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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Cyanosis requires deoxygenated hemoglobin, not typical in anemia unless hypoxia coexists. Hypertension isn’t linked; anemia often lowers pressure from reduced viscosity, making this pair unlikely in severe cases.

Choice B reason: Pulmonary edema and fibrosis stem from heart or lung disease, not anemia directly. Low hemoglobin reduces oxygen delivery, but these reflect fluid or scarring, not primary anemic findings.

Choice C reason: Dyspnea and tachycardia occur in severe anemia as low hemoglobin limits oxygen transport. The heart compensates with faster beats, and lungs work harder, matching physiologic response to tissue hypoxia.

Choice D reason: Dysrhythmias may occur late in anemia from hypoxia, but wheezing suggests airway issues, not anemia. These aren’t primary findings; respiratory and cardiac strain manifest differently in this condition.

A. Give the PRN acetaminophen (Tylenol). B. Notify the health care provider of these findings. C. Obtain oxygen saturation using pulse oximetry. D. Give the scheduled IV antibiotic.

Correct Answer is B

Explanation

Choice A reason: Acetaminophen reduces fever, but 101.2°F isn’t critical in sepsis, where hypotension (90/56 mmHg) signals shock. Addressing fever alone ignores systemic instability, delaying urgent intervention for a deteriorating patient needing comprehensive management.

Choice B reason: Hypotension (90/56 mmHg) and tachypnea (34 breaths/min) indicate septic shock, requiring immediate escalation. Notifying the provider ensures rapid fluid resuscitation and vasopressors, critical in gram-negative sepsis to reverse hypoperfusion and prevent organ failure.

Choice C reason: Pulse oximetry assesses oxygenation, useful in sepsis with tachypnea. However, hypotension is more immediately life-threatening, prioritizing provider notification for systemic treatment over a single parameter check that delays broader stabilization efforts.

Choice D reason: IV antibiotics target sepsis’s cause, but a scheduled dose doesn’t address acute hypotension urgency. Provider notification supersedes routine administration, as shock requires fluids and pressors now, not just infection control, to save the patient.

View Question and Answer

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

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

In a severely anemic patient, which assessment findings would the nurse expect to find?

Correct Answer is C

Explanation

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Correct Answer is B

Explanation

The nurse is preparing to assess Maria’s respiratory system. Which assessment findings are likely to be associated with pneumonia?

Which potential complication would the nurse identify as a high risk for a patient admitted to the hospital with pancytopenia? (Select all that apply)

Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

A patient with cystic fibrosis has blood glucose levels that are consistently between 180 to 250 mg/dL. Which action will the nurse expect to implement?

Which instruction will the nurse plan to include in discharge teaching for a patient who was admitted with a sickle cell crisis?

A patient comes to the doctor’s office with the following complaints: Moderate to severe pain over the nose, eyes, and forehead, purulent nasal drainage, fever, and malaise. The nurse suspects the patient is suffering from ___________.

The nurse is reviewing the patient’s recent symptoms and lab results. Which of the following symptoms or findings suggest worsening heart failure? (Select all that apply)

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?