Concepts of Nursing II (BSN 266) All Lesson Quizzes (in 1 pdf) | Answered Latest 2026/27.

Concepts of Nursing II (BSN 266) All Lesson Quizzes (in 1 pdf) | Answered Latest 2026/27 Maintenance of IV Therapy: Lesson 1 Post-Test Due May 31 at 11:59pm Points 5 Questions 5 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 3 minutes 5 out of 5 Score for this quiz: 5 out of 5 Submitted May 25 at 9:05am This attempt took 3 minutes. Correct answer  Question 1 1 / 1 pts Changing IV fluids. Changing IV tubing. Initiating blood therapy. Regulating the IV flow rate. Inserting a peripherally inserted central catheter. Changing the IV dressing. Ongoing assessment. Maintenance of an intravenous site includes continuous assessment, regulation of the rate of flow, changing IV fluid intravenous tubing, and changing the peripheral IV dressing. Correct answer  Question 2 1 / 1 pts Manipulation of the IV catheter by the patient. The patient's dehydration and anemia. Which of the following are part of maintenance care of a peripheral intravenous site? (Select all that apply.) A confused elderly patient has pulled out her IV twice. The health care provider has ordered restraints and that the IV be restarted for the transfusion of packed red blood cells (PRBCs). Which factors in this situation may alter the rate of infusion? (Select all that apply.) Concepts of Nursing II (BSN 266) All Lesson Quizzes (in 1 pdf) | Answered Latest 2026/27.Viscosity (thickness) and temperature of the infusion. Improperly placed restraints. The electronic infusion device (EID) being plugged into the wall outlet. The patient's age. Factors in this situation that may alter intravenous flow rate include manipulation of the IV catheter by the patient, viscosity and temperature of the blood to be infused because it is thicker than typical IV solutions and is refrigerated, and improperly placed restraints. The patient's age, dehydration, and anemia may make initiating an IV more difficult but are unlikely to alter the rate of infusion once it is begun. The electronic infusion device should remain plugged into the wall outlet to keep the battery from getting low. It may be unplugged when the patient is ambulating or being transported. Correct answer  Question 3 1 / 1 pts The patient is probably developing phlebitis. There is now air in the tubing. The rate of infusion has increased. The patient is lying on the tubing. With the change in patient position, the patient may now be lying on the tubing or there may be a crimp in the tubing causing an occlusion of flow. Correct answer  Question 4 1 / 1 pts Hand. Foot. Forearm. Scalp. The use of the foot for an IV site is used with infants and young children but is avoided in the adult because of the danger of thrombophlebitis. The forearm may be used in children and adults. The scalp is used for infants. Correct answer The nursing assistive personnel turned and repositioned the patient as requested. However, now the electronic infusion device is alarming. Which of the following situations is most likely to have set off the alarm? Which of the following is an acceptable IV site in a child but not a routine site in adults? Question 5 1 / 1 pts allows the IV site to air-dry for 30 seconds after cleaning with chlorhexidine. palpates the IV insertion site through the dressing daily. cleans the injection port with an alcohol swab before accessing the system. palpates the IV insertion site after the site is cleansed to verify vein location before needle insertion. The nurse should not palpate the insertion site after it has been cleansed with a single-use antiseptic solution because this will contaminate the site. The IV site should be allowed to air-dry after a single use antiseptic is applied—30 seconds for chlorhexidine and at least 2 minutes for povidone-iodine solution. The nurse should palpate the IV insertion site daily through the intact dressing to assess for tenderness at the site. The nurse should clean the injection port with a single use antiseptic before accessing the system, whether it be to attach a secondary set or administer an IV push medication. Quiz Score: 5 out of 5 A vital factor in the care of a peripheral IV infusion is the prevention of infection. Which of the following, if performed by the nurse, would indicate that the nurse requires further instruction in IV fluid therapy management? The nurse:Maintenance of IV Therapy: Lesson 2 Post-Test Due May 31 at 11:59pm Points 12 Questions 12 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 16 minutes 12 out of 12 Score for this quiz: 12 out of 12 Submitted May 25 at 9:28am This attempt took 16 minutes. Correct answer  Question 1 1 / 1 pts None, if the patient has a volume-control device. The patient may experience infiltration. None, if the patient has an inline filter. The catheter may clot off. The patient may receive less than the prescribed amount of IV fluids. The patient may receive more than the prescribed amount of IV fluids. None, because the nursing assistive personnel may regulate the IV in the nurse's absence. If the bag or bottle of IV fluids runs empty, the catheter may become clotted off and patency of the IV will be lost, resulting in the need to restart the IV. A volume-control device helps prevent fluid overload but does not prevent clotting off if the fluids should run dry. If the IV catheter becomes clotted off or the tubing is kinked, the patient may receive less than the prescribed amount of fluids. Without monitoring, the patient may experience undetected infiltration. Electronic infusion devices may continue to infuse IV fluids after an infiltration has begun. If a patient's IV is positional and unmonitored, a patient could accidentally receive more fluids than prescribed, which could result in circulatory overload. If the patient has decreased circulatory blood volume, an IV infusion rate that is too slow can further increase the patient's likelihood of circulatory collapse. An inline filter may prevent particulate matter from entering the patient but does not prevent fluid overload or deficiency. It is inappropriate for assistive personnel to regulate an IV infusion. If a nurse fails to monitor a patient's intravenous (IV) infusion, what complications could develop? (Select all that apply.)Correct answer  Question 2 1 / 1 pts 21 1000 mL / 8 hours = 125 mL per hour 125 mL / 1× 10 gtt/mL / 60 minutes = 20.8 gtt/min = 21 gtt per minute Correct answer  Question 3 1 / 1 pts 63 500 mL/2 hour = 250 mL per hour 250 mL / 1 × 15 gtt/mL / 60 minutes = 62.5 gtt/min = 63 gtt per minute Correct answer  Question 4 1 / 1 pts Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates. Order: 1000 mL of D 1/2NS (dextrose 5% in 0.45% sodium chloride) in 8 hours Available: 1 liter of D 1/2NS (dextrose 5% in 0.45% sodium chloride); IV macrodrip tubing 10 gtt per milliliter The patient should receive gtt per minute. __ 1 5 5 Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates. Order: 500 mL of D W in 2 hours Available: 500 mL of D W; IV macrodrip tubing 15 gtt per milliliter The patient should receive gtt per minute. __ 1 5 5 Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates. Order: 500 mL of D5W in 5 hours100 500 mL / 5 hours = 100 mL per hour 100 mL / 1 × 60 gtt/mL / 60 minutes = 100 gtt per minute The setting on the electronic infusion devices (EID) would be 100. Correct answer  Question 5 1 / 1 pts 25 2000 mL / 80 mL/hr = 25 hours Correct answer  Question 6 1 / 1 pts “Calculation and regulation of IV flow rates is inappropriate for nursing assistive personnel to perform.” “Most electronic infusion devices use microdrip tubing, and therefore the setting on the electronic infusion device in milliliters per hour is the same as the calculated gtt per minute.” “It is unnecessary to monitor infusion rates when an electronic infusion device is being used.” “An electronic infusion device may continue to infuse IV fluids after an infiltration has begun.” Infusion controllers or electronic infusion devices are imperfect and do not replace frequent, accurate nursing evaluation. EIDs may continue to infuse IV fluids after an infiltration has begun. Calculation and regulation of IV flow rates is the responsibility of the nurse. Most electronic infusion devices use Available: Electronic infusion device; 500 mL of D W, microdrip tubing (drop factor 60 gtt/mL) The electronic infusion device rate is gtt per minute. __ 1 5 Calculate the following problem. Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates. Order: 0.9% normal saline at 80 mL per hour It will take hours for 2000 mL to infuse. __ 1 The nursing staff attended an in-service on IV fluid management with discussion on patient safety. Which of the following statements, if made by one of the staff, indicates further instruction is needed?microdrip tubing that delivers 60 gtt per minute. When calculated, the milliliters per hour will be the same as the number of gtt per minute. For example, it is essential to monitor the infusion site for infiltration because an infiltration may become quite significant before the EID alarm will sound. Correct answer  Question 7 1 / 1 pts An electronic infusion device. A smart pump. A volume-control device. Gravity IV controller. Smart pumps contain computer software to prevent errors that relate directly to administration of IV medications. The pump will sound an alarm if the pump setting does not match the medication administration guidelines, assisting in prevention infusion errors. Correct answer  Question 8 1 / 1 pts Determine if there is a kink in the tubing or if the IV is positional. Determine if the electronic infusion device is plugged in or if the “low battery” signal is displayed. Assess the site for complications such as infiltration, phlebitis, or clotting of the catheter. Assess the patient for symptoms of fluid volume overload. The patient should have received 300 mL of IV fluid in this time but instead received 500 mL. The nurse should first slow the rate to the keep-vein-open (KVO) rate and assess the patient for any adverse effects, primarily symptoms of fluid volume overload. Correct answer  Question 9 1 / 1 pts Discontinue present IV. The nurse has received an order to infuse an IV medication. Which of the following would be the safest choice of equipment to use? A patient has an order for the administration of 1000 mL of 0.9% normal saline at 100 mL/hr. The nurse begins the infusion at 0900. At noon the nurse notices that 500 mL has infused. Of the following options, which should be the nurse’s highest priority action? A patient has received 1000 mL of IV fluid in 2 hours. The patient has dyspnea, tachycardia, crackles in the lungs, and peripheral edema. What is the nurse’s priority action at this time?Slow infusion to KVO and notify health care provider. Check for positional changes that affect rate, height of IV container, kinking of tubing, or obstruction. Assess the patient for symptoms of fluid volume overload. The nurse should slow the IV infusion to KVO and notify the health care provider so further orders may be received to treat the patient’s symptoms of fluid volume overload. Correct answer  Question 10 1 / 1 pts A child who has experienced nausea and vomiting for the last 24 hours. A hypotensive adult trauma victim with cool, clammy skin. An older adult who is being treated for congestive heart failure. A young adult being treated for asthma with an order for D W at 60 mL/hr. Macrodrip tubing should be used when large quantities or fast intravenous infusion rates are necessary, as in this instance where the patient is demonstrating signs of shock. Hourly rates greater than 100 mL/hr may lend themselves more to macrodrip tubing. Microdrip tubing is preferred for pediatric applications. Microdrip tubing should be used when small or very precise volumes are to be infused. Extra precautions should be made for patients at risk for fluid volume excess, such as elderly cardiac patients or renal patients. Correct answer  Question 11 1 / 1 pts 94 12 hours − 4 hours = 8 hours left 750 mL / 8 hour = 93.75 = 94 mL/hr A nurse working in the emergency room has elected to use macrodrip IV tubing. For which patient would this be most appropriate? 