview, not during or at the end of the interview. Q. A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger people. What is the reason for this? A. An aged person is usually lonely and likes to have someone with whom to talk. B. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said. C. Aged people lose much of their mental abilities and require longer time to complete an interview D. An aged person has a longer story to tell. ANSWER D. An aged person has a longer story to tell. The interview usually takes longer with older adults because they have a longer story to tell. It is not necessarily true that all older adults are lonely, have lost mental abilities, or are hard of hearing. Not all older adults are lonely, have lost mental abilities, or are hard of hearing. Instead, the interview usually takes longer because older adults have a longer story to tell. Q. During an interview, a parent of a hospitalized child is sitting in a recliner with his legs extended and his arms at his sides. As the interviewer begins to discuss his son's treatment, however, he suddenly changes positions and crosses his arms against his chest and crosses his legs. What does this change in posture suggest? A. Tired and needs a break from the interview B. More comfortable in this position C. Simply changing positions D. Uncomfortable talking about his son's treatment ANSWER D. Uncomfortable talking about his son's treatment The parent was in an open position, one in which there is extension of large muscle groups which shows relaxation, physical comfort, and a willingness to share information. However, he moved into a closed position, in which the arms and legs are crossed. This closed position tends to look defensive and anxious. If a person in a relaxed position suddenly tenses, then this change in posture suggests possible discomfort with the new topic. The parent's position should be noted. If a person in an opened, relaxed position (legs and arms extended) suddenly tenses and moves to a closed position (arms and legs crossed) then this change in posture suggests possible discomfort with the new topic and is more than just changing positions to get comfortable or needing a break. Q. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? A. "I check the color of my toes every evening just like I was taught." B. "I'm able to transfer myself from the wheelchair to the bed without help." C. "The pain is decreasing, but I still need to take acetaminophen." D. "I broke my right leg in a car accident 2 weeks ago." ANSWER B. "I'm able to transfer myself from the wheelchair to the bed without help." Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues. Statements such as "I broke my right leg in a car accident 2 weeks ago," "the pain is decreasing, but I still need to take acetaminophen," or "I check the color of my toes every evening just like I was taught" are statements concerning health or illness issues and not a person's self-care or functional ability. Q. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?" ANSWER B. "Are you able to dress yourself?" Whether a person is able to dress himself or herself assesses his/her ability to perform an activity of daily living. A functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that he/she can or cannot do. The other responses do not relate to functional assessment. Asking whether a patient wears glasses, has any thyroid problems, and how many bowel movements he or she has each day are not part of a functional assessment. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. Q. The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? A. "When did you come to the United States and from what country?" B. "Why did you come to the United States?" C. "Are you planning to return to your home?" D. "What made you leave your native country?" ANSWER A. "When did you come to the United States and from what country?" Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions. When a patient is a new immigrant several biographic questions should be added to the health history. Why the person came to the United States, what made him/her leave his/her native country, and when he/she is planning to return are not necessary and do not provide any biographic data. Q. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? A. "This has been a difficult year for you." B. "What did you do to cope with the loss of both your husband and mother?" C. "That is a lot of stress; now let's go on to the next section of your history." D. "I don't know how anyone could handle that much stress in 1 year!" ANSWER B. "What did you do to cope with the loss of both your husband and mother?" Questions about coping and stress management include questions regarding the kinds of stresses in one's life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. Options A, B, and D do not assess the person's methods to cope or alleviate their stress. When asking questions about coping and stress, the nurse should ask regarding the kinds of stresses in one's