MED SURG FINAL EXAM| ALL QUESTIONS AND
CORRECT ANSWERS |ALREADY GRADED A+ |
VERIFIED ANSWERS | LATEST VERSION 2025 |
BRAND NEW VERSION!!!
A chest tube is a flexible, hollow tube placed through the chest wall and in to the
pleural space. The chest tube is able to relieve trapped air and fluid. If a chest
tube is dislodged and comes out, the nurse would immediately apply an occlusive
dressing such as Vaseline gauze (many times kept in the client's room). The
dressing is taped on three sides. The first action always focuses on the client. The
nurse would direct another licensed nurse to immediately notify the health care
provider. The nurse would then assess the respiratory status. The nurse would
obtain vital signs and await further orders.
After having a lobectomy for lung cancer, a client receives a chest tube connected
to a three-chamber chest drainage system. The nurse observes that the drainage
system is functioning correctly when noting which of the following? Select all that
apply.
Fluctuations in the water-seal chamber occur when the client breathes.
Crepitus forms at the chest tube insertion site.
Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in
the suction control chamber. Drainage is collecting in the drainage chamber. -
,CORRECT ANSWER-Fluctuations in the water-seal chamber occur when the client
breathes.
Intermittent bubbling occurs in the water-seal chamber.
Gentle bubbling occurs in the suction control chamber.
Drainage is collecting in the drainage chamber.
Fluctuations in the water-seal compartment (or tidal movements) indicate normal
function of the system as the pressure in the tubing changes with the client's
respirations. There also should be intermittent bubbling in the water-seal
chamber, indicating that air is being removed from the pleural cavity by the
system. Gentle bubbling in the suction control chamber indicates that the proper
suction level has been reached. Drainage is expected to collect in the drainage
chamber after a lobectomy. Crepitus indicates that air is leaking into the
subcutaneous tissues. The physician should be notified of this finding.
The nurse is planning care for a child with a pneumothorax. The nurse adds the
nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube"
to the care plan. When writing the care plan, what should the nurse be sure to
include as interventions?
Keep dry gauze at the bedside
Ensure a pair of hemostats are at the bedside
Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's condition warrants
Maintain chest tube bottle in an upright position and below the level of the chest
- CORRECT ANSWER-Ensure a pair of hemostats are at the bedside
,Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's condition warrants
Maintain chest tube bottle in an upright position and below the level of the chest
A client with unresolved hemothorax is febrile, with chills and sweating. He has a
nonproductive cough and chest pain. His chest tube drainage is turbid. What
should the nurse request in SBAR communication with the health care provider?
Portable chest X-ray
Antibiotic therapy
Intubation and mechanical ventilation
Arterial blood gasses - CORRECT ANSWER-Antibiotic therapy
Any condition that produces fluid accumulation or sequestration of fluid with
infective properties can lead to empyema, an accumulation of pus in a body
cavity, especially the pleural space, as a result of bacterial infection. An infected
chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever,
chills, and sweating associated with infection. With the symptoms of infection,
antibiotic therapy would be recommended. Nothing in the question demonstrates
a need for chest X-ray, intubation, or ABGs.
A client has a chest tube inserted for the treatment of a pneumothorax. While
turning in the bed, the client dislodges the tube and it is found in the bed. As the
registered nurse is directing the health care team, place the actions of the
registered nurse in the correct order. All options must be used. - CORRECT ANSWER-
Apply an occlusive dressing over the puncture site
Tape the dressing on three sides
, Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care
provider.
Assess the client's respiratory status.
Assess vital signs and await further medical orders
If the tube becomes dislodged from the child's chest, the nurse must apply
Vaseline gauze and an occlusive dressing to prevent air leakage into the pleural
space. A pair of hemostats should be kept at the bedside to clamp the tube
should it become dislodged from the drainage container. Pulse oximetry and lung
assessments help ensure proper placement of the chest tube. To maintain proper
drainage, the bottle must be kept upright and below the level of the chest.
The nurse has received a change-of-shift report. The nurse should assess which
client first?
a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08
a 36-year-old with chest tube due to spontaneous pneumothorax with current
respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal
cannula a 28-year-old who is 2 days postappendectomy with discharge
prescriptions written and whose husband is waiting to take her home
a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose
hemoglobin is 13.8 g/dL (138 g/L) - CORRECT ANSWER-a 72-year-old admitted 2 days
ago with a blood alcohol level of 0.08
The nurse should closely monitor the client admitted with an elevated blood
alcohol level for several hours for signs and symptoms of withdrawal,
administering sedation as needed; delirium tremens, the most severe form of
withdrawal, usually peaks at 48 to 72 hours following the last drink. The client
CORRECT ANSWERS |ALREADY GRADED A+ |
VERIFIED ANSWERS | LATEST VERSION 2025 |
BRAND NEW VERSION!!!
