Summer 2023 Pre-Test

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

• Stoma oozing red drainage

• Shiny, moist stoma

• Purplish-colored stoma

• Rosebud-like stoma orifice

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

• Increased respiratory rate

• Stable oxygen saturation

• Clear breath sounds

• Brisk capillary refill

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

•     Preoxygenate the client for 4 minutes prior to tracheostomy care.

• Clean the tracheostomy stoma with a chlorhexidine solution.

• Perform tracheostomy care for the client every shift.

• The nurse should place the client in a supine or semi-Fowler's position to promote oxygenation and allow access to the tracheostomy site.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

• Clamp the chest tube prior to transferring the client to a wheelchair

• Disconnect the chest tube from the drainage system during transport.

• Keep the drainage system below the level of the client's chest at all times.

•   Empty the collection chamber prior to transport.

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take?

• Clamp the tube when the client is ambulating.

• Keep the collection device below the level of the client's chest.

• Coil the tubes carefully to prevent kinking.

• Lay the client flat to avoid leaks in the tubing

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

• Chest tube eyelets not visible

• Continuous bubbling in the suction control chamber

• Presence of tidal fluctuation in the water seal chamber

•      Development of subcutaneous emphysema

A nurse is caring for a client who is scheduled for surgery and has a history of alcohol abuse. The nurse should identify that alcohol abuse increases the client's risk for which of the following postoperative complications?

• Nausea

• Blood clots

• Bleeding

• Malignant hyperthermia

A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

• The client will acknowledge alcohol dependence and need for treatment.

• The client will rebuild damaged interpersonal relationships.

• The client will implement alternative strategies for managing anxiety.

• The client's withdrawal from alcohol will be managed without complications.

A nurse is caring for a client who is to receive a mechanically altered diet. Which of the following client food choices necessitates intervention by the nurse?

• Scrambled eggs

• Cottage cheese

• Piece of wheat toast

• Sliced banana

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

• Lemon sherbet

• Plain yogurt

• Cranberry juice

• Carrot juice