Tiêu đề ENHANCEMENT -PB EXAM - NP 3- STUDENT COPY.docx.pdf ✅

Situation: A 28-year-old male is brought to the emergency department due to motorcycle accident. He complains difficulty of breathing, pain on the left side and use of accessory muscle was noted. Upon assessment, the nurse noticed decreased breath sound and hyperresonance on the side affected. Pneumothorax is the diagnosis. 11. What instruction should the nurse initially instruct the patient to do? a. Inhale and exhale deeply b. Inhale and strain against a closed glottis c. Hold their breath and remain still to prevent air from entering d. Partially cover the wound with the heel of his hand 12. The immediate goal for this diagnosis is to? a. To stabilize breathing and relieve pain b. Normalize breath sounds c. Prevent infection d. Evacuate air from the pleural space and promote lung re-expansion 13. To remove air from the pleural space, a chest tube is to be inserted in what area? a. 2 nd intercostal pace b. 3 rd -4th intercostal space c. 4 th -5th intercostal space d. 6 th intercostal space 14. To assess whether a tension pneumothorax is developing, what should the nurse evaluate? a. Dull percussion sounds on the injured side b. Severe respiratory distress and tracheal deviation c. Muffled and distant heart sounds accompanied by decreasing blood pressure d. Reduced chest movement and diminished breath sounds on the affected side 15. When pneumothorax is confirmed, what should the nurse do immediately? a. Insert a large-bore needle to relieve pressure b. Provide a high concentration of supplemental oxygen c. Insert a chest tube and connect to suction d. Call the primary healthcare provider to take the patient for surgery Situation: COPD 16. A patient is long-term smoker complaining of sputum production and frequent infection. what is likely the reason for their symptoms based on the effect of smoking? a. Constant irritation from smoking causes inflammation and increases the number of mucus-secreting and goblet cells causing hypersecretion of mucus b. Due to abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli c. Smoking depresses the activity of scavenger cells and affects the respiratory tract’s ciliary cleansing mechanism d. carbon monoxide combines with hemoglobin to form carboxyhemoglobin 17. COPD patients are prone to infection and may worsen hypoxemia. What should the nurse encourage to prevent infection? a. Avoid going outdoors if there is significant air pollution b. Avoid exposure to high temperatures with low humidity c. Avoid extremes of heat and cold d. Get immunized against influenza and pneumonia 18. When assessing a patient with history of emphysema, which characteristic change in the patient’s chest should the nurse identify to assess the progression of the disease? a. Anteroposterior and transverse diameter ratio of 2:1 b. Depression in the lower portion of the sternum. c. Anteroposterior and transverse diameter ratio of 1:2 d. Displacement of the sternum and an increase in the anteroposterior diameter 19. The breathing pattern of most people with COPD is shallow, rapid, and inefficient. Which breathing exercise should the nurse recommend to improve breathing efficiency? a. Perform upper chest breathing to expand lung capacity. b. Perform diaphragmatic breathing to decrease respiratory rate and increase alveolar ventilation. c. Hold breath for 10 seconds and exhale forcefully. d. Exhale and inhale normally. 20. Which dietary adjustment helps fulfill the nutritional requirements of patients with COPD? a. Consuming a diet high in carbohydrates and low in fat b. Eating soft, small, frequent meals c. Eating mostly hot-prepared meals d. Drinking fluids during meals to aid digestion Situation: Chest tube drainage system is used to remove abnormal accumulations of air and fluid from the pleural space. 21. In wet suction system, what determines the level of suction applied? a. Amount of bubbling observed in the suction chamber. b. Diameter of suction chamber. c. Height of chest drainage system. d. Amount of water instilled in the suction chamber. 22. Dr. Zach asked you to assist him with the removal of chest tube. You would instruct the client to; a. Take a deep breath, exhale, and do valsalva maneuver. b. Breathe normally during the removal. c. Inhale three times and exhale as the tube is pulled out. d. Take shallow breath to minimize discomfort. 23. Chest tube diameter is measured in: a. Gauge b. French c. Inches d. cm H2O 24. When transporting a patient with chest tube, how should the chest drainage system be managed? a. At the same level as the chest. b. Positioned lower than the chest level. c. Clamped at all times. d. Above the level of chest to allow for easier monitoring. 25.A patient with a chest tube is being managed with wall suction to help drain air and fluid from the pleural space. The physician orders to discontinue suction therapy. As a nurse, what should you do next to ensure proper management of the chest drainage system? a. Keep the suction port attached to maintain the pressure and avoid air from entering the system. b. Detach the tubing from the suction port to allow air to escape from the pleural space into the atmosphere. c. Clamp the chest tube to prevent any air from escaping and monitor the patient for signs of tension pneumothorax. d. Seal the drainage system completely to prevent any airflow and secure the tube. Situation: Cases of Filipinos with acute and chronic kidney disease has been increasing necessitating the need for dialysis. 26. Which of the following part of the body is the most common site for creating AV fistula? a. Arm b. Forearm c. Hand d. Fingers 27. Patient Roan has just had her fistula surgically created by anastomosis of artery and vein on the right arm. She was 2 | Page