5 Remember to round off the answer to the nearest whole number, because fractions of a drop are to be avoided when calculating IV drip rates. A patient is to receive 1000 mL of 0.45% normal saline over 12 hours. The nurse begins the infusion at 0800. Four hours later, the nurse notes there is 750 mL left in the IV bag. The nurse recalculates the flow rate. The nurse should set the electronic infusion device at mL/hr. __ 1Correct answer  Question 12 1 / 1 pts 2130 1000mL ÷ 80 mL/hr = 12.5 hours 0900 + 12½ hours = 2130 Quiz Score: 12 out of 12 The nurse hangs 1000 mL of 0.9% normal saline at 0900. The ordered rate is 80 mL/hr and is infusing with microdrip tubing and an EID. The nurse would expect to hang a new IV bag at approximately at what time? (in military time—remember 2400 is midnight) __ 1Maintenance of IV Therapy: Lesson 3 Post-Test Due May 31 at 11:59pm Points 5 Questions 5 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 2 minutes 5 out of 5 Score for this quiz: 5 out of 5 Submitted May 25 at 9:34am This attempt took 2 minutes. Correct answer  Question 1 1 / 1 pts Failing to change the IV dressing. Failing to close the roller clamp on the new tubing before inserting it into the fluid container. Opening the roller clamp on the new tubing after attaching it to the catheter hub. Failing to wipe the IV catheter hub with an antiseptic swab before connecting the new tubing. The nurse should have closed the roller clamp on the new tubing before inserting it into the fluid container. This would have prevented the fluid from filling the tubing rapidly and creating air bubbles, which had to be removed. If the roller clamp had been closed before placing the insertion spike into the fluid container, the nurse could have slowly opened the roller clamp, allowing the solution to prime the The nurse performed hand hygiene and applied clean gloves to perform an intravenous (IV) tubing change. Which step(s) described in the following was missed or performed incorrectly? Remove IV dressing covering catheter hub and slow rate of infusion to keep-vein-open (KVO) by regulating the roller clamp. Fill drip chamber of old tubing, remove IV container from IV pole, and remove old tubing from the solution. Place insertion spike of new tubing into the old fluid container opening and hang it on the IV pole. Fill tubing rapidly with solution, creating air bubbles in the tubing. Turn roller clamp to the "off" position on the new tubing and remove as much air as possible. Turn roller clamp on the old tubing to the "off" position. Stabilize hub of the catheter, disconnect the old tubing from the catheter hub, and quickly insert adapter of new tubing into catheter hub. Open roller clamp on new tubing, and regulate IV drip according to health care provider's orders. Secure tubing with a piece of tape. Place label with date and time on tubing below drip chamber. Discard old tubing and used supplies, remove gloves, and perform hand tubing without creating air bubbles. It is unnecessary to wipe the IV catheter hub with an antiseptic swab when new tubing is connecting directly to the IV catheter. Once the new tubing is connected, the roller clamp should be opened to reestablish the infusion and the rate set according to health care provider’s order. The IV dressing should be changed if it becomes wet or soiled. Correct answer  Question 2 1 / 1 pts When changing tubing, the nurse disconnects the old tubing and attempts to insert the adapter of the new tubing without removing the protective cap. The nurse changes the primary intermittent tubing set every 96 hours. The nurse attaches the IV bag of gentamicin (Garamycin) to new tubing, primes the tubing, and changes the bag and tubing all at one time when the dose is ordered. The nurse wipes the port on the extension tubing with an alcohol swab and flushes the vascular access device with 3 mL of normal saline when the infusion is complete. When it is time to hang a new dose of gentamicin (Garamycin), the nurse connects the tubing to the injection port using the same needleless adapter that has been hanging on the IV pole for 4 hours without a protective cover. If the nurse attempts to connect tubing to a port or catheter hub without first removing the protective cap, this would cause unwanted contamination because the protective cover is unsterile and would be touching an area that leads directly to the patient’s bloodstream. Primary intermittent tubing should be changed every 24 hours, not every 96 hours, because the system is interrupted, increasing the risk for contamination. If the needleless adapter is left unprotected between doses, a new adapter should be applied before connecting it to the patient. It is easier and there is a lesser chance of contamination if the IV bag and tubing are changed all at one time, if possible. The peripheral vascular access device should be flushed with normal saline between doses of medication if continuous fluids are not ordered. Correct answer  Question 3 1 / 1 pts The patient has an order to infuse gentamicin (Garamycin) 500 mg IV in 50 mL sodium chloride at a rate of 100 mL/hr every 4 hours. The patient does not have an order for continuous fluids, and therefore the medication is infused with primary tubing and the peripheral access device is saline locked between doses. Which of the following actions could cause contamination or increase the risk of infection? (Select all that apply.)The roller clamp is in the “off” position. The drip chamber is one-third to one-half full. It has been 48 hours since the IV tubing was changed. Air is present in the tubing. If the roller clamp is left in the “off” position, the EID will alarm as an occlusion because the fluid will be unable to infuse. The EID alarm will also sound if there is air in the tubing. The nurse should check the tubing to be sure all air bubbles are removed before putting it into the EID and starting the infusion. Correct answer  Question 4 1 / 1 pts “Sterile technique is used to change IV tubing.” “The bag of fluids should be changed when there is approximately 100 mL of solution left in the bag to avoid disruption in fluid therapy to the patient.” “When a peripheral IV site is being changed, you should change the IV administration set.” “Sterile IV tubing used for a continuous infusion of normal saline may remain sterile for 96 hours.” Change the solution when fluid remains only in