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10 Cards in this Set
- Front
- Back
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Nurse is assessing a client who has emphysema. The nurse should report which of the following assessment findings?
1. digital clubbing 2.Elevated Temp. 3. Barrel Chest 4. Diminished Breath sound |
1.digital clubbing-normal findings 2.Elevated temp-higher risk for pneumonia and rest. infections 3. barrel chest -normal findings 4. diminished breath sounds-normal findings |
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Pt taking albuterol what side effect should the nurse watch for?
1.Hyperkalemia 2.Dyspnea 3.Tachycardia 4.Candidasis |
1.hyperkalemia-Not a side effect of this med 2.Dyspnea- you would give the med to treat this 3.Tachy- common side effect of the drug 4.Candidiasis(thrush)- side effect of inhaled glucocorticoids(beclomethasone) |
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RN caring for PT following Chest Tube insertion. RN should plan to have which item in the room?
1.Extra drainage System 2.Suture set 3. container of Sterile water 4.Nonadherent pads |
1.Extra drainage- not needed 2.Suture set- not needed until removal 3. Sterile Water- should have in case tube becomes disconnected b/c place open tube in water to prevent pnuemothroax. 4. Nonadherent pads- not needed |
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RN assessing PT with Chest tube. Which finding needs intervention?
1. fluctuation of drainage in the tubing with inspiration. 2. Continous bubbling in the water seal chamber 3. Drainage of 75ml in 1st hr 4. Several blood clots in tubing |
1. fluctuation with inspiration- expected(normal) 2. continuous bubbling in water seal- AIR LEAK 3. Drainage of 75ml in 1st hr- only concerned if over 100ml in 1hr 4. clots in tubing- expected (normal finding) |
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PT underwent bronchoscopy with conscious sedation. What is the priority assessment?
1. Gag reflex 2. Pain Level 3. Dehydration 4. Redness at IV site |
1. Gag reflex- Greatest risk is ASPIRATION due to depressed gag reflex. 2. Pain level- needed but not priority ABC 3. dehydration- needed since NPO but not priority 4.Phlebitis- Needed due to med through IV but again not priority. |
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RN is to perform NG Suctioning on PT. Which should the nurse need to clairfy before performing.
1. Closed head injury and lethargic 2.Fractured femur and reporting sever pain 3. Ruptured appendix and temp of 102.2 4. Emphysema PT with RR of 36 |
1. Head injury- No suctioning b/c it will increase ICP 2. Femur- does not matter 3. Temp/appendix- does not matter 4. Emphysema- does not matter |
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PT in acute respiratory failure who is on mechanical ventilation what assessment would the nurse check to see effectiveness of the mechanical ventilation? 1. BP 2. Cap refill 3. ABG 4. HR |
1.BP- should monitor for circulatory system but not for respiratory. 2. Cap refill- should monitor for circ. system but not resp. 3. ABG- ABC's ABG's determine O2 saturation and acid- base balance. 4. HR- should monitor for circ. system but not resp. |
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PT suffering from Acute respiratory distress syndrome. What would indicate a decline in status?
1.Increase RR 2.Increase in O2 sat 3.Decrease in CO2 retention 4.Decrease in intercostal retractions |
1. High RR- increased work load harder breathing de to not meeting oxygen requirements. 2.O2 Sat- would be a sign of improvement 3.decreased CO2 retention- would be a sign of improved gas exchange 4.decreased retractions- would be a sign of improving gas exchange |
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PT 1 hr post-op thoracentesis which is the priority assessment?
1. Pallor 2.Insertion site pain 3.Tracheal deviation to unaffected side 4.Temp 37.3 |
1. Pallor- can indicate blood loss but not priority 2.pain at site- can lead to shallow respirations but not priority 3.Traceal deviation- ABC's can indicate a tension pneumothorax (emergency) 4. temp- can indicate infection but not priority. |
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RN giving instruction on using a Montelukast to treat chronic asthma which statement indicates understanding by the client? 1. will take with each meal 2.will take during attacks 3.will take up to 3 times a day when I wheeze 4. will take every evening, even if asymptomatic |
1. with meals- this med should only be given once/day 2. asthma attacks- this med is used for maintenance therapy. 3. when I wheeze- this med should be on a schedule 4. every evening- This med is used as prophylaxis for asthma exacerbation and should be taken on a daily basis in the evening as part of a maintenance therapy. |
