Targeted Med-Surg Practice Assessment 2021/22 (ALL ANSWERS ARE 100% CORRECT)

A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse expect? - PaO2 58mmHg Rat.: nurse should expect to find a low partial pressures of oxygen for a patient who has acute resp. failure A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? - Elevated temp. Rat.: clients who have emphysema are at risk for the development of pneumonia and other resp. infections. A nurse should report this as it indicates a possible resp. infection. A nurse is caring for a client who is postop and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. What ABG values support the nurses suspicion of respiratory acidosis? - pH 7.30, PO2 80mmHg, PaCO2 55mmHg, HCO3 22mEq/L Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which indicates resp. acidosis. A nurse is positioning a client who has emphysema to promote effective breathing. The nurse should place the client in what position? - High fowlers position with arms supported on the overbed table. Rat.: The nurse should place the client in a position that allows for greater expansion of the chest. A nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. Which of the following instructions should the nurse include? - "Expect your urine and other secretions to be orange while taking this medication." A nurse working in th ER is caring for a client following an acute chest trauma. Which of the following findings indicates tot he nurse the client is possibly experiencing a tension pneumothorax? - Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side A nurse is caring for a client who has COPD. What findings should the nurse report to the provider? - Productive cough with green sputum Rat.: A nurse should report this as it indicates an infection A nurse is assisting with a thoracentesis. What actions is appropriate for the nurse to take when assisting with this procedure? - -Wear goggles and mask during the procedure: should wear this to reduce the risk of exposure to pleural fluid. -Cleanse the area with an antiseptic solution: this decreases the risk of infection, which is increased due to the invasive procedure. -Apply pressure to the site after the needle is withdrawn: this decreases the risk of bleeding at the needle insertion site A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority? - Administer heparin via continuous IV infusion. Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore, this is the priority intervention. A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? - container of sterile water. Rat.: the nurse should plan to place the open end of the tubing if it becomes disconnected into the sterile water to prevent a pneumothroax. The tubing and sterile water are then placed below the clients chest. A nurse is caring for a client who is in respiratory distress. What device should the nurse use to provide the highest level of oxygen via a low-flow system? - Nonrebreather mask Rat.: this mask is made up of a reservoir bag from which the client obtains the oxygen, a one way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FlO2 which provides the highest level of oxygen. A nurse is caring for four clients. What client is at greatest risk for pulmonary embolism? - A client who is 12hr postop following a total hip arthroplasty Rat.: it is this client due to decreased mobility of the affected extremity. A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? - asthma A nurse is caring for a client who is 4hr postop following a total laryngectomy for laryngeal cancer. What assessment is priority? - Oxygen saturation Rat.: Using ABC's approach the nurse should identify the client's oxygen sat is the priority. This client is at risk for hypoxia due to airway obstruction and decreased oxygen sat is an indication of an obstructed airway. A nurse is assessing a client who has a chest tube in place following thoracic surgery. What finding indicates a need for intervention? - Continuous bubbling in the water seal chamber. Rat.: continuous bubbling is the water seal chamber suggests an air leak. A nurse is caring for a client who is experiencing a pulmonary embolism. What actions should the nurse take first? - Apply supplemental oxygen.