The nurse is caring for a patient who is comatose and on a ventilator. When she enters the room, she notices that the patient’s trachea has shifted toward the left side of the patient’s neck, and he has become tachycardic. She assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having
recognized that the patient has developed which of the following conditions? ANS: C For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located? ANS: A The patient’s chest tube is attached to a one-way flutter valve that allows air to escape the chest cavity and prevents air from reentering. How does the nurse document this finding? ANS: A The nurse is caring for a patient who has a chest tube connected to a
water seal. The patient is not on a ventilator. Which of the following would the nurse consider normal? ANS:
A The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage contains a large amount of pus. What does the presence of the
pus indicate? ANS: C What is indicated by continuous bubbling in the water-seal chamber with no bubbles noted in the suction control chamber of the drainage system? ANS: A What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure? ANS: D Which of the
following is an expected outcome of chest tube insertion? ANS: B What should the nurse do to establish a two-chamber waterless chest tube system? ANS: D Which of the following represents appropriate technique when providing care for a patient
with chest tubes? ANS: D Which of the following is the correct positioning for a patient after a chest tube has been inserted for a hemothorax? ANS: D What is the
expected amount of drainage for an adult patient with a mediastinal chest tube? ANS: A What is the expected amount of drainage for an adult patient with a posterior chest tube? ANS: A A nurse determines that there may
be a leak in the chest tube system. Clamps are applied near the patient’s chest, and the nurse finds that the bubbling stops. What should the nurse do next? ANS: D During assessment of a patient, the chest tube becomes dislodged. What should the nurse do first? ANS: D What does the expected role of the nurse include during chest tube removal? ANS: C Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is noted when the nurse: ANS: B Of the following nursing assessments, which should be reported to the primary care provider
immediately by the nurse? ANS: D The nurse is providing care for a patient with a pneumothorax. She anticipated
removal of the chest tube because of the absence of an air leak for the past _____ hours. ANS: C The nurse is caring for a patient with blood collecting in the pleural space. The nurse documents this as: ANS: B The nurse knows that _______________ is the proper term to describe that the
patient’s water seal is fluctuating up and down with each breath. ANS: B The nurse is caring for a patient with a chest tube connected to water-seal drainage. The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)? ANS: D The patient has a chest tube for a pneumothorax. Assessment revealed no continuous bubbling in the water-seal chamber. The nurse finds no loose connections. After the chest tube near the patient is clamped, the bubbling stops. The nurse’s first action should be to: ANS: A A pneumothorax can be caused by which of the following? (Select all that apply.) ANS: A, B, C The nurse is caring for a patient with a chest tube connected to wall suction. To keep the tube patent, the nurse should implement which of the following? (Select all that apply.) ANS: B, C The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage is blood-tinged. What might this indicate to the nurse? (Select all that
apply.) ANS: A, B The nurse is preparing to assist the physician in removal of a chest tube. What should the nurse do to prepare the patient? (Select all that apply.)
ANS: A, B, C The nurse is caring for a patient who has a chest tube. Attached to the top of the patient’s bed are two shodded hemostats. In which situations would these be used? (Select all that apply.) ANS: A, B, D The nurse is performing an initial assessment of a patient with a chest tube placed in the eighth intercostal space. Which of the following findings would the nurse need to assess
further? (Select all that apply.) ANS: B, C, D The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse begins her shift assessment, she should ensure that what equipment is at the bedside? (Select all that apply.) ANS: A, B, C, D How should the nurse identify a patient before obtaining a laboratory specimen from him? ANS: A When discussing the collection of a clean-voided urine specimen, it is important for the nurse to instruct the patient to: ANS: C The nurse needs to obtain a
sterile urine specimen for culture and sensitivity (C&S) from a patient who has an indwelling catheter. The catheter was placed the night before. What must the nurse do to obtain the specimen? ANS: B What should the nurse do first if a patient is unable to void on demand for a clean-voided specimen? ANS: C What must the nurse do to collect a midstream urine sample from an infant? ANS: A What should the nurse do when a patient is required to provide a timed urine specimen? ANS: C What instructions does the nurse provide to the patient to obtain a double-voided urine specimen? ANS: C An appropriate procedure for urine testing with reagent strips for chemical properties of the sample is to: ANS: B A patient is concerned because her first guaiac test is positive. What information should the nurse share with the
