Home
Practice Exams
Medical and Surgical Nursing (NCLEX Exams)
Medical-Surgical Nursing Exam 7
Medical and Surgical Nursing (NCLEX Exams)

Medical-Surgical Nursing Exam 7

Practice Mode

Welcome to your Medical-Surgical Nursing Exam 7! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

✔ Exam Details

  • Number of Questions: 25 items
  • Mode: Practice Mode

✔ Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

✔ Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Think about the central nervous system and the various effects a drug like Diazepam, which is a type of benzodiazepine, can have. Remember, it's not typically used for inflammatory or cognitive conditions.

1 / 25

1. A patient is prescribed a dosage of 10 mg Diazepam (Valium), to be taken orally three times a day. Apart from its role in reducing anxiety, the nurse informs the patient that this medication also has other therapeutic effects?

💡 Hint

One of these tests can indicate the balance between the volume of red blood cells and total blood volume, which can shift due to severe burns and fluid resuscitation.

2 / 25

2. Which of the following blood tests is most valuable in assessing the appropriateness of fluid replacement in a patient with severe burns?

💡 Hint

Shock is a life-threatening condition that requires immediate medical attention. It often leads to a drastic decrease in blood flow throughout the body, affecting vital organs. Understanding the typical physiological responses in such situations can help identify the condition.

3 / 25

3. Situation: In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

After a tragic accident on the farm where Mr. Goodfrey's arm becomes entangled in a corn auger, resulting in severe damage to his lower left arm and hand, he is rushed to the hospital by paramedics in a state of shock. What typical signs would a nurse likely observe in a patient experiencing shock? Mr. Goodfrey would exhibit:

💡 Hint

Fluid overload can lead to an array of symptoms. However, some of these symptoms are specifically related to the impact of excess fluid on the respiratory system.

4 / 25

4. The nurse is delivering the prescribed intravenous fluids (IVF) to the patient. During her evaluation, she suspects fluid overload due to which of the following signs?

💡 Hint

When using heating devices like a hydrocollator pack, it's crucial to provide a protective barrier between the heat source and the skin to prevent burns. The type of material used for this barrier should have good heat insulation properties to prevent direct contact, yet allow the therapeutic heat to reach the patient's body.

5 / 25

5. In the event that a nurse is applying a commercially produced hot moist pack, also known as a hydrocollator, to a patient's lower back, what should the nurse do to minimize the likelihood of causing a thermal injury?

💡 Hint

The initial response to a burn incident aims to cool down the area, which helps to alleviate pain and prevent further tissue damage. However, extremely cold substances or those that might cause infection should be avoided.

6 / 25

6. Mr. Jackson was engaged in an outdoor barbecue when the gas tank detonated. He suffered second and third-degree burns on the front side of BOTH arms, the top half of his front torso, and both the front and back of his left lower limb.

In a situation like this, what would generally be the BEST immediate burn management technique to be applied at the scene?

💡 Hint

In a situation where there's inflammation due to an injury, recall the RICE method - Rest, Ice, Compression, and Elevation. This method is often recommended for initial treatment, and one of its components might be particularly helpful in this case, which could pique your interest in learning more about first aid strategies.

7 / 25

7. After a recent accident involving a staircase, a woman is grappling with sudden swelling and discomfort in her ankle that intensifies with motion. Her doctor, considering the situation, has referred her for an x-ray at the local hospital. In order to mitigate the swelling as the patient awaits the x-ray of her lower leg, which nursing approach would be the most beneficial?

💡 Hint

Rheumatoid arthritis is a chronic inflammatory disorder that primarily affects the joints. Its early signs often revolve around joint-related issues, typically involving stiffness or soreness. It's quite intriguing how our bodies signal us about something being amiss, isn't it?

8 / 25

8. Sheila is suffering from severe rheumatoid arthritis affecting her hands and spine. Upon her admission to the hospital, what symptom is Sheila most likely to report as the initial sign that prompted her to seek medical help?

💡 Hint

Mafenide is a powerful antimicrobial that is used for its ability to penetrate burn eschar. However, its use can have certain metabolic impacts on the body.

9 / 25

9. The physician prescribes Mafenide for application to the burned area. The nurse recognizes that one downside of this medication is:

💡 Hint

Consider the physical exertions that might increase the pressure in the spinal column, thereby leading to heightened pain in a herniated disc scenario.

10 / 25

10. A construction worker patient is suffering from intermittent episodes of lower back pain, which now extends into his buttocks, accompanied by a sensation of numbness and tingling in his legs. The physician postulates that the patient may have a herniated intervertebral disc in the lumbar region of the spine. When evaluating the condition of the disc, the nurse would expect the patient's pain to intensify during which of the following actions?

💡 Hint

Emotional support is vital when patients are dealing with sudden and dramatic changes to their physical condition. The presence of a familiar and reassuring person can often help to soothe the patient's distress.

11 / 25

11. Situation: In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

After Mr. Goodfrey wakes from anesthesia, he discovers that his forearm has been amputated. He responds with a barrage of profanity and breaks down into uncontrollable sobs. What would be the most appropriate action for the nurse to take in this situation?

💡 Hint

The Rule of Nines is a standard method used to quickly assess the total body surface area affected by burns in adults. This rule assigns 9% (or multiples thereof) to major body parts.

12 / 25

12. Mr. Jackson was engaged in an outdoor barbecue when the gas tank detonated. He suffered second and third-degree burns on the front side of BOTH arms, the top half of his front torso, and both the front and back of his left lower limb.

Upon reaching the emergency room, the nurse evaluates the extent of Mr. Jackson's burns, guided by the Rule of Nines. Which of the following options would provide the BEST estimate of the total body surface area affected by the burns?

💡 Hint

The iliac crest is the curved superior border of the hip bone. In medical contexts, it often serves as a landmark for certain procedures or devices. Isn't it fascinating how our body parts can be used as reference points in healthcare practices?

13 / 25

13. A woman is grappling with intense lower back discomfort. She possesses a pelvic traction belt which she utilizes periodically throughout her day. As a nurse, you're tasked with assisting her in putting on the traction belt. Where would it be most effective to position the upper part of this belt?

💡 Hint

The water-seal system provides a one-way valve action, which allows air to exit from the pleural space and prevents it from reentering.

