Mock Exam 2

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

• Milk the chest tube gently to remove any clots

• Clamp the chest tube momentarily to check for the origin of the air leak

• Assist the patient to deep breath, cough, and use IS

• Set up the PCA pump and administer the loading dose of morphine

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned with which assessment finding is observed?

• An air leak in the water seal chamber

• 400mL of blood in the collection chamber

• Complaint of pain with each deep inspiration

• Subcutaneous emphysema at the insertion site

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

• Observe for distended neck veins

• Auscultate for crackles in the lungs

• Palpate for heaves or thrills over the heart

• Review hemoglobin and hematocrit values

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

• Start a peripheral IV line to administer the necessary sedative drugs.

• Position the patient sitting upright on the edge of the bed and leaning forward

• Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time

• Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

• Oxygen saturation 88%

• Blood pressure is 145/90 mm Hg

• Respiratory rate of 24 when lying down

• Pain level 5 out of 10 with deep breaths

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 bpm, blood pressure of 100/60 mmHg, and respirations of 42 breaths per minute. Which action should the nurse take first?

• Administer anticoagulant drug therapy

• Notify the healthcare provider immediately

• Prepare for a spiral CT

• Elevate the head of the bed to Semi-fowlers

A patient is admitted to the ER with an open stab wound to the left chest. What is the first action that the nurse should take?

• Position the patient so that the left chest is dependent

• Tape a nonporous dressing on three sides over the chest wound

• Cover the sucking chest wound firmly with an occlusive dressing

• Keep the head of the bed at less than 30 degrees

An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance. Which intervention should the nurse anticipate doing next.

• Increase the rate of the dopamine infusion

• Decrease the rate for nitroglycerine infusion

• Increase the rate of sodium nitroprusside infusion

• Decrease the rate of the D5W infusion

After receiving 2 L of NS, the CVP for a patient who has septic shock is 10 mmHg, but the blood pressure is still 82/40 mmHg. The nurse will anticipate an order for

• Nitroglycerine

• Norepinephrine

• Sodium nitroprusside

• Methylprednisolone

Which of the following is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective?

• Hemoglobin in WNL

• Urine output 60mL in one hour

• CVP is normal

• MAP is 72 mmHG