the neck of the container (or approximately 50 mL) or when a new type of solution has been ordered to prevent waste of solution. This statement indicates the student requires further instruction. IV administration sets with a continuous infusion of IV fluids other than blood, blood products, or lipids may not require changing for 96 hours. The Infusion Nurses Society (INS) states that tubing used for intermittent infusion through an injection/access port should be changed every 24 hours because both ends of the tubing are manipulated more often than tubing used for continuous infusion. Sterile technique should be maintained when changing fluids or tubing to decrease the risk of infection. When the short peripheral site is rotated, the administration set should be changed (INS, 2016). Correct answer  Question 5 1 / 1 pts The electronic infusion device (EID) is alarming after changing the bag of IV fluids on a continuous infusion. What could be the possible cause(s)? (Select all that apply.) The nursing students are studying in a group. Which of the following statements, if made by a nursing student, indicates further instruction is needed? The nurse is changing IV fluids. She has performed hand hygiene and applied clean gloves. The nurse hung the new bag of fluids on the IV pole, removed the protective cover of the tubing port, removed the spike from the old bag, and accidentally touched the spike with her hand. Which action should be taken at this time?Wipe the spike off with an alcohol swab, allow it to dry completely, and insert it into the bag of fluids. Continue with inserting the spike into the new bag of IV fluids because she was wearing gloves at the time. Obtain a new IV tubing set and a new bag of IV fluids; discard the bag of fluids she just hung and on which she had removed the protective covering of the tubing port. Obtain a new IV tubing set, remove the protective cover of the spike and insert it into the tubing port of the IV bag she just hung. Prime the tubing. If the spike is contaminated, a new IV tubing set is required. The gloves were not sterile gloves and therefore the spike is considered contaminated. It is unnecessary to obtain another new bag of IV fluids because the nurse did not insert the contaminated spike. Quiz Score: 5 out of 5Maintenance of IV Therapy: Lesson 4 Post-Test Due May 31 at 11:59pm Points 5 Questions 5 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 6 minutes 5 out of 5 Score for this quiz: 5 out of 5 Submitted May 25 at 9:43am This attempt took 6 minutes. Correct answer  Question 1 1 / 1 pts The patient's IV dressing got wet during bathing. It has been 2 days since the last change of a transparent IV dressing. There is blood underneath the transparent dressing from movement of the catheter. Twenty-four hours have elapsed since the last gauze IV dressing change. There has been a change in the health care provider's order for the type of IV fluids. Peripheral IV dressings must be changed when loose, wet, or soiled. A transparent membrane dressing should be changed with catheter site rotation and immediately if the integrity of the dressing is compromised. Gauze dressing should be changed routinely every 2 days and immediately if integrity is compromised. If blood is present under the dressing, the dressing requires changing, because it may provide a medium for bacterial growth. Furthermore, the presence of blood from catheter movement indicates that the catheter was not well secured and the patient would benefit from an adhering IV dressing. The type of fluids infusing does not affect the frequency of a peripheral IV dressing change. Correct answer  Question 2 1 / 1 pts Identify the situations in which a peripheral intravneous (IV) line dressing requires changing. (Select all that apply.) A nursing instructor is assisting a student nurse to change the peripheral IV dressing on a patient. Which action, if made by the nursing student, indicates further teaching is necessary? (Select all that apply.)The student nurse applies sterile gloves and removes the old dressing, being careful to avoid dislodging the catheter. After completing the dressing change, the student nurse documents in the patient's chart the presence of swelling, coolness, blanching, and complaints of pain at the insertion site. The student stabilizes the IV, cleans the insertion site with chlorhexidine gluconate (CHG) solution using friction in a back and forth motion for 30 seconds. The student nurse cleans the site with a povidone-iodine swab in a concentric circle and immediately applies a new dressing to protect against infection. The student nurse labels the dressing with date and time of insertion, date and time of dressing change, gauge and length of catheter, and identification of student nurse. The student nurse should perform hand hygiene before applying clean gloves. It is unnecessary to wear sterile gloves to remove the old dressing. If signs of symptoms of infiltration are present, the infusion should be temporarily discontinued, the catheter removed, and the IV relocated. The student should do more than simply document the presence of the symptoms, because the infiltration will only worsen. To reduce skin surface bacteria, the student nurse should allow the antiseptic to dry completely before applying the new dressing. The student nurse provided appropriate labeling of the dressing. Correct answer  Question 3 1 / 1 pts Patient is afebrile; absence of symptoms of infection at IV insertion site. Catheter is leaking at connection of hub. Insertion site is pale, cool to touch, and extremity edematous. Dried blood is present on the dressing. Small amount of purulent drainage is at insertion site; redness is noted. Signs and symptoms of infiltration (i.e., insertion site pale, cool to touch, edema) require the infusion to be temporarily discontinued, the catheter removed, and the IV relocated with a new sterile catheter. Localized infection at the insertion site (redness, purulent drainage) also requires discontinuation of the present IV and relocation. It is unnecessary to relocate the IV site if the patient is afebrile and without symptoms of infection at the IV site. If the catheter is