life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful. Q. The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. Which is the best way for the nurse to document the findings in the patient's chart? A. Use the words the child has said to describe how the injury occurred. B. Document what the child's caregiver tells the nurse. C. Record what the nurse observes during the conversation. D. Rely on photographs of the injuries. ANSWER A. Use the words the child has said to describe how the injury occurred. When documenting the history and physical findings of suspected child abuse and neglect, use the words the child has said to describe how his or her injury occurred. Remember, the abuser may be accompanying the child. Although photographs of injury can be invaluable, they are not the best method of documentation and should not be relied upon. Although the child's caregiver may be able to provide information, that is also not the best way to document and the nurse needs to keep in mind that the caregiver could be the abuser. While the nurse will document what he or she observes, the best way to document the history and physical findings of a child suspected of being abused is to use the words the child has said to describe how his or her injury occurred. A female patient has denied any abuse when answering the questions on an abuse assessment screening tool, but what finding by the nurse during the interview process is associated with IPV? A. Frequent colds B. Asthma C. Depression D. Confusion C. Depression Abuse victims have significantly more depression, suicidality, post-traumatic stress disorder (PTSD), and problems with substance abuse. Abused women also have been found to have more chronic health problems, such as cardiovascular, endocrine, immune, gastrointestinal, and gynecologic problems. Asthma, confusion, and frequent colds are not problems associated with abuse. What is the main condition for Enteral nutrition? The client MUST have a functioning GI system. What are the main indications for enteral nutrition tubes? -clients that can not eat (surgery, intubated etc) - clients with nutritional deficit - clients with impaired swallowing/gag reflex - Gastric decompression What are examples of long term tubes? Gastrostomy or jejunostomy tubes What size would you expect a large/small bore tube to be? lg- 12 french sm- 8-12 french How long does a short term tube usually stay in? 4-6 weeks T/F Salem Sump can be on continuous suction. TRUE, when used for gastric decompression T/F Enteriflex can only be used for gastric decompression FALSE!! Enteriflex is used for feeding only! ( small bore tube) Salem Sump is used for decompression What are common uses for large bore tubes, and what are they? Salem Sump/Levin used for short term feeding, and gastric decompression. Which size tube has an increased risk for aspiration, tube migration and misplacement? Large bore tubes What is the main benefit of small bore tubes? comfortable and reduce gastric erosion. Also less aspiration risk or migration What are the risks associated with small bore tubes? easily occulded, and can not be aspirated. What is the most common small bore tube? Enteriflex Which tube has a wire in-situ, and a weighted metal tip to be verified on x-ray? enteriflex What are the surgically inserted vs. endoscopically inserted tubes? sx- gastrostomy, jejunostomy Endo- PEG, PEJ, GJ What are the indications for long term tubes? Long term feeding ( months- years) aspiration risk hx of aspiration pneumonia gastroparesis Why would a GJ tube have two ports? One port in the stomach for decompression and another for medication/feed Why would you use a GJ tube over others? Dysmotility, aspiration risk, frequent vomiting. Which feed schedule requires the use of a pump? Continuous feeds. ** I feel like we use pumps for all..but this was in the slides* How long can feeding systems be open? Open- max 4 hours Closed- max 48hrs ( usually finished within 24) What are the 4 steps when assessing tube placement? - assess for s/s of aspiration/migration - check marker at nares - measure external length - check pH ( if needed) T/F GVR is only checked with large bore tubes? TRUE! not checked for small bore or post pyloric tubes. Also not checked if client is taking anything PO Which of the following situations would you need to pause a tube feed? SATA a. medication admin b. personal care c. SOB/ diaphoretic d. lowering HOB abcd T/F When flushing a feeding tube you need to use sterile water? TRICK!!! Follow agency policy ( but usually tap water is fine :) ) When you come on shift you notice your client has a NG tube and when giving meds you see prescribed Esomeprazole 40 mg tab, and ramipril 10mg. What is your next action? a. crush both meds, mix with warm water and give individually b. call pharmacy as these medications can not be given via NG tube. c. dissolve esomeprazole, and crush ramipril d. dissolve esomeprazole and open ramipril d You are caring for a client who has been receiving continuous EN for 3 days and