NSG 2400 Exam 4 75 Question Exam
With Correct Answers & Detailed Rationales.
A client has a closed chest drainage system in place. What should the nurse do to determine the amount
of chest tube drainage?
1.Refer to the date and time markings on the outside of the collection chamber.
2.Aspirate the drainage from the collection chamber.
3.Replace the existing system with a new one to access the drainage in the existing system.
4.Clamp the chest tube and empty the fluid from the collection chamber ✔✔CORRECT ANSWERS✔✔1
Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached
to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest
tube is functioning properly?
1.Remains constant in the chest drainage chamber.
2.Is bubbling gently in the chest drainage chamber.
3 Is bubbling vigorously in the suction control chamber.
4 Rises in the tube of the water-seal chamber during inspiration. ✔✔CORRECT ANSWERS✔✔4
Increased negative intrapleural pressure on inspiration causes the fluid to rise; a decrease in negative
intrapleural pressure on expiration causes the fluid to fall. Remaining constant in the chest drainage
chamber indicates that an obstruction is present in the drainage tubing or that the suction is too low; a
slight increase in fluid should be evident in this chamber postoperatively. Bubbling gently in the chest
drainage chamber indicates an air leak. If the water is bubbling vigorously in the suction control
chamber, the suction is too high; bubbling should be gentle.
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-
chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is
not fluctuating. What initial action should the nurse take?
1.Take the client's vital signs.
2.Inform the healthcare provider.
3.Turn the client to the unaffected side.
4.Check the tube to ensure that it is not kinked. ✔✔CORRECT ANSWERS✔✔4
,After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is
attached to suction. When excessive bubbling is observed in the water-seal chamber, what should the
nurse do?
1.Strip the chest tube catheter
2.Check the system for air leaks
3.Decrease the amount of suction pressure
4.Recognize that the system is functioning correctly ✔✔CORRECT ANSWERS✔✔2
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out.
What is the nurse's immediate action?
1 Place the client in the supine position
2.Spread a clamp in the insertion site to hold the site open
3.Obtain a sterile Vaseline gauze to cover the opening
4.Cover the opening with the cleanest material available ✔✔CORRECT ANSWERS✔✔4
This emergency situation requires covering the opening with the cleanest material available to prevent
atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the
potential for infection. Placing the client in the supine position is useless and will impair further the
client's breathing. Using a clamp to hold the insertion site open is unsafe because it allows atmospheric
air to enter the thoracic cavity. Although an occlusive dressing is desirable, atmospheric air will enter the
thoracic cavity while time is taken to obtain the occlusive dressing.
A client who has a diagnosis of endometriosis is concerned about the side effect of hot flashes from her
prescribed medications. Which medication should the nurse explain causes this side effect?
A.Estrogen
B.Leuprolide
C .Diclofenac
D.Ergonovine ✔✔CORRECT ANSWERS✔✔2
A client at the women's health clinic tells the nurse that she has endometriosis. What factors associated
with endometriosis does the nurse anticipate the client will report? Select all that apply.
1
,Insomnia
2
Ecchymosis
3
Rectal pressure
4
Abdominal pain
5
Skipped periods
6
Pelvic infections ✔✔CORRECT ANSWERS✔✔3 4
The nurse is obtaining a health history from a client with endometriosis. What consequences can occur
as a result of this disorder? Select all that apply.
1
Menopause
2
Metrorrhagia
3
Impaired fertility
4
Bowel strictures
5
Voiding difficulties ✔✔CORRECT ANSWERS✔✔2 3 4 5
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance
test. What information should the nurse consider before replying?
1
Pancreatic scarring predisposes the child to diabetes.
, 2
The thickened mucus blocks the insulin-secreting glands.
3
The test reveals the degree to which the child adheres to the diet.
4
Adjustments of the dosage of pancreatic enzymes are based on the results of the test. ✔✔CORRECT
ANSWERS✔✔1
A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that
these children will probably be small and underdeveloped for their age?
1
There is muscle atrophy from lack of motor activity.
2
There is decreased secretion of pituitary growth hormone.
3
These children digest little food because pancreatic enzymes are blocked.
4
These children have anorexia with minimal amounts of nutritional intake ✔✔CORRECT ANSWERS✔✔3
A nurse is caring for a child with a diagnosis of cystic fibrosis. Which schedule of chest physiotherapy
(CPT) is best?
1
Three times a day, before meals
2
Three times a day, halfway between meals
3
Two times a day, on awakening and at bedtime
4
Two times a day, after breakfast and after dinner ✔✔CORRECT ANSWERS✔✔2
With Correct Answers & Detailed Rationales.
