OTC LPN Oxygenation NCLEX Practice Questions

OTC LPN Oxygenation NCLEX Practice Questions ScienceMedicineNursing sean_casey19 Save An adult client is admitted for diagnosis and treatment of a left lung lesion. A bronchoscopy was performed under local anesthesia. What nursing action is of highest priority when he returns following the bronchoscopy?

• Collect all sputum for examination.
• Assess level of consciousness frequently.
• Withhold food and fluids until gag reflex has returned.
• Monitor blood pressure and pulse at 10 minute intervals.
• Withhold food and fluids until gag reflex has returned.

Food and fluids should be withheld to prevent aspiration. The client will have received a local anesthetic to block the gag reflex during the bronchoscopy. The nurse should observe sputum for color but it is not necessary to collect it. Bronchoscopy is usually done under a local anesthetic so level of consciousness is not a priority. Vital signs may be monitored but preventing aspiration is of highest priority.

A lower left lobectomy was performed on an adult client. He was returned to his room following an uneventful stay in the recovery room. It is most important for the nurse to

• Encourage him to perform deep breathing and coughing exercises.
• Assist him with arm exercises to prevent shoulder ankylosis.
• Help him perform leg exercises to prevent thrombophlebitis.
• Position him in semi-Fowler's position on his left side.
• Encourage him to perform deep breathing and coughing exercises.

Deep breathing and coughing assume highest priority after a thoracotomy. Arm and leg exercises are also important. He would be positioned in semi-Fowler's position on his right side (nonoperative).A client who has had a lobectomy returns to the nursing unit. He has a chest tube attached to portable water seal drainage system and oxygen per nasal cannula. The first nursing measure concerning the water seal drainage is to

• Milk the tubing to prevent accumulation of fibrin and clots.
• Raise the drainage apparatus to bed height to accurately assess the meniscus level.
• Attach the chest tubes to the bed linen to assure that airflow and drainage are unhindered

by kinks.

• Mark the time and level of drainage in the collection chamber.
• Mark the time and level of drainage in the collection chamber.

It is important to monitor the amount of chest drainage. Chest tubes are milked only if there is an obstruction in the tubing and only with a physician's order. The chest drainage system should not be raised above chest level. It should remain low. Chest tubes should not be attached to the linens.

• An adult client had a left thoracotomy. He has portable water seal chest drainage. On the

first postoperative day the fluid in the water seal chamber stops fluctuating. What does this most likely indicate?

• The chest tube is clogged by fibrin or a clot.
• There is an air leak in the system.
• Pulmonary edema has occurred due to increased blood volumes in remaining lung tissue.
• The client's left lung has reexpanded.
• The chest tube is clogged by fibrin or a clot.

Fibrin and clots will obstruct the outflow of air from the patient's thoracic cavity. It is too soon for the lung to have reexpanded. An air leak in the system would cause an absence of bubbling in the suction control chamber not the water seal chamber.

• An adult client had a left lower lobectomy. Passive exercises are started on his left arm

after surgery. The exercises are designed to prevent

• Hyperflexion of the wrist.
• Ankylosis of the shoulder.
• Flexion contractures of the elbow.
• Spasticity of the intercostal muscle
• Ankylosis of the shoulder

The muscles have been cut during surgery. Range of motion exercises will help to prevent ankylosis of the shoulder or frozen shoulder. Patients also tend to splint incisional discomfort by limiting movement on the affected side.

• An adult client is admitted to the acute care hospital with bacterial pneumonia. On

admission she was pale to dusky in color. Her respirations were 32, temperature 1030F and pulse 110. Auscultation revealed decreased or absent lung sounds in both bases and rhonchi in both upper lung fields. She was oriented to person, time and place, but her responses were brief. Oxygen per nasal cannula is started at 7 l / minute. IV antibiotics were started.While checking the client one hour after admission the nurse notes that she is less responsive, answering only yes or no questions. Her respirations are somewhat more shallow and have decreased to 27 per minute. What is the best INITIAL action for the nurse to take?

• Increase the IV infusion rate to increase the amount of circulating antibiotics.
• Notify the physician of the client's changed mental status and await further orders.
• Increase the oxygen flow rate to 10 liters / minute.
• Continue to stimulate her until she responds appropriately.
• Notify the physician of the client's changed mental status and await further orders.

Changes in mental status are always significant. Since her respirations are decreasing it is doubtful if oxygen would be effective.

• A tracheostomy tube is inserted in a patient who is in respiratory distress as a result of

pneumonia. The family asks why the tube is inserted. What should the nurse include when explaining to the patient and family? The purpose of a tracheostomy tube is to

• Decrease the client's anxiety by increasing the size of the airway.
• Provide increased cerebral oxygenation thereby preventing further respiratory depression.
• Facilitate nursing care since tracheal tubes have fewer side effects than nasotracheal

tubes.

• Provide more controlled ventilation and ease removal of secretions the client is unable to

handle.

• Provide more controlled ventilation and ease removal of secretions the client is unable to

handle.This is the purpose of a tracheostomy. The client may become less anxious when she is no longer hypoxic. However, relief of anxiety is not the purpose of a tracheostomy tube.