leaking, tightening the tubing and hub connection should be attempted first. Dried blood indicates the need for a dressing change but fails to require IV relocation. Which of the following indicate that the infusion needs to be temporarily discontinued, the catheter removed, and the IV relocated? (Select all that apply.)Correct answer  Question 4 1 / 1 pts Access to the catheter hub is needed when changing tubing. It will increase the risk of dislodging the catheter by an accidental pull. It will help to prevent pressure of the catheter hub against the skin It will reduce the transmission of microorganisms The nurse should avoid placing tape over the connection between the IV tubing and catheter hub because access to the catheter hub is needed in times of emergency and when changing tubing. Correct answer  Question 5 1 / 1 pts The type of gloves worn by the nurse. That the nurse does not apply the dressing. How the dressing was labeled. The direction the insertion site was cleaned. To stabilize the catheter when removing the old dressing. Using a commercial catheter stabilization device. The nurse should stabilize the catheter when removing the old dressing to prevent accidental displacement of the vascular access device (pulling tape of old dressing one layer at a time in a direction toward the insertion site). The nurse should label the dressing with date and time of insertion, time of dressing change, gauge and length of catheter, and nurse’s initials. Clean gloves may be worn. The site was cleaned in the appropriate direction. A commercial catheter stabilization device, transparent dressing, or sterile gauze dressing may be used. Quiz Score: 5 out of 5 What is the rationale for avoiding taping over the connection of the tubing to the hub? The nurse checks the identity of the patient, performs hand hygiene, and applies clean gloves. The nurse removes the old dressing, cleans the site with CHG solution in a back-and-forth motion, and allows the site to dry. The nurse applies a new manufactured catheter stabilization device, applies a transparent dressing, secures the tubing with tape, and labels the dressing with date and time of dressing change. The nurse discards used equipment and performs hand hygiene. The student nurse observing the nurse change the peripheral IV dressing correctly identifies actions the nurse should have performed. The student nurse is correct in identifying which two actions?Airway Management: Lesson 4 Post-Test Due Jun 21 at 11:59pm Points 7 Questions 7 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 3 minutes 7 out of 7 Score for this quiz: 7 out of 7 Submitted Jun 15 at 5:04pm This attempt took 3 minutes. Correct answer  Question 1 1 / 1 pts Whenever the patient begins to cough. On a routine schedule according to agency policy to reposition the tube. Only when the depth of the tube has changed from its original position (as indicated by a marking at the lip or gum line). According to health care provider orders. If endotracheal tube is inserted orally, the tube is often repositioned on the opposite side of the mouth or center of mouth according to agency protocol to prevent prolonged pressure and ulceration. Endotracheal tube care is usually performed on a routine schedule. Coughing, especially continued coughing, usually indicates a need for more frequent suctioning. Endotracheal tube care is indicated if the depth of the tube has changed. Correct answer  Question 2 1 / 1 pts Endotracheal care may be delegated to NAP only if the patient is on a ventilator. Assisting the nurse during a tape change by holding the endotracheal tube. A patient has an endotracheal tube inserted orally. When should the nurse expect to perform endotracheal tube care? Which situation can be delegated to nursing assistive personnel (NAP) in regard to endotracheal tube care?Performing respiratory assessments before and after endotracheal tube care. If the tapes are soiled, the NAP may change the tapes. NAP can help with reporting signs that the tube is loose, the tapes are soiled, or the patient is uncomfortable and assisting in holding the tube during a tape change. Assessment requires the skill and knowledge of the nurse and should not be delegated to NAP. Correct answer  Question 3 1 / 1 pts A sudden drop in oxygen saturation. Depth of tube is the same as when started or as ordered (same centimeter marking at gums or lips). Clean tape is firmly secured to cheeks, upper lip, top of nose, and tube only. Bilateral breath sounds are equal. The nurse should stop suctioning and administer oxygen. The other items are expected outcomes of performing endotracheal tube care. Correct answer  Question 4 1 / 1 pts Cut first piece of tape approximately 1 to 2 feet (24 to 48 cm) in length; lay adhesive-side up on table. When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff. Have assistant hold tube in place and note the markings on the tube indicating depth of tube insertion before removing old tape or tube holder. To secure the tapes around the tube, place the top side of the torn tape across the patient’s upper lip and tightly wrap the lower side around the tube. Never deflate the cuff during tube rotation. This could potentially dislodge the tube. Correct answer  Question 5 1 / 1 pts Which of the following is an unexpected outcome during or after endotracheal suctioning and endotracheal tube care? Which of the following is an inaccurate statement in regard to performing endotracheal tube care? The nurse is caring for a patient who has an endotracheal tube inserted orally. The nurse instructs the NAP to report if the patient indicates signs of pain. Because the patient cannot communicate verbally,Coughing or audible gurgling. Foul-smelling breath or remaining secretions in the mouth. Increased restlessness or a sudden change in vital signs. Ability of the patient to move the tube with the tongue or to bite down on the tube. Increased restlessness, inability to sleep, crying, and a sudden change in vital signs are all indicators of pain in the nonverbal patient. Coughing or audible gurgling, foul-smelling breath, or remaining secretions in the mouth indicate the patient may require suctioning but are not a sign