has not had a bowel movement since the feeds began. They now have mild lower abdominal pain. What is your priority action? Assess clients abdomen, and PQRSTU What is refeeding syndrome? hypokalemia, hypomagnesemia, and hypophosphatemia after refeeding a starved patient What are the s/s of refeeding syndrome? peripheral edema arrythmias cardiac arrest seizures delirium hypotension What are major risk factors for refeeding syndrome? ONE or more of: BMI 16, weight loss of 15% in 3-6 months. No nutrient intake for 10 days pre-existing hypo K, mg, Pho What are minor risk factors for refeeding syndrome? TWO or more of: BMI 18.5, weight loss of 10% in 3-6 mnth no nutrient intake in 5 days alcohol/drug misuse, chemo, diuretics, antiacids What is the main way to prevent refeeding syndrome? Identify who is at risk, and adjust rate to lower rate/volume than requirement You are caring for Client X, a 65-year-old client who has been admitted for depression and severe malnourishment. They recently lost their partner and is having a hard time coping. They report increased alcohol consumption and admitted to attempting to end their life by drinking anti-freeze. A gastroscopy reveals upper esophageal strictures. They are very weak and suffer from dysphagia, nausea and vomiting. The doctor initiates enteral nutrition. Their BMI is 14kg/m2 RECENT LAB VALUES: K+: 3.2 mmol/L (normal 3.5-5.0) Mg++: 0.8 mmol/L (normal 0.75-0.95) PO4: 1.8 mmol/L (normal 0.8-1.5) Na+: 136 mmol/L (normal 135-145) (1)What are the client's risk factors for developing Refeeding Syndrome (RS)? (2)How do you minimize the risk for developing RS? Risk factors à Low BMI, increased age, alcoholism, malnourishment, pre-existing hypokalemia, magnesium on the lower end of the spectrum How could you minimize? à Start at a low rate and slowly increase the feed rate; Provide thiamine and vitamin replacement, electrolytes replacement PRN, intravenous hydration PRN What are the 4 types of feed formulas? Polymetric- milk-based blended ( hospital/home) Modular- single macronutrient ( added to other food) Elemental- predigested nutrients for partially dysfunctional GI Specialty- specific needs The nursing activity most likely to prevent the clogging of a nasogastric feeding tube is: 1. Attaching the tubing to suction after each feeding 2. Filling the tube with water and clamping it after each feeding 3. Clamping the tube before all of the nourishment has drained 4. Giving the patient ice chips to suck after each feeding 2 When a patient is unable to take fluid or food by eating normally over an extended period of time, what is the best alternative? 1. Liquid nutrients through a tube leading from the mouth or nose to the stomach or intestine 2. Giving solutions through a tubing in a peripheral vein 3. Giving continuous tube feedings regulated via an electric feeding pump 4. Giving feedings through a tube inserted through the skin and tissue of the abdomen 1 What is the main goal of PN? Provide adequate nutrient to support protein synthesis and metabolic homeostasis - improve overall nutritional status -prevent muscle wasting -facilitate healing Common indications for PN? - When GI is not functioning or can not be accessed - increased metabolic needs -• Chronic severe diarrhea and vomiting • Complicated surgery or trauma • Gastrointestinal obstruction • Gastrointestinal tract anomalies and fistulas • Intractable diarrhea • Severe anorexia nervosa • Severe malabsorption • Short bowel syndrome When would you choose CPN over PPN? CPN- when the client is receiving ALL nutrients via PN PPN only when supplementing nutrition, or short term use Why must CPN be infused via a central line? Because it is a hypertonic solution! ( never infused through femoral line due to infection risk) What are two common side effects of PPN? 1. phlebitis ( due to osmolality, D10W) 2. Fluid overload What are the three modalities of PN? 1. continuous (24hrs) 2. Intradyalitic- used during hemodialysis 3. cycling- 10-20 hrs/day T/F You can mix medications with PN solutions FALSE!!!!! What is an important allergy to note if someone is receiving PN? Eggs Why do lipid emulsions need to be administered in 12 hrs? It is only stable at room temp for that time, increased risk of infection if left longer. What are the 4 common instabilities of lipid PN? Creaming = Accumulation of fat particles at the top of the emulsion Aggregation = Clumping of triglyceride particles within the emulsion Coalescence = Fusion of small triglyceride particles into larger particles Cracking = Separation of the oil and water components of the emulsion T/F Creaming in PN is normal and can be re-emulsified by gently mixing, and is safe to administer True!! if it does not mix, then DO NOT administer What is the most common filter size for PN lines? Amino acid- 0.2 micron Lipid- 1.2 micron What do you do when PN is interrupted (for example, the IV access is lost)? Call the MD, will usually need to infuse D10W at same rate as PN solution, and monitor blood glucose for signs and