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MED SURG FINAL EXAM GALEN COLLEGE OF NURSING
NEWEST 2024 ACTUAL EXAM TEST BANK 200 QUESTIONS
AND CORRECT DETAILED ANSWERS ( VERIFIED ANSWERS )
|ALREADY GRADED A+
The nurse is repositioning a client with a chest tube in bed when the chest tube accidentally becomes disconnected from the chest tube container. What is the nurse's priority action at this time?
Encourage the client to breathe slowly while the wound is covered.Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing.Call for assistance and then cover the wound with a sterile dressing.Call for assistance and cover the insertion site with clean, dry gauze. - ANSWER- Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing.
Rationale: Instructing the client to exhale forces air out and allows
the space to be covered before a sucking chest wound occurs. The wound needs to be covered with an occlusive dressing to prevent leak of air. Breathing slowly will still allow air re-entry.
The nurse is caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which items will the nurse obtain to respond appropriately to accidental disconnection of the chest tube from the drainage device? 1 / 4
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An unopened bottle of sterile water A Heimlich valve Two rubber-tipped clamps A spare chest tube insertion kit - ANSWER- An unopened bottle of sterile water
Rationale: Keep bottle of sterial saline or water at bedside. If chest
tube disconnects from drainage unit, submerge end in water.
When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply.
Measure drainage at the end of each shift.Assess chest tube dressing for bleeding.Maintain wall suction at a low setting so there is intermittent bubbling.Position the client in the prone or supine position to permit optimal drainage.Ensure all connections are securely taped. - ANSWER- Measure drainage at the end of each shift.Assess chest tube dressing for bleeding.Ensure all connections are securely taped.
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Rationale: It is important to ensure that chest tube connections are
secure so there are no air leaks. In addition, postoperative considerations include checking the chest tube dressing. The drainage would also be measured at the end of each shift. These are primary considerations postoperatively after a lobectomy. Wall suction must be continuously bubbling to ensure there is active suction in the pleural space. The client needs to be in the Fowler's position to promote effective breathing. Prone or supine would not be appropriate.
A firefighter is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized.Nearly 24 hours after admission, the firefighter reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply.
Monitor for fever.Prepare the chest for chest tube insertion.Auscultate the lungs for adventitious breath sounds.Assess for increased pulse rate.Monitor for increased anxiety levels. - ANSWER- Auscultate the lungs for adventitious breath sounds.Monitor for increased anxiety levels.Assess for increased pulse rate.
Rationale: More than half of all clients with pulmonary involvement
following inhalation injury do not immediately demonstrate 3 / 4
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pulmonary signs. Any client with possible inhalation injury must be observed for at least 24 hours for possible respiratory complications.Maintaining increased oxygen saturation levels is essential, especially following a carbon monoxide inhalation injury, to prevent the development of carboxyhemoglobin, which competes with oxygen for available hemoglobin. The client does not typically develop a fever with inhalation injury, but may progress to acute respiratory syndrome with bilateral lung infiltrates, cardiac involvement with tachycardia, and increasing anxiety due to oxygen starvation. A chest tube is not indicated.
A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client
adherence to the treatment plan, the nurse should:
administer pain medication and delay client activity.tell the client why lung expansion is important.arrange a care schedule that includes rest periods.teach the client how to use an incentive spirometer. - ANSWER- administer pain medication and delay client activity.
Rationale: Administering pain medication and delaying any activity
until the medication takes effect will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube.Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and acts as a visual progress chart for
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