The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could the nurse delegate to the assistive personnel (AP)?

Assess patient pain level associated with the chest tube.

Check the water-seal chamber for the correct fluid level.

Document the amount of drainage every 8 hours.

Obtain samples of drainage for culture from the system.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing pain requires subjective interpretation and clinical judgment to gauge severity and response. This nursing task can’t be delegated, as assistants lack training to evaluate pain’s impact on respiratory status or intervention needs.

Choice B reason: Checking the water-seal chamber involves understanding pneumothorax mechanics and system integrity. This technical skill exceeds an assistant’s scope, requiring a nurse to ensure proper function and detect complications like air leaks.

Choice C reason: Documenting drainage volume is a routine task after RN measurement, involving recording observed data. It fits an assistant’s role, as it requires no analysis or intervention, making it a safe delegation for tracking output.

Choice D reason: Obtaining drainage samples involves sterile technique and system manipulation, risking infection or disruption. This skilled procedure remains a nursing duty, as assistants aren’t trained to handle invasive equipment safely.

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Correct Answer is ["B","C"]

Explanation

Choice A reason: Oxygen saturation of 92% is low-normal (95-100%), not specific to worsening heart failure acutely. It may reflect chronic lung issues or mild hypoxia, but alone, it’s not a definitive sign of decompensation.

Choice B reason: Bilateral pulmonary congestion on x-ray shows fluid in alveoli from left heart failure, impairing gas exchange. It’s a classic sign of worsening, as rising pressure backs fluid into lungs, causing dyspnea.

Choice C reason: A 5-lb weight gain over days indicates fluid retention, a hallmark of worsening heart failure. It reflects sodium and water buildup from reduced cardiac output, directly correlating with symptom exacerbation.

Choice D reason: BUN of 28 mg/dL (normal 7-20 mg/dL) suggests mild renal stress, possibly from diuretics. It’s not specific to worsening heart failure without symptoms like dyspnea, as it may reflect dehydration instead.

Choice E reason: Potassium of 4.9 mEq/L is normal (3.5-5.0 mEq/L), not indicating worsening heart failure. It may rise with ACE inhibitors, but this value alone doesn’t signal acute decompensation or symptom progression.

A. Wheezing heard throughout both lung fields B. Finger clubbing and pallor C. Crackles or rales heard upon auscultation D. Edema

Correct Answer is C

Explanation

Choice A reason: Wheezing indicates airway narrowing, typical in asthma or COPD, not pneumonia. Pneumonia causes alveolar fluid, producing crackles, so diffuse wheezing doesn’t align with its pathophysiology of consolidation.

Choice B reason: Finger clubbing and pallor suggest chronic hypoxia or anemia, not acute pneumonia. These develop over time, whereas pneumonia presents with acute respiratory signs like crackles, not chronic markers.

Choice C reason: Crackles or rales occur in pneumonia from fluid or pus in alveoli, disrupting airflow. Heard on auscultation, they’re a classic sign, reflecting consolidation or inflammation in affected lung regions.

Choice D reason: Edema is fluid in tissues, linked to heart failure, not pneumonia directly. Pneumonia affects lungs, causing crackles, not peripheral swelling, making this unrelated to typical respiratory findings.

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The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could the nurse delegate to the assistive personnel (AP)?

Nursing Test Bank

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Correct Answer is ["B","C"]

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Correct Answer is C

Explanation

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