symptoms of hypoglycemia What are the three categories of complications related to PN? Infection, metabolic, mechanical What is one advantage of a percutaneous endoscopic gastrostomy (PEG) tube placement relative to nasogastric (NG) feedings for the client receiving long-term enteral nutrition? a. It increases client comfort. b. It eliminates the risk for aspiration. c. Feedings can be initiated before bowel sounds are present. d. More calories can be delivered than with NG feeding. A A client is receiving peripheral parenteral nutrition. The PN solution is completed before the new solution arrives on the unit. What should the nurse administer? a. 20% intralipids b. 5% dextrose solution c. 5% Ringer's lactate solution d. 0.45% normal saline solution B slides say D10W A client with anorexia nervosa shows signs of malnutrition. During initial refeeding, what does the nurse carefully assess the client for? a. Hyperkalemia b. Hypoglycemia c. Hypercalcemia d. Hypophosphatemia OK F THIS QUESTION!! TEXT BOOK SAYS A, BUT SLIDES SAY HYPOKALEMIA. DO WITH THIS WHAT YOU WILL Nurse is caring for a client receiving PN. Which of the following should the nurse recognize as a complication of this therapy? a)Stomatitis b)Diarrhea c)Polyuria d)Aspiration C A client is being weaned off PN for an oral diet. The PN solution had been running 120 mL/hr. What would you expect the order to say that will accompany the diet orders? a)Decrease the PN to 60 mL/hr b)Start 0.9% NS at 30 mL/hr c)Maintain the present infusion rate d)Discontinue the PN A A client in your care is receiving PN. You assess the client for complications of the therapy and assess the client for which of the following signs of hyperglycemia? a)High grade fever, chills, and decreased urination b)Fatigue, increased sweating, and heat tolerance c)Coarse dry hair, weakness, and fatigue d)Thirst, blurred vision, and diuresis D What are the insertion and exit sites of a CVAD? Insertion- where catheter enters blood vessel Exit- where catheter leaves skin What is the purpose of a CVAD? - F&E replacement - Medication, PN - blood products/samples - monitor CVP What are some examples of tunneled CVAD's? Hickman Line Permacath Tunneled Groshong What are the three categories of CVAD's? 1. valved/non-valved 2. tunneled/nontunneled 3. short, intermediate, long term When you assess a clients CVAD you note it is open-ended. What valve do you expect it to have? SATA a. non- valved b. valved c. distal valve d. proximal valve a d If a client has a CVAD that is valved and closed ended, what type of valve is it? Distal valve What is the difference between non-tunneled and tunneled CVAD's? NT- inserted by puncturing directly into skin and vein without tuneling into SC tissue t- proximal end is tunneled SC from insertion site and brought out through skin at exit site Where would you expect to find a short term non-tunneled, non-valved catheter?SATA a. internal jugular b. subclavian c. femoral d. basilic ABC ( femoral has high risk for infection) think it needs to be proximal, so any BV near center Where would you expect to find a intermediate valved/non-valved CVAD?SATA a. brachial b. cephalic c. basilic d. femoral PICC line ABC What CVAD devices are used for long term use? Permacath, Hickman, IVAD Which CVAD can be inserted quickly in an emergency? Percutaneous "central line" T/F Central lines are always non- valved and non-tunneled True! Short term 7-14 days Which type of CVAD has the highest risk for infection? Percutaneous CVAD- Central line ( inserted into jugular, subclavian, femoral) What are the major disadvantages to a PICC line? - requires weekly dressing changes - external device length -not for rapid infusion T/F Tunneled CVAD's do not require a securement device/dressing. True! it is fixed in place when scar tissue forms. Also has Dacron cuff Which CVAD has the lowest risk of infection? Kinda tricky! It is an IVAD!! What are the three occlusion complications that can occur with CVAD's? Partial- resistance when flushing Withdrawal- unable to withdraw blood Complete- unable to infuse/withdraw What are the 3 main causes of CVAD occlusions? 1. Thrombus- 58%! fibrin builds 2. Chemical 42%- medication precipitation 3. Mechanical- kinks, clogs etc. Which of the following are interventions when you can not withdraw blood from a CVAD? SATA a. saline flush the catheter b. reposition, and extend arm at 90' c. ask client to cough d. flush with heparin ABC What is the priority intervention when you suspect an air embolism? Call code blue - clamp lumen - admin O2 -vitals -left lateral position What is the normal placement of a chest tube for a hemothorax? Posteriorly, and lateral to the nipple line What is the normal placement of a chest tube for a pneumothorax? High and anterior What are the 3 main functions of a chest drainage unit (CDU)? - restore normal intrapleural pressure - facilitate the drainage of air and fluid - Prevent backflow of air What is the function of the collection chamber of a CDU? To collect fluid and monitor