14 / 25

14. A water-seal chest drainage system involves connecting the chest tube to a:

💡 Hint

The proper technique for turning a patient involves ensuring that the body moves as a single unit to prevent unnecessary strain or injury.

15 / 25

15. What guidance should a healthcare professional impart to a patient in order to lessen discomfort while assisting them in turning over to clean their back?

💡 Hint

The water-seal system serves as a visual indicator of breathing patterns and can provide information about the patient's lung status.

16 / 25

16. If the nurse observes fluid oscillating up and down within the water seal bottle during the patient's inhalation and exhalation, the appropriate course of action should be to:

💡 Hint

Consider the natural curvature of the spine and the distribution of body weight in different positions. It's also worth noting that one position might not fit all due to individual preferences and medical conditions.

17 / 25

17. In a scenario where the patient is required to stay in bed for an extended period, which of the following positions would a healthcare provider, such as a nurse, likely identify as the most comfortable for the patient?

💡 Hint

Continuous or excessive bubbling in the water-seal chamber of a chest drainage system may suggest an air leak in the system.

18 / 25

18. If the nurse observes vigorous and continuous bubbling in the second bottle, she should:

💡 Hint

The aim of positioning after such a surgery is to facilitate drainage and avoid putting pressure on the operated lung.

19 / 25

19. A male patient has been diagnosed with Stage 1 bronchogenic cancer and has undergone a lobectomy on his lower left lung. A two-bottle drainage system has been put in place. Post-surgery, in which position should the patient be placed while in bed?

💡 Hint

When bandaging a sprained ankle, the aim is to provide support to the injured area while also allowing for compression to minimize swelling. Starting the bandage application closer to the extremities and working upwards can help achieve this. It's interesting to see how such a simple procedure can significantly aid in recovery, isn't it?

20 / 25

20. A patient's x-ray results confirm that her bones are unharmed. However, the doctor diagnoses her with a severe ankle sprain. The doctor instructs the nurse to secure the patient's foot using an elastic roller bandage, often known as an Ace bandage. Where should the nurse initiate the bandage application?

💡 Hint

Remember, the essence of good body mechanics is to protect the body, particularly the back, from injury. The right approach often involves using the strongest muscles, such as those in the legs, and maintaining the body's natural alignment.

21 / 25

21. In the context of ensuring a patient's understanding of correct body mechanics prior to their discharge from the hospital, the nurse would need to instruct the patient on the most suitable method to employ when lifting objects. Which of the following would be an accurate piece of advice provided by the nurse?

💡 Hint

While comfort is key in any patient care scenario, think about what could offer the best firm support to align the patient's spine. Comfortable options like pillows and heat pads might not always provide the required spinal support.

22 / 25

22. To best assist a patient in maintaining spinal support, which among the following options should a healthcare professional such as a nurse utilize?

💡 Hint

The condition you're looking for is usually a sign of skin breakdown due to prolonged pressure and is particularly noticeable over bony areas. The skin might appear different in its texture and shine.

23 / 25

23. As a nurse, which observation would most likely indicate that the skin over the patient's coccyx is starting to deteriorate? The skin:

💡 Hint

The best position for a patient after a surgical procedure often aims to promote healing and reduce swelling, especially in the area affected by the surgery. Elevated extremities can often aid in achieving this goal.

24 / 25

24. In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

After Mr. Goodfrey regains consciousness from anesthesia, he finds out that his forearm has been amputated. As a nurse, in what posture should Mr. Goodfrey be positioned while you proceed with his assessment and care?

💡 Hint

A bandage's purpose is not just to provide support but also to maintain healthy circulation in the area it's applied. Any signs of discomfort or possible circulation obstruction should be attended to immediately. Isn't it fascinating how a simple piece of cloth can play such a vital role in healing?

25 / 25

25. A patient is about to be discharged from the emergency department. As part of her care, the nurse instructs her on the application of a roller bandage. The patient is advised to remove the bandage for about 20 minutes and then reapply it three times daily. However, it's crucial that the nurse informs the patient to adjust the bandage under which circumstance?

Exam Mode

Welcome to your Medical-Surgical Nursing Exam 7! This exam is carefully designed to provide you with a realistic test-taking experience, preparing you for the pressures of an actual nursing exam.

 

✔ Exam Details

  • Number of Questions: 25 items
  • Mode: Exam Mode

✔ Exam Instructions

  1. Exam Mode: This mode is intended to simulate the environment of an actual exam. Questions and choices will be presented one at a time.
  2. Time Limit: Each question must be answered within 90 seconds. The entire exam should be completed within 37 minutes and 30 seconds.
  3. Feedback and Grading: Upon completion of the exam, you will be able to see your grade and the correct answers to all questions. This will allow you to evaluate your performance and understand areas for improvement.

✔ Tips For Success

  • Read each question carefully. You have 90 seconds per question, so make sure you understand the question before selecting your answer.
  • Pace yourself. Remember, you have 37 minutes and 30 seconds in total, so try to maintain a steady rhythm.
  • Focus on one question at a time. Try not to worry about the questions to come.
  • Stay calm under pressure. Use your knowledge and trust your instincts.
  • Remember, it's not just about the score, but about the learning process.

This exam is not only a measurement of your current understanding, but also a valuable learning tool to prepare you for your future nursing career. Click 'Start Exam' when you're ready to begin. Good luck!

1 / 25

1. In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

After Mr. Goodfrey regains consciousness from anesthesia, he finds out that his forearm has been amputated. As a nurse, in what posture should Mr. Goodfrey be positioned while you proceed with his assessment and care?

2 / 25

2. Mr. Jackson was engaged in an outdoor barbecue when the gas tank detonated. He suffered second and third-degree burns on the front side of BOTH arms, the top half of his front torso, and both the front and back of his left lower limb.

In a situation like this, what would generally be the BEST immediate burn management technique to be applied at the scene?

3 / 25

3. A construction worker patient is suffering from intermittent episodes of lower back pain, which now extends into his buttocks, accompanied by a sensation of numbness and tingling in his legs. The physician postulates that the patient may have a herniated intervertebral disc in the lumbar region of the spine. When evaluating the condition of the disc, the nurse would expect the patient's pain to intensify during which of the following actions?

