Med Surg FINAL EXAM with Complete Solution
LATEST
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.
LATEST
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.
