What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?
Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises.
Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage.
Potential Condition: Pulmonary edema.
Potential Condition: Pneumonia.
The Correct Answer is B
Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Using chewing tobacco every day is a significant risk factor for laryngeal cancer. Tobacco contains many carcinogens, which can damage the cells in the larynx and lead to cancer.
Choice B rationale
Being an industrial-commercial painter is associated with an increased risk of laryngeal cancer. This is likely due to exposure to certain chemicals and toxins that are used in paints and other materials.
Choice C rationale
Being an ultrasound technician is not typically associated with an increased risk of laryngeal cancer. Ultrasound technicians are not generally exposed to the types of toxins or risk factors that are associated with laryngeal cancer.
Choice D rationale
Wearing magnetic healing bracelets is not associated with an increased risk of laryngeal cancer. There is no scientific evidence to suggest that these bracelets have any effect on cancer risk.
Choice E rationale
Having a spouse who smokes cigarettes is a risk factor for laryngeal cancer. Secondhand smoke, also known as passive smoke, contains many of the same carcinogens as the smoke inhaled by smokers. Exposure to secondhand smoke can increase a person’s risk of developing laryngeal cancer.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.
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