4 / 25

4. Situation: In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

After Mr. Goodfrey wakes from anesthesia, he discovers that his forearm has been amputated. He responds with a barrage of profanity and breaks down into uncontrollable sobs. What would be the most appropriate action for the nurse to take in this situation?

5 / 25

5. What guidance should a healthcare professional impart to a patient in order to lessen discomfort while assisting them in turning over to clean their back?

6 / 25

6. If the nurse observes vigorous and continuous bubbling in the second bottle, she should:

7 / 25

7. If the nurse observes fluid oscillating up and down within the water seal bottle during the patient's inhalation and exhalation, the appropriate course of action should be to:

8 / 25

8. In the context of ensuring a patient's understanding of correct body mechanics prior to their discharge from the hospital, the nurse would need to instruct the patient on the most suitable method to employ when lifting objects. Which of the following would be an accurate piece of advice provided by the nurse?

9 / 25

9. As a nurse, which observation would most likely indicate that the skin over the patient's coccyx is starting to deteriorate? The skin:

10 / 25

10. A male patient has been diagnosed with Stage 1 bronchogenic cancer and has undergone a lobectomy on his lower left lung. A two-bottle drainage system has been put in place. Post-surgery, in which position should the patient be placed while in bed?

11 / 25

11. In a scenario where the patient is required to stay in bed for an extended period, which of the following positions would a healthcare provider, such as a nurse, likely identify as the most comfortable for the patient?

12 / 25

12. A patient is prescribed a dosage of 10 mg Diazepam (Valium), to be taken orally three times a day. Apart from its role in reducing anxiety, the nurse informs the patient that this medication also has other therapeutic effects?

13 / 25

13. To best assist a patient in maintaining spinal support, which among the following options should a healthcare professional such as a nurse utilize?

14 / 25

14. A water-seal chest drainage system involves connecting the chest tube to a:

15 / 25

15. A patient's x-ray results confirm that her bones are unharmed. However, the doctor diagnoses her with a severe ankle sprain. The doctor instructs the nurse to secure the patient's foot using an elastic roller bandage, often known as an Ace bandage. Where should the nurse initiate the bandage application?

16 / 25

16. Situation: In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

After a tragic accident on the farm where Mr. Goodfrey's arm becomes entangled in a corn auger, resulting in severe damage to his lower left arm and hand, he is rushed to the hospital by paramedics in a state of shock. What typical signs would a nurse likely observe in a patient experiencing shock? Mr. Goodfrey would exhibit:

17 / 25

17. A woman is grappling with intense lower back discomfort. She possesses a pelvic traction belt which she utilizes periodically throughout her day. As a nurse, you're tasked with assisting her in putting on the traction belt. Where would it be most effective to position the upper part of this belt?

18 / 25

18. In the event that a nurse is applying a commercially produced hot moist pack, also known as a hydrocollator, to a patient's lower back, what should the nurse do to minimize the likelihood of causing a thermal injury?

19 / 25

19. A patient is about to be discharged from the emergency department. As part of her care, the nurse instructs her on the application of a roller bandage. The patient is advised to remove the bandage for about 20 minutes and then reapply it three times daily. However, it's crucial that the nurse informs the patient to adjust the bandage under which circumstance?

20 / 25

20. Sheila is suffering from severe rheumatoid arthritis affecting her hands and spine. Upon her admission to the hospital, what symptom is Sheila most likely to report as the initial sign that prompted her to seek medical help?

21 / 25

21. Mr. Jackson was engaged in an outdoor barbecue when the gas tank detonated. He suffered second and third-degree burns on the front side of BOTH arms, the top half of his front torso, and both the front and back of his left lower limb.

Upon reaching the emergency room, the nurse evaluates the extent of Mr. Jackson's burns, guided by the Rule of Nines. Which of the following options would provide the BEST estimate of the total body surface area affected by the burns?

22 / 25

22. The nurse is delivering the prescribed intravenous fluids (IVF) to the patient. During her evaluation, she suspects fluid overload due to which of the following signs?

23 / 25

23. After a recent accident involving a staircase, a woman is grappling with sudden swelling and discomfort in her ankle that intensifies with motion. Her doctor, considering the situation, has referred her for an x-ray at the local hospital. In order to mitigate the swelling as the patient awaits the x-ray of her lower leg, which nursing approach would be the most beneficial?

24 / 25

24. The physician prescribes Mafenide for application to the burned area. The nurse recognizes that one downside of this medication is:

25 / 25

25. Which of the following blood tests is most valuable in assessing the appropriateness of fluid replacement in a patient with severe burns?

Text Mode

Text Mode – Text version of the exam

Questions

1. In the context of ensuring a patient’s understanding of correct body mechanics prior to their discharge from the hospital, the nurse would need to instruct the patient on the most suitable method to employ when lifting objects. Which of the following would be an accurate piece of advice provided by the nurse?

A. Advise the patient to bend from the waist while lifting something.
B. Suggest the patient to bend both his knees when picking up an object.
C. Recommend the patient to maintain his feet in a close position while lifting.
D. Guide the patient to lift items quickly to reduce strain.

2. In the event that a nurse is applying a commercially produced hot moist pack, also known as a hydrocollator, to a patient’s lower back, what should the nurse do to minimize the likelihood of causing a thermal injury?

A. Encase the hot pack within numerous thick towels.
B. Seat the patient on a rubber ring.
C. Insert a pillow between the hot pack and the patient’s back.
D. Use a cold pack before applying the hydrocollator.

3. As a nurse, which observation would most likely indicate that the skin over the patient’s coccyx is starting to deteriorate? The skin:

A. Turns red once pressure is alleviated.
B. Exhibits a cool and clammy texture.
C. Is warm and moist.
D. Presents a shiny appearance over bony prominences.

4. What guidance should a healthcare professional impart to a patient in order to lessen discomfort while assisting them in turning over to clean their back?

A. “Initiate the movement with your torso, followed by your lower extremities.”
B. “Be cautious not to twist your physique during the shift.”
C. “Keep your arms crossed over your chest while turning.”
D. “Assume a fetal position prior to initiating the transition.”

5. To best assist a patient in maintaining spinal support, which among the following options should a healthcare professional such as a nurse utilize?

A. A board designed specifically for use beneath a bed mattress.
B. A square-shaped piece of foam.
C. A heat pad.
D. A mattress filled with air.