the characteristics/quantity of the drainage. What is the function of the suction control chamber of a CDU? regulate the amount of negative pressure generated What is the most common suction pressure? -20cm H20 ( recall this is the # set on the MACHINE not the wall) Which of the following is NOT true regarding the purpose of a chest tube? a. restores negative intrathoracic pressure b. removes thick mucus and secretions from the lower airway c. removes excess air and fluid from the pleural space d. Prevents the accumulation of fluid after cardiothoracic surgery B Which of the following is NOT true about Chest tubes? a. continuous bubbling in the collection chamber means there is an air leak b. The oscillation of the water level in the water-seal chamber with the patient respirations reflect normal pressure changes in the pleural cavity. c. A suction pressure of -20cm H2O is commonly recommended for adults d. In a wet system, the amount of suction is controlled by the height of the column of water in the suction control chamber, and not the setting of the suction source. A bubbling in the water seal chamber is an air leak Which assessment finding indicates a dry system is functioning effectively? a. Vigorous bubbling in the water seal chamber. b. Redness, purulent drainage or other signs of infection at the insertion site. c. Fluctuation of water in the patient drainage tubing during inhalation and exhalation. d. The bellows in the suction monitor is expanded D FITB During inspiration the intrapleural becomes ___ ____, and during exhalation becomes ___ ___. ( bonus if you know the #'s) More negative (-8cmH2o) Less negative (-4cmH2O) What happens to the pressure in the pleural space during a pneumothorax? Becomes more positive ( bad because it is the negative pressure that keeps the lungs from collapsing) Explain why a tension pneumothorax is a medical emergency? mediastinal shift= high intrapleural pressure causes tension on heart and vessels causing a shift to the unaffected side. Cardiac output is compromised! What are the 4 classifications of pleural effusion? 1. transudate (clear) 2. exudate (cloudy) 3. chylothorax (lymph) 4. empyema (pus) Which of the following are examples of pleural effusion manifestations? SATA a. progressive dyspnea b. dull percussion c. night sweats d. weight loss e. fine crackles ABCD You are working with a nurse and they ask you to bring them a small-bore chest tube. What is the size range you should be looking for? a. 7-12 french b. 8.5-14 french c. 6.5-14 french d. 8-12 french B When would a large bore (24-32 fr) be indicated? SATA a. acute hemothorax b. pleural effusion c. post-op (cardio/thoracic) d. pneumothoraces AC (BD are small-bore) Why are chest tubes clamped during insertion? To prevent air from entering the pleural space. Which of the following is NOT a reason why tidaling stops? a. lung expanded b. clot in tube c. kinked tubing d. air leak D T/F Total volume indicated on a digital CDU is the total for the day? FALSE it is the total since start of therapy How are large bore chest tubes secured? What about small bore? lg= purse string suture sm= stat lock Which of the following are part of a chest tube safety kit? SATA a. toothed clamps b. sterile water bottle c. occlusive dressing d. Gauze BCD ( we want NON TOOTHED clamps!! to make sure we dont damage the tube) What are the only conditions when chest tube should be clamped? - momentarily in an emergency - to assess for air leak -specimen collection - empty/change CDU - to assess for removal What do you do if the chest tube falls out? Apply petroleum impregnated gauze and occlusive dressing and tape. Which position would you place a client experiencing a pneumothorax? Semi-high fowlers. Air rises to the highest point of chest, and tube usually inserted in 3rd ICS In which position would you place a client experiencing a hemothorax or effusion? High fowlers, to help drain fluid A patient returns from thoracic surgery with a chest tube. One hour after the initial physical assessment the nurse notes 750 mL in the last hour of bright red drainage in the collection chamber of the chest tube. Prioritize the list of nursing interventions. 1. Take vital signs 2. Prepare to administer intravenous fluids 3. Notify most responsible health care provider 4. Suggest a current complete blood count be collected 1342 A patient has a suspected tension pneumothorax following the insertion of a chest tube. What action is considered a nursing priority? 1. Assess the chest tube to ensure it is not clamped or occluded. 2. Cross-clamp the chest tube close to the patient's chest. 3. Change the dressing using nonocclusive material. 4. Instruct the patient to deep-breathe and cough. 