Professional Documents
Culture Documents
Post Test
There are two normal breath sounds. Bronchial and vesicular. Breath sounds
heard over thetracheobronchial tree are called bronchial breathing and
breath sounds heard over the lung tissue are called vesicular breathing. The
only place where tracheobronchial trees are close to chest wall without
surrounding lung tissue are trachea, right sternoclavicular joints and
posterior right interscapular space. These are the sites where bronchial
breathing can be normally heard. In all other places there is lung tissue and
vesicular breathing is heard.
The bronchial breath sounds over the trachea has a higher pitch, louder,
inspiration and expiration are equal and there is a pause between inspiration
and expiration.
The vesicular breathing is heard over the thorax, lower pitched and softer
than bronchial breathing. Expiration is shorter and there is no pause between
inspiration and expiration. The intensity of breath sound is higher in bases in
erect position and dependent lung in decubitus position.
The breath sounds are symmetrical and louder in intensity in bases
compared to apices in erect position. No adventitious sounds are heard.
Breath Sounds by Dr David W.Cugell NW University Chicago
SITUATION: John Mark is 21 year old male client who was rushed following an
automobile accident. He is very anxious, dyspneic and in severe pain. Refer to
question numbers 14-15
14.To ensure that the system is functioning effectively, the nurse should:
A. Observe for intermittent bubbling in the water seal chamber
B. Flush the chest tube with 30 to 60 mL of NSS every 4 hours
C. Maintain the client in a side-lying position always
D. Strip the chest tube in the direction of towards the client
15.JMs chest tube is said to be functioning correctly when which of the following
is observed?
A. Continuous bubbling in the waterseal chamber
B. Fluctuation in the water seal chamber
C. Drainage chamber more than 100ml/hr
D. Absent breath sounds heard in all lung fields
Closed chest drainage.
One or more tubes may be inserted to:
1. Restore intrapleural pressure
2. Allow re-expansion of lungs
3. Prevents air and fluid from returning to the chest
Tube to drain air is located near apex (top); to drain fluid is located near base
(bottom). A chest tube that allows air to escape from the chest will be placed
anterior and superior in the chest because air within the pleural space will
rise to the highest point in the chest. A chest tube to drain fluid or blood will
be placed posterior and inferior because fluid will collect in the most
dependent part of the pleural space.
The insertion site should be covered with airtight dressingtubes are usually
sutured in place. Tape all connections to ensure they do not become loose.
The chest drainage system should always be kept below the level of the
chest.
Tubing:
1. Should be coiled on the bed.
2. No dependent loops.
3. Avoid kinks in tubing.
4. Do NOT milk clots from line.
Pleurovac Three chambers.
1. Drainage chamber (look right to left)
2. Water seal
3. Suction
The water seal chamber acts as a one-way valve (air goes out, none goes
in). Monitor for continuous bubbling in the water seal chamber. Bubbles on
forceful expiration or coughing, not normal otherwise. Intermittent bubbling
in water seal chamber with forced expiration or cough is OK. Continuous
bubbling in the water seal is abnormal and indicates an air leak. IF the nurse
notes that there is CONTINUOUS bubbling in the water seal chamber, check
for leaks in the system. With physicians order, RN places padded clamp
closest to dressing. If leak stops, air leak is at insertion site. If bubbling
continues, leak is between clamp and drainage system.
Water should rise and fall in water seal (undulate) with respirations due to
pressure changes in pleural space.
Undulation: increase with inspiration, decrease tidal wave with expiration.
No fluctuations or tidal undulations in water seal:
1. Tube is kinked
2. Pt laying on tube
3. Fluid in the tube
4. Lung fully expanded (blocking the tube eyelets)
Suction chamber: While suction is applied, it is normal to have gentle
bubbling in the suction chamber. Suctioncan be applied to enhance
pressure differences. Very low wall suction: 5-10 mm Hg. There will be gentle
bubbling (should not be vigorous bubbling) in the suction chamber.