6. In a scenario where the patient is required to stay in bed for an extended period, which of the following positions would a healthcare provider, such as a nurse, likely identify as the most comfortable for the patient?

A. Lying on his side with his hips and legs extended in a straight line.
B. Resting on his back with his head and knees slightly raised.
C. Lying on his side in a fetal position, with knees bent towards the chest.
D. Lying flat on his back with both his head and knees straight.

7. A patient is prescribed a dosage of 10 mg Diazepam (Valium), to be taken orally three times a day. Apart from its role in reducing anxiety, the nurse informs the patient that this medication also has other therapeutic effects?

A. It acts as a relaxant for skeletal muscles.
B. It encourages a more restful sleeping pattern.
C. It helps in alleviating emotional depression.
D. It assists in improving memory and cognitive function.

8. A construction worker patient is suffering from intermittent episodes of lower back pain, which now extends into his buttocks, accompanied by a sensation of numbness and tingling in his legs. The physician postulates that the patient may have a herniated intervertebral disc in the lumbar region of the spine. When evaluating the condition of the disc, the nurse would expect the patient’s pain to intensify during which of the following actions?

A. During the act of consuming food.
B. While experiencing a sneeze.
C. In periods of rest or inactivity.
D. During the process of urination.

9. A woman is grappling with intense lower back discomfort. She possesses a pelvic traction belt which she utilizes periodically throughout her day. As a nurse, you’re tasked with assisting her in putting on the traction belt. Where would it be most effective to position the upper part of this belt?

A. At a position where she experiences the greatest comfort.
B. Aligned with her iliac crest.
C. Slightly beneath her rib cage.
D. Directly above her hip joint.

10. Sheila is suffering from severe rheumatoid arthritis affecting her hands and spine. Upon her admission to the hospital, what symptom is Sheila most likely to report as the initial sign that prompted her to seek medical help?

A. Inability to use her fingers effectively.
B. Experiencing sharp, piercing pain in her hands.
C. Encountering stiffness and discomfort in her joints.
D. Persistent lower back discomfort.

11. A patient is about to be discharged from the emergency department. As part of her care, the nurse instructs her on the application of a roller bandage. The patient is advised to remove the bandage for about 20 minutes and then reapply it three times daily. However, it’s crucial that the nurse informs the patient to adjust the bandage under which circumstance?

A. If she chooses to wear a cotton sock.
B. If her toes maintain a relatively warm sensation.
C. If the bandage becomes soiled or damp.
D. If she observes that her toes are becoming swollen.

12. A patient’s x-ray results confirm that her bones are unharmed. However, the doctor diagnoses her with a severe ankle sprain. The doctor instructs the nurse to secure the patient’s foot using an elastic roller bandage, often known as an Ace bandage. Where should the nurse initiate the bandage application?

A. Around the area of the metatarsals.
B. Below the knee region.
C. Above the knee area.
D. Over the patient’s calf.

13. After a recent accident involving a staircase, a woman is grappling with sudden swelling and discomfort in her ankle that intensifies with motion. Her doctor, considering the situation, has referred her for an x-ray at the local hospital. In order to mitigate the swelling as the patient awaits the x-ray of her lower leg, which nursing approach would be the most beneficial?

A. Keeping the foot stationary.
B. Performing exercises with the foot.
C. Raising the foot above heart level.
D. Letting the foot hang loosely.

Situation: In a race against time, Mr. Goodfrey, still unconscious, is swiftly transported to the operating room. The skilled medical team embarks on a critical mission, amputating his arm just above the elbow in a bid to save his life.

14. After Mr. Goodfrey wakes from anesthesia, he discovers that his forearm has been amputated. He responds with a barrage of profanity and breaks down into uncontrollable sobs. What would be the most appropriate action for the nurse to take in this situation?

A. Quietly remains in the room, at his bedside.
B. Explain the medical necessity of the amputation immediately.
C. Exit the room to give him space to process his anger.
D. Advise him to regain composure.

15. After Mr. Goodfrey regains consciousness from anesthesia, he finds out that his forearm has been amputated. As a nurse, in what posture should Mr. Goodfrey be positioned while you proceed with his assessment and care?

A. Lying supine with the amputated arm elevated on a pillow.
B. Sitting upright with the amputated arm hanging down.
C. In a prone position with the amputated arm under the body.
D. Sitting in a chair with the amputated arm resting on a table.

16. After a tragic accident on the farm where Mr. Goodfrey’s arm becomes entangled in a corn auger, resulting in severe damage to his lower left arm and hand, he is rushed to the hospital by paramedics in a state of shock. What typical signs would a nurse likely observe in a patient experiencing shock? Mr. Goodfrey would exhibit:

A. A declining blood pressure.
B. A reduced heart rate.
C. An escalation in urine production.
D. Enhanced skin elasticity.

Situation: Mr. Jackson was engaged in an outdoor barbecue when the gas tank detonated. He suffered second and third-degree burns on the front side of BOTH arms, the top half of his front torso, and both the front and back of his left lower limb.

17. In a situation like this, what would generally be the BEST immediate burn management technique to be applied at the scene?

A. Smear butter or oil over the burned areas.
B. Wash the region with a mild soap and water.
C. Douse the burned areas with cold water.
D. Cover the affected area with a clean dressing.

18. Upon reaching the emergency room, the nurse evaluates the extent of Mr. Jackson’s burns, guided by the Rule of Nines. Which of the following options would provide the BEST estimate of the total body surface area affected by the burns?

A. 18%
B. 36%
C. 45%
D. 54%

19. Which of the following blood tests is most valuable in assessing the appropriateness of fluid replacement in a patient with severe burns?

A. Blood Urea Nitrogen (BUN) levels.
B. Hematocrit (Hct) levels.
C. Carbon Dioxide (CO2) tension.
D. Serum sodium levels.

20. The nurse is delivering the prescribed intravenous fluids (IVF) to the patient. During her evaluation, she suspects fluid overload due to which of the following signs?

A. Slow heart rate (bradycardia) and low blood pressure (hypotension).
B. Facial redness and muscle twitching.
C. Excessive thirst and frequent urination.
D. Moist rales (crackling sounds heard in the lungs).

21. The physician prescribes Mafenide for application to the burned area. The nurse recognizes that one downside of this medication is:

A. Its need for constant application.
B. It may lead to skin discoloration.
C. Its potential to cause lactic acidosis.
D. Its minimal penetration into eschar (dead tissue).

