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 C
Explanation
Choice A rationale
While it’s possible for a virus to reactivate in the body, this is not typically the case with the common cold. The common cold is a viral infection primarily in the nose, with most people recovering in seven to ten days.
Choice B rationale
While it’s true that cold season tends to end as the weather warms up, this doesn’t address the patient’s concern about their repeated colds. It’s important to note that colds are caused by viruses, which can be spread year-round, although they are more common in the colder months.
Choice C rationale
This is the correct answer. The common cold is indeed a virus that can be spread by a person two days before they experience any symptoms. This means that people can spread the virus before they know they’re sick, which can make it difficult to avoid catching a cold.
Choice D rationale
While wearing a mask can help prevent the spread of viruses, it’s not typically necessary for someone who is simply sensitive to colds. Masks are more commonly recommended for people who are already sick to prevent them from spreading the virus, or for people who are at high risk of serious complications from the cold.
Correct Answer is B
Explanation
Choice A rationale
While ensuring that nurses demonstrate competency by passing a medication administration test is important, it is not the first step in developing a program to decrease medication administration errors. This strategy focuses on the individual skills of the nurses, but does not address the systemic issues that may have contributed to the errors.
Choice B rationale
Reviewing the circumstances leading up to each medication error is the first step in understanding why the errors occurred. This process allows the committee to identify patterns and common factors that contribute to errors. It is a crucial step in the development of effective strategies to prevent future errors.
Choice C rationale
Developing a quality improvement program for nurses involved in medication errors is a strategy that could be implemented after understanding the root causes of the errors. This approach ensures that the program addresses the specific issues that led to the errors.
Choice D rationale
Conducting an in-service training on medication administration for all nurses is a valuable strategy for preventing medication errors. However, it should be based on the findings from the review of the circumstances leading up to each error. Therefore, it is not the first strategy to consider.
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