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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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale
Intermittent oxygen use is common in clients with COPD, especially during activities that increase oxygen demand or during acute exacerbations.
Choice B rationale
Clubbing of fingers is a sign of chronic hypoxia, which can occur in advanced COPD78.
Choice C rationale
Pursed-lip breathing is a technique often used by clients with COPD to improve exhalation and reduce breathlessness.
Choice D rationale
Prolonged exhalation is a common finding in COPD due to airway obstruction and air trapping.
Choice E rationale
Dyspnea on exertion is a common symptom in COPD due to decreased lung function and increased work of breathing.

A. A never event. B. A near miss. C. An adverse event. D. A sentinel event.

Correct Answer is C

Explanation

Choice A rationale
A never event refers to a particularly shocking medical error (such as wrong-site surgery) that should never occur. A surgical site infection, while unfortunate, does not fall into this category.
Choice B rationale
A near miss refers to an event that could have had adverse consequences but did not, either by chance or timely intervention. In this case, the client did experience an adverse consequence (the infection), so this term does not apply.
Choice C rationale
An adverse event is an injury caused by medical management rather than the underlying disease. In this case, the surgical site infection that developed after the knee replacement surgery can be considered an adverse event.
Choice D rationale
A sentinel event is a specific type of unexpected occurrence involving death or serious physical or psychological injury. While serious, a surgical site infection requiring prolonged antibiotic therapy and wound care does not typically fall into this category.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) who is being evaluated for a lung transplant. What findings should a nurse expect when performing an initial physical assessment on a client diagnosed with COPD? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

A 65-year-old client with a history of diabetes mellitus was admitted to the hospital for a scheduled knee replacement surgery. During the postoperative period, the client developed a surgical site infection that required prolonged antibiotic therapy and wound care. This event is categorized as:

Correct Answer is C

Explanation

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