1 The nurse is caring for a patient with a chest tube in the right side of the thorax. On first assessment, the nurse notes bubbling in the water-seal chamber. This patient is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. Which following action should the nurse take? a. Clamp the chest tube, but vent the system to air. b. Clamp the chest tube, and disconnect it from the wall suction. c. Do not clamp the chest tube, and disconnect it from the wall suction. d. Do not clamp the chest tube and connect it to temporary intermittent suction. c The nurse notes tidalling of the water level in the tube submerged in the water-seal chamber in a client with closed chest tube drainage. What should the nurse do? a. Continue to monitor this normal finding. b. Check all connections for a leak in the system. c. Lower the drainage collector further from the chest. d. Clamp the tubing at progressively more distal points from the client until the tidalling stops. a What is the usual WALL suction for a CDU? -80cm H2O T/F A water seal units suction can be assessed by the bellows? FALSE water seals do not have bellows A nurse just received report on 4 clients with chest tubes. Which client should they see first? a. the client with tidaling in the drainage tubing. b. the client whose drainage system is standing on the floor. c. the client with continuous bubbling in the drainage chamber. d. the client with the suction pressure set at -20cm H2O C- an air leak! You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak d A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move. c What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system b The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system d . You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes. a 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? A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings The answer is A. It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician. b A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal. bcde Option A: is wrong because this is not how the Valsalva Maneuver is performed (the correct way is detailed in option D). Option F: is wrong as well because this position would not faciltate breathing...Fowler's position is best after removal. A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing. b When is it required to call the MRP regarding the amount of drainage in the CDU? when 100ml/hr of bright red blood ( after 1st hour after placement) What is the time limit for administering blood products? 30 minutes after the initial check, and finish within 4 hours. What is the reason 0.9%NS is used to prime transfusion lines? a. to prevent clotting b. to thin the blood c. to prevent hemolysis d. to keep vein open c What is the initial action when suspecting an acute intravascular hemolytic reaction? Stop the transfusion and start NS infusion TKVO. What is the most common transfusion reaction? Febrile non-hemolytic transfusion reaction When suspecting a transfusion reaction in a client the nurse knows they need to start infusing NS. What is the correct way to implement this intervention? a. clamp blood and open secondary saline line on y-port. b. keep blood open and start secondary NS on y port, as it will override the blood. c. unhook blood and start new line of NS d. run both blood and NS as dilution will help. c Do not turn off the blood and simply turn on the 0.9% normal saline that is connected to the Y-tubing infusion set. This would cause blood remaining in the Y-tubing to infuse into the patient. Even a small amount of mismatched blood can cause a major reaction Fifteen minutes after blood administration, your patient develops dyspnea, a cough, and a rapid heart rate. You suspect: 1. Sepsis 2. Anaphylaxis 3. Acute hemolytic reaction 4. Circulatory overload 4 T/F Dyspnea is an early sign of transfusion reactions? FALSE it is a sign of fluid overload Which solutions are compatible with a blood transfusion? a. Lactate Ringers b. Dextrose 5% c. KCL 20 mmol d. None of the above d ONLY NS 0.9% What are the primary reasons we give blood transfusions? 1. increase circulating blood volume postop 2. increase RBC # and Hgb 3. provide selected cellular components Which complications of transfusions can be decreased by the use of leukocyte depletion or reduction of red blood cell transfusion? a. Chills and hemolysis b. Leukostasis and neutrophilia c. Fluid overload and pulmonary edema d. Transmission of cytomegalovirus and fever D A nurse is caring for a client who is receiving a transfusion of platelets. For what condition would a client require this type of blood component therapy? a. Thrombocytopenia b. Immunodeficiency c. Symptomatic anemia d. Organ rejection A When would you administer the following blood products: a. Plasma b. platelets c. albumin 5% d. albumin 25% e. IVIG a. Bleeding, replacement of coagulation fx b. thrombocytopenia c. hypoproteinaemia- burns, hypoalbuminemia -shock/ARDS d. increase intravascular oncotic pressure e. autoimmune/inflammatory conditions Why do blood infusions sets contain 170-260 micron filters? to remove clots and small clumps of platelets and WBC that form during storage Once you have initiated a blood transfusion you will start the flow at __ml/hr, and stay with the client for ___ minutes. a. 5ml/h, 50 min b. 50ml/h, 