Situation: A male patient has been diagnosed with Stage 1 bronchogenic cancer and has undergone a lobectomy on his lower left lung. A two-bottle drainage system has been put in place.

22. Post-surgery, in which position should the patient be placed while in bed?

A. Trendelenburg position (lying on the back with the body tilted so that the head is lower than the feet).
B. Prone position (lying flat, face down).
C. Supine position (lying flat on his back).
D. Lying on his right side.

23. A water-seal chest drainage system involves connecting the chest tube to a:

A. Rubber or glass tube that is immersed in water.
B. Suction machine directly, without any intermediary.
C. Rubber tube that is exposed to the open air.
D. Device with a one-way valve system.

24. If the nurse observes fluid oscillating up and down within the water seal bottle during the patient’s inhalation and exhalation, the appropriate course of action should be to:

A. Promptly inspect the bottle for potential leaks.
B. Adjust the height of the drainage system.
C. Refrain from any action as this is a normal occurrence.
D. Immediately notify the physician and clamp the chest tube.

25. If the nurse observes vigorous and continuous bubbling in the second bottle, she should:

A. Temporarily clamp the tube to check for an air leak.
B. Extract the chest tube to eliminate the air leak.
C. Check the patient’s vital signs and respiratory status.
D. Supply the patient with additional oxygen.

Answers and Rationales

​​1. Correct answer:

B. Suggest the patient to bend both his knees when picking up an object. Proper body mechanics involve using the largest and strongest muscles in the body to perform tasks, which are the muscles of the legs and arms. Bending the knees when lifting engages the powerful leg muscles and avoids strain on the lower back. It also helps maintain the body’s center of gravity and balance, reducing the risk of falls or other injuries.

Incorrect answer options:

A. Advise the patient to bend from the waist while lifting something. Bending from the waist while lifting places significant strain on the lower back and can lead to injury. It’s better to bend the knees and use the strength of the legs to lift, rather than relying on the back muscles.

C. Recommend the patient to maintain his feet in a close position while lifting. Keeping feet in a close position while lifting can cause instability and increase the risk of falling. It’s generally recommended to keep the feet shoulder-width apart for the best balance and support when lifting.

D. Guide the patient to lift items quickly to reduce strain. Lifting items quickly can actually increase the risk of injury, as it may lead to improper body mechanics and can catch the body off-guard. It’s safer to lift objects slowly and carefully, ensuring proper form and control.

2. Correct answer:

A. Encase the hot pack within numerous thick towels. Hydrocollator packs can become very hot, and direct contact with the skin can cause burns. To prevent this, hydrocollator packs should be wrapped in several layers of towels to create a barrier between the heat source and the skin. This allows for therapeutic heat to be applied without causing thermal injury. The number of towel layers may vary based on the heat of the pack and the sensitivity of the patient’s skin, and the patient’s comfort level should be regularly assessed.

Incorrect answer options:

B. Seat the patient on a rubber ring. Sitting on a rubber ring does not have any significant effect on preventing thermal injury from a hot pack on the lower back. The rubber ring may provide comfort when sitting for extended periods, especially for those with tailbone or coccyx pain, but it’s not directly related to hot pack application.

C. Insert a pillow between the hot pack and the patient’s back. Pillows are generally not recommended as barriers between the heat source and the skin as they may not distribute the heat evenly and could still allow for areas of too much heat, potentially causing a burn.

D. Use a cold pack before applying the hydrocollator. Applying a cold pack before a hot one can confuse the body’s thermal receptors and may not provide the desired therapeutic effect. Moreover, it does not directly prevent the risk of burns from the hot pack.

3. Correct answer:

D. Presents a shiny appearance over bony prominences. In certain circumstances, a shiny appearance over bony prominences may indicate skin tension or stretching, which could be an early sign of skin deterioration due to pressure. This is especially true when the skin is also tight, edematous, or discolored. It’s important to note that these signs could indicate a deep tissue injury, which is a severe form of pressure ulcer where damage begins in the underlying tissues near a bony prominence and may not be immediately visible on the skin’s surface.

Incorrect answer options:

A. Turns red once pressure is alleviated. While redness that does not fade or “blanch” can indicate pressure-induced skin damage, if the skin returns to a normal color once pressure is alleviated, it generally means that the tissue is still resilient and the blood flow is not yet compromised.

B. Exhibits a cool and clammy texture. Cool and clammy skin may be indicative of other health issues, such as shock or hypotension, but it is not typically associated with pressure-induced skin damage or deterioration.

C. Is warm and moist. Warm and moist skin can indicate a variety of conditions, including fever, infection, or excessive sweating, but it’s not a typical sign of skin breakdown due to pressure.

4. Correct answer:

B. “Be cautious not to twist your physique during the shift.” When turning, it’s important to maintain alignment and avoid twisting the body, which can cause discomfort or strain. Twisting can also increase the risk of injury to the back or other body parts. The nurse should assist the patient in moving as a whole, in a log-rolling manner, to maintain alignment and minimize discomfort.

Incorrect answer options:

A. “Initiate the movement with your torso, followed by your lower extremities.” This could lead to a twisting motion which may increase discomfort or cause injury. It’s better to turn the body as a whole, in a log-rolling manner.

C. “Keep your arms crossed over your chest while turning.” While this may help in some situations, it’s not necessarily the best advice for all patients, especially those with arm or shoulder injuries. In general, patients should use their arms to help with the turning movement, if possible.

D. “Assume a fetal position prior to initiating the transition.” The fetal position could lead to a twisting motion, which is not recommended when turning. It could also be uncomfortable for some patients depending on their condition.

5. Correct answer:

A. A board designed specifically for use beneath a bed mattress. A board placed beneath a mattress can provide additional support and help to maintain proper spinal alignment, which is particularly important for patients who may have back or spinal issues. These boards, often referred to as bed or mattress boards, are designed to offer firmness and prevent sagging of the mattress, which can contribute to discomfort and poor spinal alignment.

Incorrect answer options:

B. A square-shaped piece of foam. While foam can be used to provide support in certain circumstances, it is not typically the best option for maintaining spinal support. It can compress under the patient’s weight and may not provide the firm, even support necessary for proper spinal alignment.

