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 A

Explanation

Choice A reason: Community-acquired pneumonia (CAP) fits symptoms like cough or fever from pathogens outside hospitals. It’s the most likely without hospital exposure history, aligning with typical outpatient respiratory infection patterns.

Choice B reason: Cor pulmonale involves right heart failure from lung disease, not primary infection. Maria’s acute symptoms suggest pneumonia, not chronic pulmonary hypertension, making this less probable without supporting cardiac findings.

Choice C reason: Hospital-acquired pneumonia requires recent hospitalization, not indicated here. Maria’s presentation lacks nosocomial context, favoring community-acquired pneumonia as the diagnosis based on typical outpatient symptom onset.

A. I get short of breath when I climb a lot of stairs. B. My fingers hurt when I go outside in cold weather. C. My legs cramp when I walk more than a block. D. When I stand too long, my feet start to swell.

Correct Answer is C

Explanation

Choice A reason: Shortness of breath on stairs suggests cardiopulmonary issues, not intermittent claudication. Claudication is leg pain from arterial insufficiency during activity, not dyspnea, which reflects lung or heart strain.

Choice B reason: Finger pain in cold weather points to Raynaud’s or vasospasm, not claudication. Intermittent claudication affects lower limbs from arterial occlusion, not upper extremities or temperature-related vasomotor changes.

Choice C reason: Leg cramping after walking a block is classic intermittent claudication, from reduced blood flow in peripheral artery disease. Pain with activity, relieved by rest, matches its ischemic pathophysiology perfectly.

Choice D reason: Foot swelling from standing suggests venous stasis or edema, not claudication. Claudication involves arterial insufficiency causing pain with exertion, not fluid accumulation from prolonged static posture.

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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

Naxlex Comprehensive Predictor Exams

Based on Maria’s presenting symptoms and diagnostic test, the nurse suspects the patient will be diagnosed with ___________.

Correct Answer is A

Explanation

Which patient statement supports a history of intermittent claudication?

Correct Answer is C

Explanation

Which finding is the most concerning and should prompt immediate action by the nurse?

The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?

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Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

A nursing student is reviewing medications used to treat a patient with Peripheral Artery Disease (PAD). Which of the following medications should the nurse identify as commonly prescribed for this condition? (Select all that apply)

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)?