Post Test1. A client has chest tubes due to a pneumothorax. The nurse recognizes that chest tubes may be

used to:a. Regain positive intrapleural pressureb. Prevent pleural irritationc. Remove air and fluid from the intra-pleural spaced. Establish negative pressure in the intra-alveolar space

2. Nursing care of the client with closed chest drainage should include :a. Clamping chest tube every 2 hoursb. Elevating the chest tube higher then the client’s chestc. Milking chest tube only if obstructed by clotsd. Clamping chest tube when moving the patient

3. While bathing a client with chest tubes the nurse notices that there is continuous bubbling in the water seal chamber. This means that:

a. There is a leak in the systemb. The system is functioning properlyc. The client is exhalingd. The client needs to be turned to the left

4. A physician asks you to assist him with the removal of his chest tube. You would instruct the client to:

a. Continuously breathe normally during the removal of the chest tubeb. Take a deep breathe , exhale and bear downc. Exhale upon actual removal of the chest tubed. Hold breath until the chest tube is pulled out

5. Chest tube diameter is measured or expressed ina. Frenchb. Millimetersc. Gauged. Inches

6. When transporting a client with a chest tube, the system should be:a. Disconnectedb. Closedc. Placed lower than the patient’s chestd. Placed between the legs of the client to prevent accidental breakage

7. In a client with new rib fractures which assessment finding would best alert the nurse to the possible development of a pneumothorax?

a. Pink frothy sputumb. Hoarsenessc. Decreased breath sounds on the affected side

d. Dullness to percussion on the unaffected side8. The nurse is caring for a client post thoracotomy after having been stabbed in the chest. He was

attached to a 3 way water seal drainage system. Which is an appropriate nursing priority?a. Apply a thoracic binder to prevent tension in the chest wallb. Observe for fluid fluctuations in the water seal chamberc. Observe for fluid fluctuations in the suction control bottled. Clamp tubing to prevent a rapid decline in pressure

9. A chest tube is inserted to decompress the lung. The most important purpose of this is to prevent which of the following complications?

a. Hypoventilationb. Painc. Pneumoniad. Mediastinal shifting

10. A client is admitted with severe dyspnea related to Pneumothorax. The nurse would expect to hear

a. Bronchial breath sounds over affected areab. Hyperresonance on percussion of the affected lungc. Whispered pectoriloquyd. Increased tactile fremitus

11. The following statements are generally considered accurate for clients with pleural effusion EXCEPT.

a. Associated diseases include PTB and Lung CAb. Chest Xray generally turns positive with fluids of more than 250 ccc. Primary management is through the use of antibioticsd. Signs and symptoms generally manifest with fluids greater than 100cc

12. A client is having a severe asthmatic attack. Which finding will reinforce your assessment?a. Bilateral cracklesb. Wheezingc. Diminished breath sounds d. Stridor

13. A client with COPD complains of w 10 pound weight gain in a week. The complication that may have precipitated this weight gain is

a. Polycythemia verab. Cor pulmonalec. Left ventricular hypertrophyd. Compensated acidosis

14. A client with chronic bronchitis has unresolved bronchial infection in:a. 2 consecutive months in 3 consecutive yearsb. 3 consecutive months in 2 consecutive yearsc. 1 full yeard. 6 consecutive months within a year

15. A physician prescribes O2 at 2 LPM via nasal cannula for a patient with COPD. Which statement best describes why the patients O2 therapy is maintained at this relatively low level?

a. Prolonged exposure to high O2 causes structural damage to the lungb. Increased o2 concentration of inspired air can cause alveoli to collapsec. Increased O2 can eliminate the stimulus for breathing in a patient with COPDd. O2 may affect the eyes causing tearing, edema and visual impairment

16. The physician orders aminophylline IV drip for the patient. The nurse should be alert for which sign of drug toxicity?

a. Depressionb. Tachycardiac. Lethargyd. Cyanosis

17. After the aminophylline drip is started the patients breathing improves. This occurs because aminophylline:

a. Allows more air to enter the lungsb. Decreases respiratory rate and depthc. Helps the patient cough up thick secretionsd. Increases respiratory rate and depth

18. The nurse understands that in the absence of pathology, a clients respiratory center is stimulated by:

a. O2b. Lactic acidc. Calciumd. CO2

19. A significant assessment finding in a client with a tension pneumothorax is:a. Tracheal deviation to the unaffected sideb. Inspiratory stridor and respiratory distressc. Diminished breath sounds over the affected sided. Hyper resonant percussion sound over the affected side

20. Which of the following is the emergency treatment for tension pneumothorax?a. Inserting a large bore needle into the intercostal space on the unaffected sideb. Placement of a chest tube a chest tube through the mid sternum to reduce cardiac

tamponadec. Attaching the chest tube to a continuous gravity drainage bagd. Inserting a large bore needle into the 2nd intercostal space on the affected side

21. Chest tube diameter is measured or expressed ina. Frenchb. Gaugec. Millimetersd. Inches

22. When transporting a client with a chest tube the system should be:a. Disconnected

b. Closedc. Placed lower than the patient’s chestd. Placed between the legs of the client to prevent breakage

23. The nurse enters the room of a client with COPD. The clients O2 is running at 6LPM, his color is pink and his respirations are 9/min. what is the best initial action?

a. Take vital signsb. Call the physicianc. Lower the O2 rated. Put the client in Fowlers position

24. What is the primary purpose for instructing a client with COPD to use purse lip breathing?a. Prolonged exhalation helps prevent air trappingb. This trains the diaphragm to aid inspirationc. It improves the delivery of oral and nasal medicationsd. It facilitates the movement of thick mucus

25. What is the purpose of the long glass tube that is immersed 3 cm below the water level in a water seal bottle?

a. To humidify the air leaving the pleural spaceb. To allow the drainage to mix with sterile waterc. To monitor the respirations by visualizing the fluctuationd. To prevent atmospheric air from entering the chest tube

Situation: A 60 year old male client is admitted to the emergency department with crushing substernal chest pain that radiates to the shoulder, jaw, and left arm. The admitting diagnosis is acute MI.

26. Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead ECG, and 2 mg of morphine sulfate given intravenously. The nurse should first

a. administer the morphineb. obtain a 12-lead ECGc. obtain the blood workd. order the chest radiograph

27. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of the drug is to

a. help keep him well-hydratedb. dissolve clots that he may havec. prevent kidney failured. treat potential cardiac dysrhythmias

28. If the client develops cardiogenic shock, which characteristic sign should the nurse expect to observe?

a. oliguriab. bradycardiac. elevated blood pressure

d. fever29. The pain associated with MI is due to

a. left ventricular overloadb. impending circulatory collapsec. extracellular electrolyte imbalancesd. insufficient oxygen reaching the heart muscle

30. Aspirin is administered to the client experiencing an MI because of itsa. antipyretic actionb. antithrombotic actionc. antiplatelet actiond. analgesic action

31. A basic principle of any rehabilitation program including cardiac rehabilitation, is that rehabilitation begins

a. on discharge form the hospitalb. on discharge form the cardiac care unitc. on admission to the hospitald. four weeks after the onset of illness

32. Alteplase recombinant, or tissue plasminogen activator (tPA), a thrombolytic enzyme, is administered during the first 3 hours after onset of MI to

a. control chest painb. reduce coronary artery vasospasmc. control the dysrhythmias associated with MId. revascularize the blocked coronary artery

33. The client says to the nurse, my father died of a heart attack when he was 60, and I suppose I will too. Which of the following responses by the nurse would be the most appropriate?

a. Tell me more about what you are feelingb. Are you thinking that you won’t recover from this illness?c. You have a fine doctor. Everything will be all right soon, I’m sure?d. Would you agree that this would be very unlikely?

34. While caring for client who sustained an MI, the nurse notes eight premature ventricular contractions (PVC’s) in one minute on the cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and 2 liters/minute of oxygen. The nurse’s first course of action should be to

a. increase the intravenous infusion rateb. notify the physician promptlyc. increase the oxygen concentrationd. administer a prescribed analgesic

35. Crackles heard on lung auscultation indicatea. pulmonary edemab. bronchospasmc. airway narrowingd. fluid-filled alveoli

36. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?

a. high risk for infection related to stasis of secretions in alveolib. impaired skin integrity related to pressurec. activity intolerance related to imbalance between oxygen supply and demandd. constipation related to immobility

37. The major goal of therapy for this client would be toa. increase cardiac outputb. improve respiratory statusc. decrease peripheral edemad. enhance comfort

38. Digoxin is administered intravenously to this client, primarily because the drug acts toa. dilate coronary arteriesb. increase myocardial contractilityc. decrease cardiac dysrhythmiasd. decrease electrical conductivity in the

39. The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help

a. decrease GI irritationb. retard rapid drug absorptionc. excrete fluids accumulated during the nightd. prevent sleep disturbances during the night

40. The nurse should teach the client that signs of digitalis toxicity includea. skin rash over the chest and backb. increased appetitec. colored visiond. elevated BP

41. The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a

a. low sodium levelb. high glucose levelc. high calcium leveld. low potassium level

42. Long term complications of HPN includea. renal insufficiency and failureb. valvular heart diaseasec. endocariditisd. peptic ulcer disease

43. The nurse teaches a client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to

a. open and dilate blocked coronary arteriesb. assess the extent of arterial blockagec. bypass obstructed vesselsd. assess the functional adequacy of the valves and heart muscle

44. The nurses teaches the client with angina about the common expected side effects of nitroglycerin, including

a. headacheb. high blood pressurec. shortness of breathd. stomach cramps

45. Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to prevent what complication?

a. GI bleedingb. MIc. Emesisd. Rib fracture

46. The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. Outcome criteria include that the client

a. Selects a low-cholesterol diet to control CADb. States a need for bed rest for one week after dischargec. Verbalizes safety precautions needed to prevent pacemaker malfunctiond. Explains signs and symptoms of myocardial infarction

47. Which is not an appropriate health teaching to a patient prescribed with nitroglycerine (NTG):a. Replace NTG every 6 monthsb. Always carry one or 2 tablets of NTG in your pocket for emergency needc. Take only up to 3 tablets of NTGd. Do not expose NTG to sun or extreme heat

48. Which of the following drugs is not used for the treatment of cardiac arrest?a. Dopamine hydrochlorideb. Norepinephrinec. Sodium bicarbonated. Nitroglycerin

49. A client with a prescription of sodium warfarin (Coumadin) should be given the following instructions, except:

a. Check for bleedingb. Eat green leafy vegetables once a weekc. Inject the drug subcutaneously onlyd. Avoid engaging in contract sports or using power tools

50. Before administering digoxin (Lanoxin) to a cardiac patient, the most important responsibility of the nurse to the patient is to:

a. Assess the apical pulseb. Measure the blood pressure c. Verify the doctor’s orderd. Count the respiratory rate