15min c. 50ml/h, 5 min d. 2ml/h, 30 min c (lewis states 15 minutes, but slides say 5) What does it mean if a client has an acute hemolytic reaction? ABO incompatibility!, occurs within 15 minutes You are caring for a client (she/her) receiving a transfusion of packed red blood cells after experiencing blood loss during surgery. You have verified all documentation and are now initiating the transfusion. Three minutes into the infusion, she appears restless and tells you she has chest pain. What do you do now? STOP THE BLOOD AND INITIATE REACTION IV LINE (NS infusion) You are caring for a client who received 1 unit of PRBC over 4 hours. After the blood was ordered from Blood Bank at 13:30, one of your other clients calls to go to the bathroom. They had a big bowel movement and required additional time. It is 14:10 when you return to the Nursing Station, your colleague hands you the bag of PRBC that arrived onto the unit. You notice the issue time on the bag of PRBC is 13:35. Can you still infuse this bag of PRBC? No, over 30 minutes Mrs. J, a 35 year old has been admitted to the hospital following a MVA, She will receive 2 units of PRB's this morning. She has NS infusing at 50cc/hr. Through a Y type administration set, she has a 20g cannula in her Rt. Forearm. The MD orders each unit to be infused over 3-4 hours. As you get the report the lab notifies you that the blood is ready to be picked up. Verify the order for the transfusion Ensure the client has a patent IV Prime the transfusion tubing/filter with NS Verify the consent is signed Obtain the blood from the blood bank Ask another qualified nurse to assist in verifying the product identification and client identification Adjust the infusion rate and stay with the client for 5 minutes Infuse the first 50 mL's over 15 minutes Obtain the client's vital signs before starting the transfusion ( 30 min) Documentation Verify client identification prior to administration 1.Verify the order 2.Verify the consent has been signed 3.Ensure the patient has a patent IV 4.Prime the transfusion tubing/filter with NS 5.Obtain VS prior to starting the transfusion 6.Obtain the blood product from the blood bank 7.Ask another qualified nurse to assist in verifying the product identification and patient identification 8.Assess VS including Temp, immediately prior to starting the transfusion 9.Verify patient identification prior to administration 10.Adjust the infusion rate and stay with the patient for 5 minutes 11.Infuse the first 50 mL's over 15 minutes 12.Documentation - document the type of product, product number, volume infused, time of infusion, any adverse reactions, VS (Attach blood sticker). After 20 minutes Mrs. J's assessment includes flushed skin, T 38.9, R 32, BP 100/60, c/o chest pain and chills. Identify the priority problem and prioritize the nursing interventions for this situation. __ Stop the transfusion __ Complete a transfusion reaction report and send with appropriate samples to the lab __ Infuse 0.9% NS at 50 cc/hr __ Assess the VS, breath sounds and airway patency frequently __ Disconnect the blood bag and tubing (send bag and tubing to the lab) __ Inform the MD __ Complete all the appropriate documentation __ Reconfirm the unique identifiers on client and blood component/product 1.Stop the transfusion 2.Disconnect the blood bag and tubing 3.Infuse NS at 50cc/hr 4.Assess the VS, breath sounds and airway patency frequently 5.Reconfirm the unique identifiers on patient and blood component/product (If an error occurred call TMS immediately, another patient may be at risk) 6.Inform the MD 7.Complete a transfusion reaction report and send with appropriate samples to the lab 8.Complete all appropriate documentation ● ● Which of the following do blood transfusion checks need to be performed? A.Packed red blood cells B.Platelets C.IV Immunoglobulin D.Albumin 25% E.Plasma F.Clotting Factors G.All of the above G How much time do you from the time release stamp from Blood Bank to start the transfusion? A.15 minutes B.30 minutes C.45 minutes D.60 minutes b You begin a packed red blood cells transfusion at 12:00. When is the latest time to complete the transfusion, including flushing the IV tubing? A.14:00 B.15:00 C.16:00 D.17:00 c You are with your client during the first 5 minute of platelet transfusion. You notice their lips becoming swollen. What is your priority action? A.Stop the platelet transfusion B.Initiate the emergency NS line C.Call the doctor D.Re-verify the blood product A You're providing care to a 36 year old male. The patient experienced abdominal trauma and recently received 2 units of packed red blood cells. You're assessing the patient's morning lab results. Which lab result below demonstrates that the blood transfusion was successful? A. Hemoglobin level 7 g/dL B. Platelets 300,000 µl C. Hemoglobin level 15 g/dL D. Prothrombin Time 12.5 seconds c A donor has AB- blood. Which patient or patients below can receive this type of blood safely? A. A patient with O- blood. B. A patient with