A chest tube is a flexible, hollow tube placed through the chest wall and in to the
pleural space. The chest tube is able to relieve trapped air and fluid. If a chest
tube is dislodged and comes out, the nurse would immediately apply an occlusive
dressing such as Vaseline gauze (many times kept in the client's room). The
dressing is taped on three sides. The first action always focuses on the client. The
nurse would direct another licensed nurse to immediately notify the health care
provider. The nurse would then assess the respiratory status. The nurse would
obtain vital signs and await further orders.
After having a lobectomy for lung cancer, a client receives a chest tube connected
to a three-chamber chest drainage system. The nurse observes that the drainage
system is functioning correctly when noting which of the following? Select all that
apply.
Fluctuations in the water-seal chamber occur when the client breathes.
Crepitus forms at the chest tube insertion site.
Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in
the suction control chamber. Drainage is collecting in the drainage chamber. -
,CORRECT ANSWER-Fluctuations in the water-seal chamber occur when the client
breathes.
Intermittent bubbling occurs in the water-seal chamber.
Gentle bubbling occurs in the suction control chamber.
Drainage is collecting in the drainage chamber.
Fluctuations in the water-seal compartment (or tidal movements) indicate normal
function of the system as the pressure in the tubing changes with the client's
respirations. There also should be intermittent bubbling in the water-seal
chamber, indicating that air is being removed from the pleural cavity by the
system. Gentle bubbling in the suction control chamber indicates that the proper
suction level has been reached. Drainage is expected to collect in the drainage
chamber after a lobectomy. Crepitus indicates that air is leaking into the
subcutaneous tissues. The physician should be notified of this finding.
The nurse is planning care for a child with a pneumothorax. The nurse adds the
nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube"
to the care plan. When writing the care plan, what should the nurse be sure to
include as interventions?
Keep dry gauze at the bedside
Ensure a pair of hemostats are at the bedside
Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's condition warrants
Maintain chest tube bottle in an upright position and below the level of the chest
- CORRECT ANSWER-Ensure a pair of hemostats are at the bedside
,Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's condition warrants
Maintain chest tube bottle in an upright position and below the level of the chest
A client with unresolved hemothorax is febrile, with chills and sweating. He has a
nonproductive cough and chest pain. His chest tube drainage is turbid. What
should the nurse request in SBAR communication with the health care provider?
Portable chest X-ray
Antibiotic therapy
Intubation and mechanical ventilation
Arterial blood gasses - CORRECT ANSWER-Antibiotic therapy
Any condition that produces fluid accumulation or sequestration of fluid with
infective properties can lead to empyema, an accumulation of pus in a body
cavity, especially the pleural space, as a result of bacterial infection. An infected
chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever,
chills, and sweating associated with infection. With the symptoms of infection,
antibiotic therapy would be recommended. Nothing in the question demonstrates
a need for chest X-ray, intubation, or ABGs.
A client has a chest tube inserted for the treatment of a pneumothorax. While
turning in the bed, the client dislodges the tube and it is found in the bed. As the
registered nurse is directing the health care team, place the actions of the
registered nurse in the correct order. All options must be used. - CORRECT ANSWER-
Apply an occlusive dressing over the puncture site
Tape the dressing on three sides
, Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care
provider.
Assess the client's respiratory status.
Assess vital signs and await further medical orders
If the tube becomes dislodged from the child's chest, the nurse must apply
Vaseline gauze and an occlusive dressing to prevent air leakage into the pleural
space. A pair of hemostats should be kept at the bedside to clamp the tube
should it become dislodged from the drainage container. Pulse oximetry and lung
assessments help ensure proper placement of the chest tube. To maintain proper
drainage, the bottle must be kept upright and below the level of the chest.
The nurse has received a change-of-shift report. The nurse should assess which
client first?
a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08
a 36-year-old with chest tube due to spontaneous pneumothorax with current
respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal
cannula a 28-year-old who is 2 days postappendectomy with discharge
prescriptions written and whose husband is waiting to take her home
a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose
hemoglobin is 13.8 g/dL (138 g/L) - CORRECT ANSWER-a 72-year-old admitted 2 days
ago with a blood alcohol level of 0.08
The nurse should closely monitor the client admitted with an elevated blood
alcohol level for several hours for signs and symptoms of withdrawal,
administering sedation as needed; delirium tremens, the most severe form of
withdrawal, usually peaks at 48 to 72 hours following the last drink. The client
