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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Sweat chloride tests diagnose CF, not manage dyspnea in a known patient. It’s irrelevant here, as the focus is treating acute respiratory symptoms, not reconfirming an established diagnosis in this scenario.
Choice B reason: Low-sodium diets aren’t indicated for CF; patients need high salt due to losses. Dyspnea stems from mucus obstruction, not fluid, so this intervention contradicts CF physiology and symptom management.
Choice C reason: Chest physiotherapy clears mucus in CF, improving airflow and reducing dyspnea. It targets the primary cause—thick secretions—enhancing lung function, a standard intervention coordinated with respiratory therapy for acute exacerbations.
Choice D reason: Hospice is premature for dyspnea in CF without end-stage decline. It’s inappropriate now, as active interventions like physiotherapy address reversible symptoms, prioritizing treatment over palliative care planning.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Lisinopril, an ACE inhibitor, blocks angiotensin II formation, relaxing arteries and reducing blood pressure. It directly treats hypertension by decreasing vascular resistance and preload, a first-line therapy supported by its systemic vasodilatory effects.
Choice B reason: Metformin manages type 2 diabetes by improving insulin sensitivity and glucose uptake. It doesn’t affect blood pressure directly, targeting metabolic pathways instead, so it’s not a hypertension treatment despite cardiovascular risk benefits.
Choice C reason: Hydralazine dilates arterioles by relaxing smooth muscle, directly lowering blood pressure. Used in hypertension, especially in crises, it reduces afterload, making it a potent antihypertensive agent when rapid control is needed.
Choice D reason: Aspirin prevents platelet aggregation, reducing thrombotic risk in cardiovascular disease. It doesn’t lower blood pressure directly, acting as an antiplatelet rather than an antihypertensive, so it’s not a primary treatment for hypertension.
Choice E reason: Amlodipine, a calcium channel blocker, relaxes vascular smooth muscle, decreasing peripheral resistance. It directly treats hypertension by dilating arteries, improving blood flow, and reducing cardiac workload, a common and effective long-term therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