of pain. If the patient is able to move the tub with his tongue or bite down on it, the tube may need to be resecured Correct answer  Question 6 1 / 1 pts Soiled or loose tape. Patient was recently shaved. Pressure sore on naris or corner of mouth. Breath sounds are equal and endotracheal tube remains at same depth. Foul odor of mouth. Signs and symptoms of the need to perform endotracheal tube care include the following: soiled or loose tape; a pressure sore on the naris, lips, or corner of the mouth; excess nasal or oral secretions; patient moving the tube with the tongue or biting the tube or tongue; tube repositioned by the physician or other specially trained personnel; and foul-smelling mouth. The endotracheal tube should remain at the same depth when breath sounds are equal. Shaving a male patient may be performed during endotracheal tube care. Correct answer  Question 7 1 / 1 pts Run and get help. Assess the patient for spontaneous breathing. Administer breaths with an Ambu-bag self-inflating resuscitation bag if necessary. Put the endotracheal tube back in. Put a tongue blade in the patient's mouth. what signs of pain should the NAP report? Identify the situations that require endotracheal tube care. (Select all that apply.) The nurse was changing the patient's tube holder on his endotracheal tube when he reached up and extubated himself. What actions should the nurse take? (Select all that apply.)Perform oropharyngeal suctioning. Apply sterile gloves. Remain with the patient and use the call system to obtain assistance. Correct nursing actions for unexpected extubation include the following: remain with the patient; call for assistance; assess the patient for airway patency, spontaneous breathing, and vital signs (including oxygen saturation); and prepare for reintubation by the health care provider, administering breaths with an self-inflating resuscitation bag in the meantime. Quiz Score: 7 out of 7Administration of Parenteral Medications: Intravenous Medications: Lesson 1 Post-Test Due May 24 at 11:59pm Points 4 Questions 4 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 4 minutes 4 out of 4 Score for this quiz: 4 out of 4 Submitted May 18 at 1:47pm This attempt took 4 minutes. Correct answer  Question 1 1 / 1 pts adds piggyback infusion of an antibiotic to main line IV of parenteral nutrition. explores patient’s cultural beliefs regarding use of alcohol, herbal remedies, and dietary preferences. verifies prescribed dilution and rate of administration for medication. administers solutions and medications prepared and dispensed from pharmacy when possible. The nurse should never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions because the medications may cause the blood cells to clump or cause clotting. Cultural assessment yields information about dietary preferences, tobacco and alcohol use, and use of herbal remedies that affect drug action and response. Patients may experience severe adverse reactions if IV medications are administered too quickly. Verify the rate of administration with a drug reference or a pharmacist before giving any IV medication to ensure medication is given over the appropriate time in the appropriate concentration. For risk reduction, the nurse should administer solutions and medications prepared and dispensed from the pharmacy or as commercially prepared when possible. Correct answer  Question 2 1 / 1 pts A nurse takes precautions to prevent an undesirable outcome when administering medications by the IV route. Which of the following actions may produce an undesirable outcome? The nurse:Observing for symptoms of adverse reactions. Following the six rights of medication administration. Being knowledgeable of the desired action and side effects of the medication. Adding IV medications to IV bags that are already hanging. Assessing vital signs before, during, and after infusion with potent medications. Verifying the rate of administration with a drug reference or pharmacist. Informing assistive personnel how to assess for fluid overload and evaluate medication effectiveness. Having the antidote available, if the medication has one. The nurse takes special care to avoid errors in dose calculation and preparation because once the dose enters the bloodstream, it begins to act immediately and there is no way to stop its action. The nurse uses the six rights of medication administration to verify that the right dose of the right medication is given by the right route to the right patient at the right time and then documented accurately. The nurse verifies the prescribed rate of administration with a drug reference or pharmacist before giving any IV medication so that the medication is given over the appropriate amount of time. Patients may experience severe adverse reactions if IV medications are administered too quickly. The nurse is aware of the desired therapeutic effect and potential side effects for accurate observation and evaluation of the medication therapy. The nurse continuously observes the patient for symptoms of adverse reactions so that early intervention may be implemented. This includes having an antidote available if the medication has one. When administering potent medications, the nurse assesses vital signs before, during, and after administration to assess for any alteration in the patient's status. It is inappropriate to delegate nursing assessment and evaluation to assistive personnel. Only add medications to new IV fluid containers as ordered by the health care provider, and administer solutions and medications prepared and dispensed from the pharmacy or as commercially prepared when possible. Correct answer  Question 3 1 / 1 pts Right patient. Right documentation. Right concentration. Identify nursing precautions to ensure safe patient care when administering IV medications. (Select all that apply.) When preparing to administer an IV medication, a nurse checks the health care provider's order with the medication administration record (MAR) and the label on the medication vial. The nurse verifies the IV route for administration. Next the nurse computes the correct dosage and withdraws the medication according to the MAR using the appropriate