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The nurse is caring for a patient with a barrel chest, clubbed fingers, and dyspnea. Which condition does this most likely indicate?
C. Chronic hypoxemia
Rationale: Clubbing of fingers and barrel chest are signs of chronic hypoxemia, commonly associated with conditions like COPD
The delivery of O2 to the cells and tissues depends on what 3 things?
1. The amount of O2 entering the lungs
2. The person's ability to exchange gases in the alveoli
3. The ability of the heart to pump oxygenated blood to the cells and tissues
The most important thing to remember about chest tubes?
Keep the suction device lower than the lung/tube site
Always have petroleum dressings available to put on the site in the event the tube is dislodged
A postoperative patient reports severe pain at the incision site. What is the nurse’s first action?
B. Assess the incision site for signs of complications
Rationale: Always assess the source of pain to identify potential complications before intervening
A nurse is caring for a patient after abdominal surgery. The patient reports feeling a "pop" at the incision site while coughing. What should the nurse do first?
Answer: A. Apply a sterile saline-soaked dressing to the wound
Rationale: A "pop" may indicate dehiscence, and a sterile dressing protects the wound.
A nurse is preparing to suction a patient with a tracheostomy. What action should the nurse take first?
D. Assess the patient’s lung sounds.
Rationale: The nurse must assess the need for suctioning before initiating the procedure
The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?
1. Clear breath sounds
2. Patient speaking to nurse
3. SpO2 reading of 96%
4. Respiratory rate of 18 breaths/minute
2. Patient speaking to nurse
Objective Symptoms of Respiratory Distress
- Cyanosis
- Edema
- Pursed lip breathing
- Neck vein distention
- Flaring nares
- Barrel chest
- Abnormal breathing patterns
The nurse is caring for a patient postoperatively who is at risk for atelectasis. Which intervention is most effective in preventing this complication?
B. Encouraging use of an incentive spirometer
Rationale: Incentive spirometry promotes lung expansion, reducing the risk of atelectasis.
The nurse is reviewing the discharge teaching for a patient after surgery. Which statement by the patient requires further teaching?
D. "I will stop my antibiotics once I feel better."
Rationale: Antibiotics must be taken as prescribed to prevent infection recurrence.
A nurse is caring for a patient with impaired gas exchange. Which assessment finding would indicate early signs of hypoxemia?
C. Anxiety and restlessness
Rationale: Early signs of hypoxemia include restlessness, anxiety, and tachypnea as the body compensates for decreased oxygen levels
what are three things influence the capacity of the blood to carry oxygen?
1. the amount of dissolved oxygen in the plasma,
2. the amount of hemoglobin
3. the ability of hemoglobin to bind with oxygen.
Subjective Symptoms of Respiratory Distress
- Fatigue
- Loss of endurance
- Chest Pain
- Dyspnea
Which patient is at the greatest risk for developing a postoperative infection?
Answer: A. A 67-year-old patient with diabetes mellitus undergoing colon surgery
Rationale: Older age, diabetes, and colon surgery increase the risk of infection.
Which laboratory result requires immediate intervention for a postoperative patient?
C. Potassium 2.9 mEq/L
Rationale: Low potassium levels (hypokalemia) can cause cardiac dysrhythmias, requiring immediate attention.
Altered level of consciousness, tachypnea, dyspnea, and anxiety are all signs of what?
hypoxemia
2 Types of Regulation of Ventilation
Neural Regulators - CNS sends signals to chest wall to control rate, depth, rhythm.
Chemical Regulators - CO2 & H ions affect rate and depth of ventilations.
The nurse is preparing to admit a patient with a known latex allergy for surgery. Which intervention is the priority to prevent an allergic reaction?
B. Use non-latex gloves and equipment during care.
Rationale: Avoiding direct contact with latex-containing materials is the most immediate and effective way to prevent a reaction. The other options are also important but secondary to ensuring the patient is not exposed to latex.
What is the nurse’s priority when a patient develops a sudden fever 48 hours after surgery?
C. Assess the surgical site for signs of infection
Rationale: Fever 48 hours post-surgery may indicate infection, and assessment of the site is the first step.
The nurse is assessing a patient on the first postoperative day after abdominal surgery. Which finding is most concerning?
C. Urinary output of 20 mL/hr
Rationale: Oliguria (less than 30 mL/hr) indicates impaired kidney perfusion or function, requiring urgent intervention.
The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler’s or high Fowler’s position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene. 8. Withdraw catheter.
1. Perform hand hygiene.
2. Assist patient to semi-Fowler’s or high Fowler’s position, if able.
3. Have patient take deep breaths.
4. Apply sterile gloves.
5. Lubricate catheter with water-soluble lubricant.
6. Advance catheter through nares and into trachea.
7. Apply suction.
8. Withdraw catheter.
What is Hypercapnia & Hypocapnia?
Increased and decreased levels of CO2 in blood
Which of the following is the most important question for the nurse to ask during the preoperative assessment?
A. "Do you have any allergies to latex, such as to gloves or balloons?"
Rationale: Identifying latex allergies is crucial during the preoperative assessment to prevent potential allergic reactions during surgery due to latex exposure.
The nurse is teaching a patient about measures to prevent venous thromboembolism (VTE) postoperatively. Which statement indicates understanding?
C. "I will wear compression stockings and walk frequently."
Rationale: Ambulation and compression stockings improve circulation, reducing VTE risk.
what are hand-off information to ensure patient-centered approaches are used to ensure safe care?
• Patient name and date of birth
• Operative procedure, including the site
• Patient history relevant to this surgery
• Allergies and nothing by mouth status
• Vital signs and pain level
• Laboratory data and code status
• Current medications taken the day of surgery
• Patient’s level of surgical understanding
• Cultural implications
• Whether the patient has seen the surgeon and anesthesiologist