Medical Surgical - Nursing

The nurse caring for a client who is ventilated. The alarm on the ventilator beings to sound. Which action should the nurse take first?

• Check the client

• Change the ventilator settings

• Notify the HCP

• Suction the client

The nurse notes course crackles when assessing the lung sounds of a client. Which intervention should the nurse implement?

• Instruct the client to cough deeply

• Suction the client

• Check oxygen saturation

• Obtain a sputum specimen

The nurse is caring for a client with a chest tube and notes continuous bubbling. Which action should the nurse implement?

• Add water to the water seal chamber

• Place the drainage system above chest level

• Change the collection chamber

• Check for leaks and notify the registered nurse (RN)

The nurse is caring for a client who is mechanically ventilated. To promote effective communication, which of the following should the nurse implement?

• Ask open-ended questions

• Provide a pencil and paper

• Read expressions and body language

• Place the call light within reach

• Provide a picture board

The nurse is caring for a client with lung disease of the left lung. The nurse should instruct the client to lie in which position?

• High Fowler’s position

• Right side-lying position

• Semi-Fowler’s position

• Left side-lying position

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving oxygen via nasal cannula who complains of dry nasal membranes. Which intervention should the nurse implement?

• Change the client to a simple face mask

• Increase the amount of oxygen the client is receiving

• Use a water source to humidify the oxygen

• Apply petroleum jelly to the nares

Which of the following describes the benefit of pursed-lip breathing?

• Strengthen intercostal muscles

• Strengthen the diaphragm

• Promote an increase in oxygen intake

• Promote elimination of carbon dioxide

The nurse is caring for a client with epistaxis. Which intervention should the nurse implement?

• Administer vasodilating agent as ordered

• Instruct the client to lean their head back and pinch the nose

• Instruct the client to sit in a chair and tilt head downward

• If a fracture is suspected, apply pressure to the bridge of the nose

The nurse is caring for a client with epistaxis. The client begins to swallow repeatedly. Which of the following should the nurse assess?

• Back of the throat

• Bridge of the nose

• Mucous membranes of the nose

• Lung sounds

The nurse is caring for a client with suspected sleep apnea. For which test should the nurse prepare the client?

• Nocturnal polysomnography

• CT scan

• X-Ray exam

• MRI