dilution. The nurse administers the medication intravenously at the time ordered and at the correct rate. Which of the six rights of medication administration did the nurse fail to demonstrate? (Select all that apply.)Right tubing. Right date of expiration. The nurse failed to identify the right patient by comparing the MAR to the patient's identification bracelet and asking the patient to state his or her name and birth date. Also the nurse is not described as recording the medication administration on completion of the procedure. Although the right concentration is excluded from the six rights of medication administration, the nurse did demonstrate the right dose by calculating the dosage and preparing it according to the medication order. Right tubing and right date of expiration also are not identified as among the six rights of medication administration. The nurse did verify the right drug by looking at the medication label on the vial and comparing it with the MAR. The nurse would also check the expiration date on the medication label at this time. Correct answer  Question 4 1 / 1 pts Less risk of an allergic response. Onset of therapeutic action is delayed. Delivers medication quickly in an emergency. Establishes therapeutic blood levels. Causes less discomfort with highly alkaline medications that are irritating to subcutaneous or intramuscular tissue. Requires less knowledge and skill. The advantages of administering medication by the IV route are that it provides a route for administering medication when the drug must be delivered quickly, it is the preferred route when it is necessary to establish constant therapeutic blood levels, and it causes less discomfort with highly alkaline and irritating medications than the subcutaneous or intramuscular route. After a medication enters the bloodstream, it begins to act immediately. If the patient is allergic to the medication, the reaction will be more prompt. Administering medications by the IV route requires more knowledge and skill to prevent negative outcomes. Quiz Score: 4 out of 4 Identify advantages of administering medication by the IV route. (Select all that apply.)Airway Management: Lesson 5 Post-Test Due Jun 21 at 11:59pm Points 4 Questions 4 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 1 minute 4 out of 4 Score for this quiz: 4 out of 4 Submitted Jun 15 at 5:24pm This attempt took 1 minute. Correct answer  Question 1 1 / 1 pts The outer cannula of the tracheostomy tube. The inner cannula of the tracheostomy tube. The obturator. The flange. The inner cannula may be removed and cleaned, or if disposable, discarded and replaced. The outer cannula should never be removed. Removal of the outer cannula would cause the tracheostomy tract to close, and in turn this would close the patient's airway. The obturator is a stylet used for initial insertion of the tracheostomy tube and is then removed to allow for airflow. The area under the flange, as well as the flange itself, is cleaned but not removed because it aids in securing the entire system to the patient s neck. Correct answer  Question 2 1 / 1 pts Risk of impaired skin integrity. Impaired mobility. Which of the following can be removed for cleaning, especially if the patient has copious or tenacious secretions? Which of the following would be an appropriate nursing diagnosis for the patient who has a tracheostomy tube?Fluid volume deficit. Risk of fluid volume excess. The nurse must be alert to the development of skin irritation below the tracheostomy flange and around the site of insertion. Impaired mobility, fluid volume deficit, and risk of fluid volume excess are not related to the presence of a tracheostomy tube. The nurse must be alert for defining characteristics of other nursing diagnoses, including impaired airway clearance, infection, pain, or altered skin integrity. Correct answer  Question 3 1 / 1 pts Recognizing signs and symptoms of hypoxia and how to prevent hypoxia. How to suction the tracheostomy tube. How to remove the tracheostomy tube. Expected drainage from the tracheostomy and when to notify the health care provider. The patient and/or the patient’s family should not remove the tracheostomy tube as this may result in closure of the patient’s airway. Only the inner cannula should be removed for cleaning. The patient and the patient’s family should be taught tracheostomy care, including suctioning, cleaning, replacing the ties, and recognizing the signs and symptoms of hypoxia and infection so they may take corrective action or seek additional medical care. Correct answer  Question 4 1 / 1 pts "I will drop the inner cannula into a sterile basin of normal saline." "After I secure the ends of the tracheostomy ties, I should be able to fit one finger loosely or two fingers snugly under the ties." "I will double knot the ties behind the patient's neck." "I should clean the tracheostomy stoma in a circular motion from the stoma site moving outward approximately 2 to 4 inches." "After I clean the inner cannula and replace it, I may use the brush to clean around the stoma." A patient may go home with a tracheostomy tube. Before discharge, the patient and the patient’s family should be taught all of the following routine tracheostomy tube care measures except: The nurse is preparing to perform routine tracheostomy care. Which statements, if made by the nurse, indicate that further instruction is needed? (Select all that apply.)The inner cannula should be dropped into the sterile basin of normal saline for cleaning, or if disposable, the inner cannula would be discarded. The ties should be secured in a double square knot on the side of the neck. One finger of slack prevents the ties from being too tight and also prevents movement of the tracheostomy tube. The stoma site should be cleaned to remove secretions. Moving in an outward circle pulls mucus and other contaminants away from the stoma to the periphery. The tracheostomy brush is used to remove thick or dried secretions from the cannula. It would be too harsh and contaminated to use on the peristomal skin. Sterile 4- 4-inch gauze is used to clean around the stoma. Quiz Score: 4 out of 4Closed Chest Drainage Systems: Lesson 