C. A heat pad. While a heat pad can provide comfort and relieve muscle tension, it doesn’t provide structural support to maintain spinal alignment.

D. A mattress filled with air. Air mattresses can provide comfort and distribute pressure evenly, which can help in preventing pressure ulcers. However, they may not offer the firm, consistent support necessary for optimal spinal alignment, particularly for patients with specific back or spinal conditions.

6. Correct answer:

B. Resting on his back with his head and knees slightly raised. This position, often referred to as the Fowler’s position, is typically one of the most comfortable positions for patients who are required to stay in bed for an extended period. The slight elevation of the head and knees helps to reduce strain on the back, enhance breathing, and promote better circulation. It also provides support to the lumbar spine, reducing the risk of developing pressure ulcers.

Incorrect answer options:

A. Lying on his side with his hips and legs extended in a straight line. While this position can be comfortable for short periods, it may put pressure on the hip and shoulder of the side the patient is lying on, especially during extended periods of bed rest.

C. Lying on his side in a fetal position, with knees bent towards the chest. This position may be comfortable for some patients for short periods, but during extended periods of bed rest, it may lead to discomfort and pressure points, particularly at the knees and hips.

D. Lying flat on his back with both his head and knees straight. This position, known as the supine position, can lead to increased pressure on the sacrum and heels over extended periods, leading to a higher risk of developing pressure ulcers.

7. Correct answer:

A. It acts as a relaxant for skeletal muscles. Diazepam is a benzodiazepine that has muscle relaxant properties in addition to its primary role as an anxiolytic medication. This effect can be useful in treating conditions such as muscle spasms or stiffness.

Incorrect answer options:

B. It encourages a more restful sleeping pattern. While diazepam can induce sleep and is sometimes used for short-term treatment of insomnia, its use for this purpose is typically limited due to the risk of dependency and the disturbance of sleep architecture (the natural pattern of sleep stages).

C. It helps in alleviating emotional depression. Diazepam is not typically used to treat depression. In fact, benzodiazepines can sometimes exacerbate depressive symptoms and are generally used with caution in patients with a history of depression.

D. It assists in improving memory and cognitive function. Actually, diazepam and other benzodiazepines can impair cognitive function and memory, particularly with long-term use. These medications are associated with an increased risk of cognitive impairment and dementia in older adults.

8. Correct answer:

B. While experiencing a sneeze. Sneezing can increase intraspinal and intra-abdominal pressure, which may in turn exert additional pressure on a herniated disc. This can exacerbate the pain experienced by the patient, as the increased pressure can cause further irritation or compression of the affected nerve.

Incorrect answer options:

A. During the act of consuming food. Eating does not typically influence lower back pain related to a herniated disc, as it does not involve movements or positions that would put additional strain on the lower spine.

C. In periods of rest or inactivity. Rest and inactivity generally alleviate symptoms associated with a herniated disc as they reduce pressure on the spine. However, prolonged immobility can lead to stiffness and potential worsening of symptoms upon resuming activity.

D. During the process of urination. Urination itself generally does not exacerbate lower back pain associated with a herniated disc, unless it involves straining or uncomfortable postures.

9. Correct answer:

B. Aligned with her iliac crest. The iliac crest is the large, prominent portion of the pelvic bone at the waist. Positioning the upper part of a pelvic traction belt at the level of the iliac crest allows the belt to provide optimal support and alignment for the pelvis and lower spine, potentially helping to alleviate lower back discomfort.

Incorrect answer options:

A. At a position where she experiences the greatest comfort. While comfort is important, the most effective position for a pelvic traction belt is at the level of the iliac crest to provide optimal support and alignment.

C. Slightly beneath her rib cage. This position is too high for a pelvic traction belt. The belt would not provide the necessary support to the lower back and pelvis in this position.

D. Directly above her hip joint. This position is too low for a pelvic traction belt. The belt would not provide the necessary support to the lower back and pelvis in this position.

10. Correct answer:

C. Encountering stiffness and discomfort in her joints. In the early stages of rheumatoid arthritis (RA), patients often report experiencing stiffness, discomfort, or pain in their joints, particularly in the morning or after periods of inactivity. This symptom typically prompts individuals to seek medical attention.

Incorrect answer options:

A. Inability to use her fingers effectively. While RA can eventually lead to decreased hand function, this is typically not the initial symptom. It is more likely to occur as the disease progresses and causes more significant joint damage.

B. Experiencing sharp, piercing pain in her hands. Although RA can cause pain, it’s typically described as a dull or aching discomfort rather than sharp, piercing pain. Furthermore, it’s usually not the first symptom that patients notice.

D. Persistent lower back discomfort. While RA can affect any joint in the body, it commonly begins in the smaller joints, such as those of the hands or feet. Lower back discomfort is more characteristic of other conditions like osteoarthritis or ankylosing spondylitis.

11. Correct answer:

D. If she observes that her toes are becoming swollen. Swelling can be a sign of compromised circulation or increased pressure under the bandage. Thus, if the patient observes her toes becoming swollen, it is important for her to adjust or remove the bandage and contact a healthcare provider.

Incorrect answer options:

A. If she chooses to wear a cotton sock. The choice of wearing a cotton sock does not necessitate the adjustment of a bandage unless it is causing discomfort or affecting circulation.

B. If her toes maintain a relatively warm sensation. A warm sensation in her toes is a good sign, indicating that circulation is not impaired. It is not an indication for adjusting the bandage.

C. If the bandage becomes soiled or damp. Although a soiled or damp bandage should indeed be replaced, it does not necessarily indicate the need for adjusting the bandage. However, frequent soiling or wetness could suggest that the bandage is not properly applied or that the wound is not healing properly.

12. Correct answer:

A. Around the area of the metatarsals. When applying an elastic roller bandage for an ankle sprain, the application should start from the area of the metatarsals, or the area of the foot just before the toes begin. This allows the bandage to provide consistent support and compression to the injured ankle, facilitating the reduction of swelling and promoting healing.

Incorrect answer options:

B. Below the knee region. Starting the bandage application below the knee would not provide the necessary support to the sprained ankle. The bandage needs to be directly applied to the injury site and the immediate surrounding area for effective compression and support.

C. Above the knee area. Similarly, starting the bandage application above the knee would not provide the necessary compression and support to the ankle.

