NCLEX Q and A with Rationales – MEDICAL SURGICAL NURSING

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  • Published: 2015
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MEDICAL SURGICAL NURSING

RESPIRATORY SYSTEM:

1. List 4 common symptoms of pneumonia the nurse might note on a physical

exam.

– Tachypnea, fever with chills, productive cough, bronchial breath sounds.

2. State 4 nursing interventions for assisting the client to cough productively.

– Deep breathing, fluid intake increased to 3 liters/day, use humidity to loosen

secretions, suction airway to stimulate coughing.

3. What symptoms of pneumonia might the nurse expect to see in an older client?

– Confusion, lethargy, anorexia, rapid respiratory rate.

4. What should the O2 flow rate be for the client with COPD?

– 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus

to breathe, a COPD client has hypoxic drive to breathe.

5. How does the nurse prevent hypoxia during suctioning?

– Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning.

6. During mechanical ventilation, what are three major nursing intervention?

– Monitor client’s respiratory status and secure connections, establish a communication

mechanism with the client, keep airway clear by coughing/suctioning.

7. When examining a client with emphysema, what physical findings is the nurse

likely to see?

– Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in

lung fields.

8. What is the most common risk factor associated with lung cancer?

– Smoking

9. Describe the pre-op nursing care for a client undergoing a laryngectomy.

– Involve family/client in manipulation of tracheostomy equipment before surgery, plan

acceptable communication method, refer to speech pathologist, discuss rehabilitation

program.

10. List 5 nursing interventions after chest tube insertion.

– Maintain a dry occlusive dressing to chest tube site at all times. Check all

connections every 4 hours. Make sure bottle III or end of chamber is bubbling.

Measure chest tube drainage by marking level on outside of drainage unit. Encourage

use of incentive spirometry every 2 hours.

11. What immediate action should the nurse take when a chest tube becomes

disconnected from a bottle or a suction apparatus? What should the nurse do if

a chest tube is accidentally removed from the client?

– Place end in container of sterile water. Apply an occlusive dressing and notify

physician STAT.

12. What instructions should be given to a client following radiation therapy?

– Do NOT wash off lines; wear soft cotton garments, avoid use of powders/creams on

radiation site.

13. What precautions are required for clients with TB when placed on respiratory

isolation?

– Mask for anyone entering room; private room; client must wear mask if leaving room.

14. List 4 components of teaching for the client with tuberculosis.

– Cough into tissues and dispose immediately into special bags. Long-term need for

daily medication. Good handwashing technique. Report symptoms of deterioration,

i.e., blood in secretions.