Drainage collection chamber: Do not empty the contents. Monitor chest tube
drainage q 15 minutes for at least 4 hours then at hourly intervals, for the
first 24 hours, depending on the amount of drainage. Record hourly
drainage.Mark level of drainage with marker on drainage collection
chamber. Should NOT be more that 100 ml/hr.Over 100 ml/hris excessive
notify physician. After first 24 hours, assess drainage every 8 hours.
Junctions at tube connectors are taped to avoid dislodgement.
lower. Option 2 indicates a slightly acidic pH. Option 3 indicates a neutral pH.
Option 4 indicates an alkaline pH.
26.Among the following foods, which has the highest amount of potassium?
A. Baked potato
B. Orange
C. Medium apricot
D. Banana
27.Which of the following provides the richest source of Iron per area of their
meat?
A. Pork meat
B. Lean read meat
C. Pork liver
D. Green mongo
FUNDAMENTAL HUMAN NEEDS: BOWEL/FECAL ELIMINATION
28.What is the duration of a RETENTION enema?
A.5-10 minutes
B.1-3 hours
C.5-10 seconds
D.1-3 minutes
CONCEPT 7: FUNDAMENTAL HUMAN NEEDS: ELIMINATION
***NOTE: ACTUAL BOARD EXAM QUESTION JUNE 2007 NURSING PRACTICE I NLE!
29.The following are appropriate nursing intervention during colostomy irrigation
EXCEPT:
A. Position client in semi-Fowler
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Increase the irrigating solution flow rate when abdominal cramps is felt
D. Hang the solution 18 inches above the stoma
CORRECT ANSWER: C
ANALYSIS:
OPTION A - Position client in semi-Fowler
**Place client comfortably in any of the following positions in irrigating
colostomy, (place linen saver under client if performing procedure in bed)
On commode
Sitting on chair facing toilet
In side-lying position turned towards the side of stomal opening, with
head of bed elevated 30 to 45 degrees
In supine position
RATIONALE: Provides for effective irrigation
OPTION B - Insert 2-4 inches of an adequately lubricated catheter to the
stoma- Gently insert 3 to 4 inches of irrigation tubing through cone opening
into stoma; if tubing does not ease into opening, do not force
1.
2.
3.
4.
6.
Rationale:
Procedure for blood transfusion :
Identify the patient by asking the patient their name and date of birth while
comparing it to the hospital ID band. Ensure the Blood ID Band is on the
patients wrist as this band has their unique R identifier number on it.
The patient should be assessed prior to requesting blood products.
Assessment should include temperature. If oral temperature is 100 degrees
Fahrenheit or higher, clarify with patients physician whether or not to
proceed with the transfusion.
Verify that blood product received is product that was ordered. Refer to Blood
and Blood Components Identification (blo02) to verify that the blood
product received is in date, is labeled for the intended patient, has been
crossmatched for the intended patient, and that all identifying information on
the product bag tag corresponds with the information on the patients band.
In the case of autologous blood, and if the patient is able, ask the patient to
state his/her social security number on the blood unit label. Two nurses, one
of whom is an RN, must verify the ordering information against the delivered
product, and the identification of the patient. The unique R number on the
pink Blood ID band must match the R number on the blood bag tag. DO
NOT PROCEED WITH THE TRANSFUSION IF THESE R NUMBERS DO NOT
MATCH.
If there is a problem with identification of the blood component, return the
component to the blood bank immediately.
5. Document on the bag tag, the date, the time the unit was started, the
patients vital signs and the signatures of the transfusionist and verifying
nurse.
NOTE: Take and document the patients vital signs before the transfusion, 10
minutes after initiating the transfusion and upon completion of the
transfusion. Vital signs should be taken more often whenever indicated.
Document any abnormal
findings.
For gravity infusion, verify that the Y tubing of the blood set has been
primed with saline. Using aseptic technique, attach the blood bag to the
other side of the Y tubing. Clamp tubing on saline side and open clamp on
blood bag side to allow blood to infuse.
7. For electronic controller infusion, verify that the primary set has been primed
with normal saline as well as the blood secondary set. Using aseptic
technique, attach the blood bag to the secondary blood set and connect the
D. Add the total amount of the blood to be transferred to the intake and
output
Answer: B
Rationale: Monitor and document vital signs every 5 minutes for the first 15
minutes assessing for chilling, back pain, head ache, nausea or vomiting,
tachycardia, hypotension, tachypnea, or skin rash. Altered vital signs or
other adverse reactions are early indications of a transfusion reaction.