D. Over the patient’s calf. Starting here would not ensure the required support for the injured ankle. It’s crucial to begin the bandage application closer to the injury to effectively control swelling and provide support.

13. Correct answer:

C. Raising the foot above heart level. In the case of an injury resulting in swelling, elevating the affected area above the level of the heart is a proven technique to reduce swelling. This position helps to promote venous return, thus decreasing fluid accumulation and subsequent swelling in the injured area.

Incorrect answer options:

A. Keeping the foot stationary. While this might seem like a good idea to avoid further injury, it does not actively help to reduce swelling. It is important to combine rest with elevation for best results.

B. Performing exercises with the foot. While movement can sometimes help with swelling by promoting blood flow, in the case of a suspected injury like a fracture, it is important to minimize movement to prevent further damage until a diagnosis is made.

D. Letting the foot hang loosely. This position could potentially increase swelling by reducing venous return and promoting fluid accumulation in the area.

14. Correct answer:

A. Quietly remains in the room, at his bedside. In such a distressing situation, the presence of the nurse can provide a sense of comfort and support to the patient. It’s essential to acknowledge the patient’s feelings without judgment and provide a safe space for him to express his emotions. The nurse’s role is to be empathetic and supportive, not necessarily to provide solutions or explanations immediately after such shocking news.

Incorrect answer options:

B. Explain the medical necessity of the amputation immediately. While it’s important to provide information about the medical necessity of the amputation, the immediate aftermath of such news may not be the appropriate time. The patient is likely to be overwhelmed with emotions and may not be in a state to understand or absorb the information.

C. Exit the room to give him space to process his anger. While it’s important to respect the patient’s privacy, leaving him alone at this time of high emotional distress could lead to feelings of abandonment. The nurse’s presence can provide support and reassurance.

D. Advise him to regain composure. It’s important to acknowledge and validate the patient’s feelings. Telling him to regain composure may invalidate his emotions and potentially cause more distress.

15. Correct answer:

A. Lying supine with the amputated arm elevated on a pillow. After an amputation, it’s important to control swelling and promote blood flow to aid in healing and prevent complications. Elevating the amputated limb on a pillow can help achieve this. It’s like when you sprain your ankle and you’re advised to elevate it to reduce swelling – the same principle applies here.

Incorrect answer options:

B. Sitting upright with the amputated arm hanging down. This position could lead to increased swelling (edema) in the amputated limb due to gravity. It’s like when you hang a bag of water – the water (or in this case, blood and other fluids) will naturally flow downwards, which can lead to swelling.

C. In a prone position with the amputated arm under the body. This position could put pressure on the amputated limb and impede blood flow, potentially leading to complications such as tissue damage or delayed healing.

D. Sitting in a chair with the amputated arm resting on a table. While this position may be comfortable for some activities, it’s not the best position for initial post-operative care and assessment. The arm should be elevated to control swelling and promote blood flow.

16. Correct answer:

A. A declining blood pressure. When a patient is experiencing shock, one of the most common signs is a drop in blood pressure. This is due to the body’s inability to circulate enough blood, resulting in reduced perfusion to vital organs. In the case of Mr. Goodfrey, the severe injury and potential blood loss could trigger hypovolemic shock, a type of shock caused by a severe decrease in blood volume. This could cause his blood pressure to drop significantly, which would be a critical sign for nurses to monitor.

Incorrect answer options:

B. A reduced heart rate. This is incorrect because shock typically induces an increased heart rate, not a reduced one. The body will attempt to compensate for the reduced blood volume and decreased blood pressure by increasing heart rate (tachycardia) to try to maintain adequate blood flow to the organs.

C. An escalation in urine production. This is also incorrect. In a shock state, the body’s response is to divert blood away from areas like the kidneys and towards vital organs such as the heart and brain. This would result in a decrease in urine production, not an increase.

D. Enhanced skin elasticity. This is incorrect as well. In fact, one of the signs of shock can be poor skin turgor (decreased elasticity), often alongside cool, clammy skin. This is due to dehydration and reduced perfusion to the skin.

17. Correct answer:

C. Douse the burned areas with cold water. This can help reduce the immediate heat from the burn and alleviate pain. However, this method should be used cautiously and it’s important not to use ice-cold water as this can potentially cause more damage to the skin and can lead to hypothermia, especially if large areas are involved or if the person is very young or old.

Incorrect answer options:

A. Smear butter or oil over the burned areas. This is incorrect. Applying butter, oil, or any other greasy substances on a burn can trap heat and cause further damage to the tissue. It can also increase the risk of infection.

B. Wash the region with a mild soap and water. This is incorrect as initial treatment. Although gentle cleaning with mild soap and water is part of the wound care process for burns, it should not be the first step in immediate burn management. The first step is to stop the burning process and cool the area.

D. Cover the affected area with a clean dressing. While this is an important step in the management of burns, it is generally recommended after the burn has been cooled. Covering the burn helps protect the area from further injury and infection. However, it should not be the first step in immediate burn management, and adhesive bandages should not be applied directly to the burn.

18. Correct answer:

B. 36%

The scenario states the burns are on:

  • The front side of both arms
  • The top half of the front torso
  • Both the front and back of the left lower limb

Since the burns are on the front of both arms, not both arms total, that is:

  • Both arms (front): 2 * 4.5% = 9%
  • The top half of the front torso is:
  • Front torso (top half): 18% * 0.5 = 9%

And the front and back of the left lower limb is:

  • Left lower limb (front and back): 9% * 2 = 18%

So the total is:

  • Both arms (front): 9%
  • Front torso (top half): 9%
  • Left lower limb (front and back): 18%

Total = 9% + 9% + 18% = 36%

19. Correct answer:

B. Hematocrit (Hct) levels. Hematocrit levels represent the proportion of red blood cells to the total blood volume. In the context of severe burns and fluid replacement, hematocrit levels can serve as a valuable indicator. Immediately after a burn, hemoconcentration occurs, causing an increase in hematocrit due to significant fluid loss. As fluid replacement therapy is administered, hematocrit levels should normalize if the therapy is appropriate. Continually elevated levels might indicate inadequate fluid resuscitation, whereas drastically reduced levels may signal over-resuscitation or internal bleeding.

