Tiêu đề KEY - R12 NP3.docx ✅

Situation: A chest tube thoracostomy is a medical procedure where a tube is inserted into the chest cavity to remove air, fluid, or pus and allow the lungs to fully expand. It’s often used to treat conditions like pneumothorax (air in the chest), pleural effusion (fluid in the chest), or empyema (infected fluid in the chest). 61. Maku returned from thoracic surgery 3 hours ago with two chest tubes placed at 20cm suction. Which findings would be considered abnormal? A. Bubbling in the suction control chamber B. 350 cc of sanguineous drainage in the drainage chamber over the last 3 hours C. No fluctuation in the water seal chamber D. Small amount of sanguineous drainage on the chest tube dressing Answer: C Ratio: No fluctuations in the water seal chamber may mean that there is obstruction on the chest tube system (bad indication) or lungs have re-expanded (good indication). 62. Nurse Gen is caring for Justine, a client who has just undergone a left pneumonectomy, knows that she should position Justine on: A. The back with the head of the bed flat B. The left side with the head of the bed flat C. The left side with the head of the bed elevated D. The right side with the head of the bed elevated Answer: B Ratio: Left side-lying in supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump. This allows the fluid left in the operated space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. 63. While Nurse Gen is assessing the client who has a chest tube, she notes that the tubing is kinked between the bedrails. Nurse Gen knows that this places the client at increased risk for: A. Tension pneumothorax B. Air leak C. Hemorrhage D. Cardiac tamponade Answer: A Ratio: Kinking, looping, or pressure on the drainage tubing can produce back-pressure, which may force fluid back into the pleural space or impede the removal of trapped air (w/c can cause tension pneumothorax) 64. Dianhel is rushed to the emergency department due to a pneumothorax secondary to a gunshot wound. She complains of shortness of breath and exhibits tracheal and mediastinal shifts to the left. For which procedure should her nurse prepare Dianhel? A. Intubation with an endotracheal tube B. Insertion of a closed chest drainage tube C. Paracentesis D. MRI of the chest Answer: B Ratio: Patient should be prepared for chest tube insertion to remove the accumulated air and blood/fluids and to relieve the pressure on the trachea and mediastinum. 65. Dr. Rocky is preparing to remove the chest tube from the client's left chest. To prepare for the procedure, the nurse should advise the client to: A. Breathe normally B. Hold his breath and bear down C. Take a deep breath D. Sneeze on command Answer: B Ratio: When assisting in the chest tube’s removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. This is done to prevent air from entering the pleural cavity as the tube is withdrawn. Situation: Nurse Neil is reviewing his knowledge regarding Pancreatitis for his upcoming board examination this November.
66. Nurse Neil knew that the initial diagnosis of pancreatitis is confirmed if the client's blood shows a significant in elevation which of the following serum values? A. Amylase B. Calcium C. Potassium D. Trypsin Answer: A Ratio: Pancreatitis is inflammation of the pancreas. Elevated presence of digestive enzymes (serum amylase, serum lipase) in the blood indicates inflammation of the pancreatic tissue causing its leakage. 67. In a client with acute pancreatitis, Nurse Neil should anticipate observing the following signs and symptoms: A. Diarrhea B. Jaundice C. Hypertension D. Ascites Answer: D 68. Nurse Neil reviews the client's latest laboratory results. What findings would indicate a diagnosis of acute pancreatitis? A. Hyperglycemia B. Leukopenia C. Thrombocytopenia D. Hyperkalemia Answer: A Ratio: Serum glucose is increased because of impaired excretion of insulin d/t pancreatic injury 69. Nurse Neil reviews initial plan for a client with pancreatitis would most likely focus on which of the following as a priority? A. Resting the gastrointestinal tract B. Ensuring adequate nutrition C. Maintaining fluid and electrolyte balance D. Preventing the development of an infection Answer: A Ratio: Question is asking about the initial plan. Initial plan is to put the patient in NPO to rest the GIT, prevent stimulation of pancreas and prevent further painful distention in the patient. 70. Nurse Neil knows that if a client is diagnosed with acute pancreatitis, he should carefully monitor the client for which of the following complications? A. Congestive heart failure B. Duodenal Ulcer C. Cirrhosis D. Pneumonia Answer: D Ratio: The patient with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis. Situation: Nurse Anne, an infectious control nurse, is caring for a client with Pulmonary Tuberculosis. 71. Which client has special risk factors that warrant testing for tuberculosis? A. 45-year-old Caucasian man who has been homeless for 2 years B. 15-year-old Caucasian woman with asthma C. 72-year-old woman who is a recent immigrant from Russia D. 50-year-old Iowa farmer Answer: A Ratio: One of the risk factors for TB is any person without adequate health care (the homeless, impoverished; minorities, particularly children under age 15 and young adults between ages 15 and 44) Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Twelfth Ed., pg.567