Infusing blood slowly during this period limits the amount of blood the client
receives if there is a reaction.
Reference: Craven, Ruth F. & Constance J. Hirnle, Fundamentals of Nursing:
Human Health and Function, Lippincott Williams &Wilkins, 4 th ed. 2003 page
605
45.Diego is undergoing blood transfusion of the first unit. The earliest signs of
transfusion reactions are
A. Oliguria and jaundice
B. Urticaria and wheezing
C. Hypertension and flushing
D. Headache, chills and fever
Answer: D
Rationale: Acute transfusion reactions present as adverse signs or symptoms
during or within 24 hours of a blood transfusion. The most frequent reactions
are fever, chills, urticaria, or shortness of breath, which resolve promptly
without specific treatment or complications. More serious reactions, such as
hemolysis or sepsis, are potentially fatal.
Transfusion reactions require immediate recognition, laboratory
investigation, and clinical management. If a transfusion reaction is suspected
during blood administration, the safest practice is to stop the transfusion and
keep the intravenous line open with 0.9% sodium chloride (normal saline). A
clerical check of the blood unit label and patient should be performed. In
most cases, the blood product should be returned to the blood bank, and a
transfusion reaction investigation should be initiated.
Acute transfusion reactions may present in complex clinical situations when
diagnosis requires distinguishing between a reaction to the transfused blood
product and a coincidental complication of the illness being treated that
occurs during or immediately after a blood transfusion.
In option C, hypertension rarely exists in transfusion reaction, instead there is
HYPOTENSION as a part of anaphylactic reaction of the body to transfusion of
blood.
(http://www.emedicine.com/med/topic2297.htm)
46.In case Diego will experience an acute haemolytic reaction, what will be your
priority intervention?
A. Immediately stop the blood transfusion, infuse Dextrose 5% in
water and call the physician
B. Slow the blood transfusion and monitor the patient closely
C. Immediately stop the blood transfusion, notify the blood bank and
administer antihistamines
D. Immediately stop the blood transfusion, infuse normal saline
solution, call the physician, notify the blood bank
Answer: D
Rationale: Acute hemolytic reaction
- most serious among acute transfusion reactions and can be life
threatening. occurs when the donors blood is incompatible with the
recipients blood
- always monitor vital signs before starting the infusion and during the first
five minutes when the blood is infusing slowly. If you suspect a hemolytic
reaction, stop the transfusion immediately and keep the IV open with
normal saline.
Reference: Craven, Ruth F. & Constance J. Hirnle, Fundamentals of Nursing:
Human Health and Function, Lippincott Williams &Wilkins, 4 th ed. 2003 page
607
47.Which of the following is the correct procedure in transfusing Fresh Frozen
Plasma?
A.Confirm doctors order after gathering materials
B.Get baseline vital signs after the transfusion
C.Administer Fresh Frozen Plasma for the first 15 minutes, then transfuse
according to the computed rate if there will be no adverse reaction
D.Administer Fresh Frozen Plasma immediately
FLUIDS AND ELECTROLYTES
48.The nurse assesses a client to be experiencing muscle cramps, numbness,
and tingling of the extremities, and twitching of the facial muscle and eyelid
when the facial nerve is tapped. The nurse reports this assessment as
consistent with which of the following?
A. Hypokalemia
B. Hypernatremia
C. Hypermagnesemia
D.Hypocalcemia
49.The nurse writes the nursing problem of fluid volume excess (FVE). Which
intervention should be included in the plan of care?
A.Change the IV fluid from 0.9% NSS to D5W
B.Restrict the clients sodium in the diet.
C.Monitor blood glucose level
D.Prepare the client for hemodialysis
50.The client has been vomiting and has had numerous episodes of diarrhea.
Which laboratory test should the nurser monitor?
A.Serum Calcium
B.Serum Phosphorus
C.Serum potassium
D.Serum sodium