MED SURG FINAL EXAM 2024-2025 ACTUAL EXAM ALL 200 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES (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
CORRECT DETAILED ANSWERS WITH RATIONALES (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