Incorrect answer options:

A. Blood Urea Nitrogen (BUN) levels. Although BUN levels can reflect hydration status and kidney function, they are influenced by various other factors, such as high protein intake, stress, and certain medications. Therefore, they may not provide the most accurate assessment of fluid replacement in a burn patient.

C. Carbon Dioxide (CO2) tension. CO2 tension is generally used to assess lung function and acid-base balance, rather than fluid balance. It’s not the primary test to evaluate the adequacy of fluid replacement in burn patients.

D. Serum sodium levels. While sodium is a key electrolyte and its imbalance can reflect fluid status, it is not the most direct measure of the adequacy of fluid replacement in burn patients. Various other factors can affect sodium levels, including dietary intake, certain medications, and kidney function.

20. Correct answer:

D. Moist rales (crackling sounds heard in the lungs). Fluid overload, or hypervolemia, often leads to pulmonary edema where fluid builds up in the air sacs of the lungs. This fluid causes the crackling sounds heard in the lungs, known as moist rales, when listening with a stethoscope. It’s a common sign of fluid overload and should prompt the nurse to reassess the rate and volume of IV fluid administration and notify the healthcare provider.

Incorrect answer options:

A. Slow heart rate (bradycardia) and low blood pressure (hypotension). These symptoms are more commonly associated with fluid deficit or specific cardiac conditions, not fluid overload. With fluid overload, you’d typically see an increased heart rate (tachycardia) and potentially elevated blood pressure.

B. Facial redness and muscle twitching. These symptoms are not typically associated with fluid overload. They may be seen in other conditions such as allergic reactions, certain neurological conditions, or electrolyte imbalances.

C. Excessive thirst and frequent urination. These symptoms are more commonly seen in conditions like diabetes mellitus and diabetes insipidus, not typically in fluid overload.

21. Correct answer:

C. Its potential to cause lactic acidosis. Mafenide acetate, a sulfonamide-type medication used in the treatment of severe burns, is known to inhibit an enzyme called carbonic anhydrase. This can disrupt the balance of acid and base in the body, potentially leading to a metabolic acidosis, specifically lactic acidosis. Nurses should monitor patients on mafenide for signs of acidosis, such as rapid breathing, confusion, lethargy, and nausea or vomiting.

Incorrect answer options:

A. Its need for constant application. While mafenide does require regular application, this is true of many topical burn treatments and is not generally considered a significant downside.

B. It may lead to skin discoloration. Mafenide does not typically cause skin discoloration. Some other burn medications might have this side effect, but it’s not a common issue with mafenide.

D. Its minimal penetration into eschar (dead tissue). Actually, mafenide is known for its excellent penetration into eschar, which is one of the reasons it’s used in severe burns.

22. Correct answer:

D. Lying on his right side. This is the correct position for a patient after a lobectomy. By lying on the unaffected side (right side), we maximize ventilation and perfusion to the remaining healthy lung tissue. It also helps prevent fluid accumulation in the operated area.

Incorrect answer options:

A. Trendelenburg position (lying on the back with the body tilted so that the head is lower than the feet). This position could potentially increase the risk of aspiration and is not typically used after thoracic surgery.

B. Prone position (lying flat, face down). This position is not recommended after thoracic surgery as it can increase difficulty with breathing and can place unnecessary pressure on the surgical site.

C. Supine position (lying flat on his back). While this position is common for many postoperative patients, in the case of a lobectomy, it’s better to position the patient on his right side to maximize ventilation to the healthy lung and minimize fluid accumulation in the surgical site.

23. Correct answer:

A. Rubber or glass tube that is immersed in water. A water-seal chest drainage system is designed to allow air and fluids to be drained out of the pleural space without allowing anything to go back in. This is accomplished by connecting the chest tube to another tube that is immersed in water. The water acts as a one-way valve – air and fluids can bubble up through the water and escape, but the water prevents anything from moving back up the tube into the chest.

Incorrect answer options:

B. Suction machine directly, without any intermediary. Connecting a chest tube directly to a suction machine would not provide a water seal, which is important to prevent the backflow of air or fluids into the pleural space.

C. Rubber tube that is exposed to the open air. Leaving a chest tube open to air could allow for the introduction of air back into the pleural space, potentially leading to a pneumothorax or other complications.

D. Device with a one-way valve system. While there are chest drainage systems that incorporate one-way valves, these are not typically described as water-seal systems. The defining feature of a water-seal system is the use of water as a one-way valve.

24. Correct answer:

C. Refrain from any action as this is a normal occurrence. The oscillation or tidaling of fluid in the water seal chamber of a chest drainage system with the patient’s respiration is a normal finding. It indicates that the system is patent and there is no obstruction in the chest tube. The fluid level rises with inspiration and falls with expiration in spontaneous breathing. This pattern can be reversed in mechanically ventilated patients.

Incorrect answer options:

A. Promptly inspect the bottle for potential leaks. There is no need to check for leaks when you observe oscillation of the fluid level. This is a normal occurrence and indicates a functioning drainage system.

B. Adjust the height of the drainage system. The height of the drainage system does not need to be adjusted in response to normal fluid oscillation. It should remain at chest level.

D. Immediately notify the physician and clamp the chest tube. There is no need to notify the physician or clamp the chest tube for normal fluid oscillation. This could actually cause harm by preventing the drainage of air or fluid from the pleural space.

25. Correct answer:

A. Temporarily clamp the tube to check for an air leak. Continuous bubbling in the water-seal chamber of a chest drainage system could indicate an air leak in the system. Clamping the tube temporarily (if allowed by facility policy) is a way to check for and locate the leak. The nurse should start at the patient’s chest and clamp the tube. If the bubbling stops, the leak is between the patient and the clamp. If the bubbling continues, the nurse should move the clamp down the tube, segment by segment, until the bubbling stops. Once the leak is located, appropriate action can be taken to fix it.

Incorrect answer options:

B. Extract the chest tube to eliminate the air leak. Removing the chest tube is not the correct response to a suspected air leak. This could lead to complications like pneumothorax or hemothorax. The nurse should instead locate and address the source of the leak.

C. Check the patient’s vital signs and respiratory status. While it’s always important to monitor a patient’s vital signs and respiratory status, this alone does not address the problem of an air leak in the chest drainage system.

D. Supply the patient with additional oxygen. Providing additional oxygen does not solve the issue of an air leak. It’s important to address the source of the leak itself.

Related Posts