patient? ANS: C When teaching a patient about home testing for occult blood, the nurse instructs the patient that: ANS: C A patient asks what food may be eaten before a stool specimen is obtained for occult blood. What food should the nurse allow the patient to eat? ANS: B The nurse evaluates that an expected outcome for analysis of gastric secretions is: ANS: B An appropriate technique for the
nurse to implement when obtaining throat cultures is to: ANS: B
What step should the nurse take to obtain a vaginal specimen for a culture? ANS: D When using a commercially prepared tube to collect a culture, the nurse should: ANS: C A nurse suspects that the patient may have tuberculosis. She sends a sputum sample to the lab for testing. When the following tests are compared, which will best support the diagnosis of possible tuberculosis? ANS: A The patient has come to the emergency department complaining of coughing up bloody sputum. The patient has a 30-year history of smoking and has lost 15 pounds in the last month. What will the nurse expect the sputum specimen to be
evaluated for? ANS: C An appropriate technique that the nurse can tell the patient to implement before obtaining a sputum specimen is to: ANS: B During a sputum collection, the patient becomes hypoxic. What action should the nurse take? ANS: C The nurse
has delegated ADL care of a patient with a large wound that is draining. Which of the follow should the nurse instruct the nurse assistant to report back to her? ANS: A An appropriate technique for the nurse to use when culturing wound drainage that is suspected to contain anaerobic bacteria is to: ANS: C The patient is diagnosed with suspected bacteremia. The physician has ordered blood cultures from two different sites. The patient is complaining of chills and has an elevated temperature. What action should the nurse take in the presence of these
symptoms? ANS: C When blood specimens are drawn, which of the following is
true? ANS: C A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What should the nurse do when given this information? ANS: D The nurse is preparing to perform a venipuncture on a patient. Which of the following is an appropriate action for the nurse to take? ANS: B An appropriate technique for the nurse to implement when preparing for a venipuncture is to: ANS: B The nurse is drawing blood from a patient to determine the blood alcohol level. Which step is an appropriate action for the nurse to take? ANS: A When
performing a venipuncture, the nurse should: ANS: D When obtaining a venipuncture sample for a blood culture, the nurse should: ANS: C When teaching about the procedure for capillary puncture, the nurse instructs a patient to: ANS: C Which of the following is the site of choice for obtaining samples for ABG? ANS: A An appropriate technique for the nurse to implement when obtaining an ABG
specimen is to: ANS: A What should the nurse do after obtaining a sample for ABG? ANS: A When collecting specimens, the nurse should: (Select all that apply.) ANS: A, B, C, D When obtaining laboratory specimens, the nurse needs to be aware that: (Select all that apply.) ANS: A, B A timed urine collection can be used for which of the following? (Select all that apply.) ANS: A, B Hemoccult testing helps to reveal blood that is visually undetectable. This test is a useful diagnostic tool for which of the following conditions? (Select all that apply.) ANS: A, B, C, D The nurse is caring for a patient who has had a craniotomy. The patient appears to need endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.)
ANS: A, B, C, D In explaining to the patient about obtaining a sputum specimen to diagnose
tuberculosis, the nurse explains which of the following? (Select all that apply.) ANS: A, B, C Assessment of the chemical properties of urine is done by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The _____________ of the strip or tablet indicates the presence of any of unique chemical properties. ANS: A common test performed on fecal material is the ________ test for fecal occult blood. ANS: ______________ is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis. ANS: Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify _______________. ANS: _______________ organisms grow in superficial wounds exposed to the air. ANS: The least traumatic method of obtaining a blood specimen is known as __________. ANS: What does continuous bubbling in the water seal chamber indicate?Bubbling in the water seal chamber indicates an air leak. Air leak management remains the main problem in the discussion of the pneumothorax.
When excessive bubbling is identified in the water seal chamber the nurse should?Assessing for an air leak: Clamp off suction for one minute. An air leak is present if there is constant bubbling in the water-seal chamber. An air leak alerts the nurse that he or she must assess for the location of the leak by checking the connections from the chest drainage unit to the insertion site.
What does bubbling in the water seal chamber of a chest tube drainage system that continues after temporarily clamping the tube indicate?Continuous bubbling in this chamber indicates a leak in the system. Fluctuations in the water level in the water-seal chamber of 5 to 10 cm, rising (during inhalation) and falling (during expiration), should be observed with spontaneous respirations.
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