A- blood. C. A patient with B- blood. D. A patient with AB- blood d As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction? A. A 38 year old male who has received multiple blood transfusions in the past year. B. A 42 year old female who is immunocompromised. C. A 78 year old male who is B+ that just received AB+ blood during a transfusion. D. A 25 year old female who is AB+ and just received B+ blood a Before a blood transfusion you educate the patient to immediately report which of the following signs and symptoms during the blood transfusion that could represent a transfusion reaction: A. Sweating B. Chills C. Hives D. Poikilothermia E. Tinnitus F. Headache G. Back pain H. Pruritus I. Paresthesia J. Shortness of Breath K. Nausea A, B, C, F, G, H, J, and K Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the patient's unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within _________. A. 5 minutes B. 15 minutes C. 30 minutes D. 1 hour c A patient who needs a unit of packed red blood cells is ordered by the physician to be premeditated with oral diphenhydramine and acetaminophen. You will administer these medications? A. 15 minutes before starting the transfusion B. Immediately after starting the transfusion C. Right before starting the transfusion D. 30 minutes before starting the transfusion d A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will: A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion. B. Administer the IV antibiotic via secondary tubing into the blood transfusion's y-tubing. C. Hold the antibiotic until the blood transfusion is done. D. Administer the IV antibiotic as scheduled in a second IV access site d A patient is ordered to receive 2 units of packed red blood cells. The first unit was started at 1400 and ended at 1800. You send for the other bag of red blood cells. As the nurse you know it is priority to: A. obtain signed informed consent for the second unit of blood from the patient B. obtain a new y-tubing set for this unit of blood C. type and crossmatch the patient D. hang a new bag of dextrose to transfuse with the blood b Before starting a blood transfusion the nurse will perform a verification process with __________. This will include? A. any available personnel; physician's order, patient's identification, blood bank's information, expiration date of blood B. licensed personnel only (another RN); physician's order, patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, assess the bag of blood for damage or abnormal substances C. blood bank; patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, bag of blood for damage or abnormal substances D. licensed personnel only (another RN); blood compatibility, physician order, expiration date b Before initiating the blood transfusion, you obtain the patient's baseline vital signs, which are: heart rate 100, blood pressure 115/72, respiratory rate 18, and temperature 100.8'F. Your next action is to: A. Administer the blood transfusion as ordered. B. Hold the blood transfusion and reassess vital signs in 1 hour. C. Notify the physician before starting the transfusion. D. Administer 200 mL of the blood and then reassess the patient's vital signs c You've started the first unit of packed red blood cells on a patient. You stay with the patient during the first 15 minutes and: A. run the blood at 100 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. B. run the blood at 20 mL/min and then increase the rate after 15 minutes, if tolerated by the patient. C. run the blood at 200 mL/min and then decrease the rate after 15 minutes, if tolerated by the patient. D. run the blood at 2 mL/min and then increase the rate after 15 minutes, if tolerated by the patient d A patient started receiving their first unit of blood at 1000. It is now 1010 and the patient is reporting itching, chills, and a headache. In addition, the patient's temperature is now 99.8'F from 98'F. Your next nursing action is: A. Stop the transfusion B. Notify the physician C. Decrease the rate of the transfusion D. Reassure the patient that this is normal and will resolve in 30 minutes a A patient with O+ blood received A+ blood. The patient is at risk for? A. Febrile transfusion reaction B. None: O+ and A+ are compatible blood types C. Hemolytic transfusion reaction D. Allergic transfusion reaction c Your patient is having a transfusion reaction. You immediately stop the transfusion. Next you will: A. Notify the physician. B. Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%. C. Collect urine sample. D. Send the blood tubing and bag to the blood bank b What are the most common blood vessels to insert a PIV? Metacarpal Basilic Cephalic Median antebrachial In adults which sites are recommended to avoid inserting a PIV? Ventral surface of the wrist Antecubital fossa Lower extremities Any area of flexion T/F Midline catheters are central lines. FALSE Midline catheters are inserted into the same veins as PICC but terminate at the axilla What are the most common blood vessels to insert a PIV?