A client has a closed chest drainage system in place. What should the nurse do to determine the amount
of chest tube drainage?
1.Refer to the date and time markings on the outside of the collection chamber.
2.Aspirate the drainage from the collection chamber.
3.Replace the existing system with a new one to access the drainage in the existing system.
4.Clamp the chest tube and empty the fluid from the collection chamber ✔✔CORRECT ANSWERS✔✔1
Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached
to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest
tube is functioning properly?
1.Remains constant in the chest drainage chamber.
2.Is bubbling gently in the chest drainage chamber.
3 Is bubbling vigorously in the suction control chamber.
4 Rises in the tube of the water-seal chamber during inspiration. ✔✔CORRECT ANSWERS✔✔4
Increased negative intrapleural pressure on inspiration causes the fluid to rise; a decrease in negative
intrapleural pressure on expiration causes the fluid to fall. Remaining constant in the chest drainage
chamber indicates that an obstruction is present in the drainage tubing or that the suction is too low; a
slight increase in fluid should be evident in this chamber postoperatively. Bubbling gently in the chest
drainage chamber indicates an air leak. If the water is bubbling vigorously in the suction control
chamber, the suction is too high; bubbling should be gentle.
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-
chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is
not fluctuating. What initial action should the nurse take?
1.Take the client's vital signs.
2.Inform the healthcare provider.
3.Turn the client to the unaffected side.
4.Check the tube to ensure that it is not kinked. ✔✔CORRECT ANSWERS✔✔4
,After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is
attached to suction. When excessive bubbling is observed in the water-seal chamber, what should the
nurse do?
1.Strip the chest tube catheter
2.Check the system for air leaks
3.Decrease the amount of suction pressure
4.Recognize that the system is functioning correctly ✔✔CORRECT ANSWERS✔✔2
While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out.
What is the nurse's immediate action?
1 Place the client in the supine position
2.Spread a clamp in the insertion site to hold the site open
3.Obtain a sterile Vaseline gauze to cover the opening
4.Cover the opening with the cleanest material available ✔✔CORRECT ANSWERS✔✔4
This emergency situation requires covering the opening with the cleanest material available to prevent
atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the
potential for infection. Placing the client in the supine position is useless and will impair further the
client's breathing. Using a clamp to hold the insertion site open is unsafe because it allows atmospheric
air to enter the thoracic cavity. Although an occlusive dressing is desirable, atmospheric air will enter the
thoracic cavity while time is taken to obtain the occlusive dressing.
A client who has a diagnosis of endometriosis is concerned about the side effect of hot flashes from her
prescribed medications. Which medication should the nurse explain causes this side effect?
A.Estrogen
B.Leuprolide
C .Diclofenac
D.Ergonovine ✔✔CORRECT ANSWERS✔✔2
A client at the women's health clinic tells the nurse that she has endometriosis. What factors associated
with endometriosis does the nurse anticipate the client will report? Select all that apply.
1
,Insomnia
2
Ecchymosis
3
Rectal pressure
4
Abdominal pain
5
Skipped periods
6
Pelvic infections ✔✔CORRECT ANSWERS✔✔3 4
The nurse is obtaining a health history from a client with endometriosis. What consequences can occur
as a result of this disorder? Select all that apply.
1
Menopause
2
Metrorrhagia
3
Impaired fertility
4
Bowel strictures
5
Voiding difficulties ✔✔CORRECT ANSWERS✔✔2 3 4 5
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance
test. What information should the nurse consider before replying?
1
Pancreatic scarring predisposes the child to diabetes.
, 2
The thickened mucus blocks the insulin-secreting glands.
3
The test reveals the degree to which the child adheres to the diet.
4
Adjustments of the dosage of pancreatic enzymes are based on the results of the test. ✔✔CORRECT
ANSWERS✔✔1
A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that
these children will probably be small and underdeveloped for their age?
1
There is muscle atrophy from lack of motor activity.
2
There is decreased secretion of pituitary growth hormone.
3
These children digest little food because pancreatic enzymes are blocked.
4
These children have anorexia with minimal amounts of nutritional intake ✔✔CORRECT ANSWERS✔✔3
A nurse is caring for a child with a diagnosis of cystic fibrosis. Which schedule of chest physiotherapy
(CPT) is best?
1
Three times a day, before meals
2
Three times a day, halfway between meals
3
Two times a day, on awakening and at bedtime
4
Two times a day, after breakfast and after dinner ✔✔CORRECT ANSWERS✔✔2
