Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
When caring for a client with a post right thoracotomy who has
undergone an upper lobectomy, the nurse focuses on pain
management to promote:
11. A client has a chest tube in place following a left lower lobectomy
done after a stab wound to the chest. When repositioning the client,
the nurse notices 200 cc of dark, red fluid flows into the collection
chamber of the chest drain. What is the MOST appropriate nursing
action?
12. When caring for a client with a post right thoracotomy who has
undergone an upper lobectomy, the nurse focuses on pain
management to promote:
a. Pallor
b. Increased temperature
c. Dyspnea
d. Involuntary muscle spasms
a. Esophagitis
b. Leukopenia
c. Fatigue
d. Skin irritation
17. The nurse is caring for a child immediately after surgical correction
of a ventricular septal defect. Which of the following nursing
assessments should be a PRIORITY?
1. Answer B. The priority is postoperative respiratory toilet. This client will quickly
develop profound atelectasis and eventually pneumonia without adequate gas exchange.
This will only be achieved with the appropriate pain management.
2. Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated
and usually will not clot. It is not unusual for blood to collect in the chest and be released
into the chest drain when the client changes position. The dark color of the blood indicates
it is not fresh bleeding inside the chest
3. Answer D. Although all of these findings are abnormal, the elevated potassium is a life
threatening finding and must be reported immediately.
5. Answer B. The purpose of the chest tube is to create negative pressure and remove the
air that has accumulated in the pleural space.
6. Answer A. The findings are indicative of circulatory impairment. The physician (or
practitioner) must be notified immediately.
7. Answer C. A low oxygen level acts as a stimulus for respiration. A high concentration
of supplemental oxygen removes the hypoxic drive to breathe, leading to increased
hypoventilation, respiratory decompensation, and the development of or worsening of
respiratory acidosis. Unless corrected, it can lead to the client’s death.
8. Answer C. Reinforce the dressing, elevate the extremity to decrease blood flow into the
extremity and thus decrease bleeding, and call the physician immediately. This is an
emergency post surgical situation.
9. Answer B. A number of situations can cause the high pressure alarm to sound. It can be
as simple as the client coughing. A quick assessment of the client will alert the nurse to
whether it is a more serious or complex situation that might then require using a manual
resuscitation bag and calling the respiratory therapist.
10. Answer D. Although all of these findings are abnormal, the elevated potassium is a life
threatening finding and must be reported immediately.
11. Answer D. Blood that comes in contact with the pleural space becomes
defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest
and be released into the chest drain when the client changes position. The dark color of the
blood indicates it is not fresh bleeding inside the chest.
12. Answer B. The priority is postoperative respiratory toilet. This client will quickly
develop profound atelectasis and eventually pneumonia without adequate gas exchange.
This will only be achieved with the appropriate pain management.
13. Answer C. Client’s having the insertion of a central venous catheter are at risk for
tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this
complication.
15. Answer B. Clients develop leukopenia due to the depressant effect of radiation therapy
on bone marrow function. Infection is the most frequent cause of morbidity and death in
clients with cancer.
16. Answer B. The purpose of the chest tube is to create negative pressure and remove the
air that has accumulated in the pleural space.
17. Answer B. The atrioventricular bundle (bundle of His), a part of the electrical
conduction system of the heart, extends from the atrioventricular node along each side of
the interventricular septum and then divides into right and left bundle branches. Surgical
repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over
the opening.
18. Answer B. Deep air excursion by turning, coughing, and deep breathing will expand
the lungs and stimulate surfactant production. The nurse should instruct the client on how
to splint the chest when coughing. Humidification, hydration and nutrition all play a part in
preventing atelectasis following surgery.
20. Answer C. Loss of the pulse in the extremity would indicate impaired circulation.