advised to take care of her fistula. Which of the following statements by Roan would not indicate proper understanding of care of fistula? a. I will do hand-flexing exercises such as ball squeezing to mature the fistula b. I will take my BP on the right arm only c. I must touch the shunt several times a day to feel for a thrill d. I will avoid carrying bags and heavy stuff on my right arm 28. Roan is scheduled to have her hemodialysis session today and is also under antihypertensive medications. She asked the nurse if she should take her morning dose of lisinopril. What should the nurse reply? a. “anti-hypertensive medications should be withheld and must continue following dialysis” b. “it is okay to take your antihypertensive medication while undergoing dialysis” c. “I’ll ask your physician about this and will get back to you” d. “you must not skip your maintenance medication as it may cause some problems” 29. Yuki, a 30-year-old woman, is involved in a vehicular accident sustaining significant trauma to her lower back and abdomen. Upon assessment, she is found to have bruising around her flanks. Imaging studies reveal damage to her kidneys. Over the next 24 hours, her urine output decreases significantly, has elevated BUN and creatinine. What type of renal failure is she experiencing? a. Prerenal b. Intrarenal c. Postrenal d. Acute renal failure 30. Acute renal failure (ARF) is characterized by a rapid loss of renal function caused by damage to the kidneys. This condition often impacts urine output, which can vary from normal levels to significant changes. During a patient assessment, the nurse observes that the patient's urine output has decreased to less than 500 mL in 24 hours. How should this condition be classified? a. Oliguria b. Non-oliguria c. Anuria d. Polyuria 31. Soyo, a patient with chronic kidney disease is undergoing peritoneal dialysis and is the middle of an exchange. The nurse notices that the peritoneal fluid is draining more slowly than usual and his abdomen is increasing in girth. What is the most appropriate intervention? a. Advance the catheter 2 to 4 cm further into the peritoneal cavity to promote drainage b. Reposition the patient to facilitate drainage for possible obstruction c. Clamp the catheter and notify the physician d. Apply gentle pressure to the abdomen to promote drainage 32. The nurse is caring for a patient who has recently returned from surgery after a nephrectomy. During an hourly assessment, the nurse notices the patient is less alert, has a low blood pressure, and is producing very little urine. What should the nurse do next? a. Assess the patient for signs of bleeding and notify the physician immediately b. Reassess the vital signs for the next hour to monitor for changes c. Increase the patient’s oral fluid intake to improve blood pressure and urine output d. Reposition the patient 33. The dialysis solution is pre-warmed before peritoneal dialysis mainly to: a. Facilitate elimination of serum urea. b. Promote vasoconstriction and reduce clearance. c. Provide additional warmth to the body. d. Encourage relaxation of the abdominal muscles. 34. The nurse is educating a client with chronic renal failure on maintaining proper nutrition. Which of the following dietary choices would be most suitable? a. High in carbohydrates and protein. b. High in calcium, potassium, and protein. c. Low in protein, sodium, and potassium. d. Low in protein but high in potassium. 35. The client with acute renal failure has an elevated serum potassium level, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This medication works by: a. Enhancing potassium excretion through the colon. b. Promoting calcium absorption in the colon. c. Releasing hydrogen ions in exchange for sodium ions. d. Exchange sodium for potassium ions in the colon. Situation: Dex, 10-years old, comes to the emergency department accompanied by his mother. He states that he experiences periorbital and facial edema and decreased urine output. He also notices cola-like color in his urine. The nurse suspects glomerulonephritis. 36. Which question should the nurse ask to help confirm the diagnosis of glomerulonephritis? a. “Do any of your family members have this problem? b. “Has the child had any history of infection involving the skin or throat?” c. “Do the child frequently pee or feel pain on urination? d. “Do you consume an excessive amount of sodium in your diet?” 37. Which of the following findings requires the most urgent intervention? a. Significant generalized swelling throughout the body b. Urine specific gravity reading of 1.035 c. High levels of albumin detected in the urine d. A 24-hour urine output of 1,500 mL 38. Dex is found to have elevated BUN and hypertension in addition to the initial assessment. Which selection of foods should the nurse anticipate? a. Fries, apple juice, and cookies b. Grilled salmon, donuts, and fruits c. Wheat bread, fruit juice box, and hotdogs d. Baked chicken, steamed broccoli, and milk 39. Dex is started on treatment focused on preserving kidney function, corticosteroid therapy and managing hypertension and proteinuria. Which of the following outcomes indicate that the treatment is not effective? a. Increasing urine output and decreased edema b. Decreased blood pressure and reduced proteinuria c. Increasing blood pressure and persistent proteinuria d. urine specific gravity of 1.009 40. Dex is about to be discharged, which statement indicates that the mother understood the discharge instruction? a. “I’ll make sure that my son will not get any respiratory problems” b. “I will make sure that my son will get enough rest and I’ll limit his fluid intake” c. “I will ensure that my son will take the full course of antibiotics as prescribed if he again contracts infection” d. “Foods high in potassium should be restricted from now on to protect his kidneys” Situation: Joy, a 77-year-old woman is admitted for the management of her chronic health condition and has urinary catheter in place. Over the past 24 hours, the nurse has noticed some changes and suspects a urinary tract infection. 41. The nurse is monitoring Joy for urinary tract infection. Which initial symptoms is Joy likely to manifest that would indicate UTI? 3 | Page