1 Post-Test Due Jun 7 at 11:59pm Points 4 Questions 4 Time Limit None Score for this quiz: 4 out of 4 Submitted Jun 1 at 2:11pm This attempt took 2 minutes. Correct answer  Question 1 1 / 1 pts In the second or third intercostal space. In the mediastinum, just below the sternum. In the fifth or sixth intercostal space. Posteriorly or laterally. A mediastinal chest tube is placed in the mediastinum, just below the sternum. Mediastinal chest tubes are inserted for open-heart surgery patients to drain fluid away from the pericardial sac. Placing a chest tube in the second or third intercostal space is for the resolution of a pneumothorax. A chest tube located in the fifth or sixth intercostal space either posteriorly or laterally is the typical placement to remove blood or fluid from a hemothorax. Correct answer  Question 2 1 / 1 pts "Normally, atmospheric pressure in the pleural space is negative." "Besides difficulty breathing, an indication of a tension pneumothorax is a shift of the contents in the mediastinum (e.g., trachea and heart) to the opposite (unaffected) side of the chest." A patient is being prepared for open-heart surgery. Where would you expect the chest tube to be located when the patient returns from surgery? A student nurse is working as a tutor for a group of freshman physiology students. Which statement, if made by someone in the study group, would require correction?"Obstruction such as caused by kinking or clamping of the chest tube can result in a tension pneumothorax." "Physiologically, inspiration is a passive process that requires less work than expiration." The act of inspiration involves more muscles and effort than expiration. Expiration is a passive activity, whereas inspiration requires the muscles to push against negative pressure in the pleural cavity. Atmospheric pressure in the pleural space is normally negative (−4 to −10 mm Hg). Besides breathing difficulty, another indication of a tension pneumothorax is a shift of the contents in the mediastinum (e.g., trachea and heart) to the opposite (unaffected) side of the chest. Tension pneumothorax can also be caused by mechanical ventilation, cardiopulmonary resuscitation (CPR), and prolonged occlusion of chest tubes, such as obstruction of the chest tube by a blood clot. Patients with chest trauma, fractured ribs, or invasive thoracic bedside procedures (such as insertion of central lines) and those on highpressure mechanical ventilation are at risk for tension pneumothorax. Correct answer  Question 3 1 / 1 pts "When the intactness of the pleural space is broken, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue." "The exact cause remains unknown, but it is thought a collapsed lung may occur as a result of a weakened diaphragm." "Several factors can cause a lung to collapse, such as an increase in fibrous lung tissue, especially in the patient who smokes." "The negative pressure between the parietal pleura and the visceral pleura becomes too great." Normally, atmospheric pressure in the pleural space is negative (−4 to −10 mm Hg). If the integrity of the pleural space is interrupted, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue. Correct answer  Question 4 1 / 1 pts The patient has an open pneumothorax. Two nursing students are studying for an upcoming exam. One student quizzes the other regarding the cause of a patient's lung collapsing. What is the student's best response? A patient suddenly becomes short of breath, is complaining of chest pain, and has a drop in blood pressure. The nurse auscultates the lung sounds and hears normal lung sounds on the left and very diminished lung sounds on the right. The patient’s trachea appears to be deviated to the left. What should the nurse suspect?The patient has a hemothorax. The patient has a pneumohemothorax. The patient has a tension pneumothorax. These symptoms are consistent with a tension pneumothorax as evidenced by the shift in mediastinal contents. Quiz Score: 4 out of 4Closed Chest Drainage Systems: Lesson 2 Post-Test Due Jun 7 at 11:59pm Points 16 Questions 16 Time Limit None Attempt History Attempt Time Score LATEST Attempt 1 10 minutes 16 out of 16 Score for this quiz: 16 out of 16 Submitted Jun 1 at 3:18pm This attempt took 10 minutes. Correct answer  Question 1 1 / 1 pts The patient's chest tube has become dislodged. There is no water in the water-seal chamber. The wall suction needs to be increased. The patient is breathing shallowly and avoiding coughing. The water seal is dry, allowing air to enter the chest and preventing the lung from expanding. The level of water in the suction control chamber maintains the level of suction. Correct answer  Question 2 1 / 1 pts It will increase the rate of lung expansion. It will create more vigorous bubbling and faster evaporation of water. It will increase the frequency of emptying the drainage collection device. A patient has returned from the operating room with a chest tube in his sixth intercostal space with orders to connect the patient to wall suction. The patient has a three-chamber water-seal system. Eight hours later the nurse finds the patient complaining of increased chest pain, a respiratory rate of 40, and a pulse of 110. The water-seal chamber is dry. The patient is in obvious distress. What should the nurse suspect as the primary cause for the respiratory distress? What effect will increasing the suction source, creating more negative pressure, have on a threechamber water-seal chest tube drainage system connected to suction?It will damage lung tissue if the negative pressure is too great. Increasing wall suction creates more vigorous (and louder) bubbling and faster evaporation of water from the chamber. The level of water in the suction control compartment maintains the level of suction. The rate of lung reexpansion may be affected by a low water level (as fluid level decreases, the amount of suction also decreases) or by a drainage system that is too full and needs emptying. The chest tube drainage system has a built-in release valve to prevent tissue damage. If the suction source delivers more negative pressure than the suction control chamber water level allows, atmospheric air is pulled into the suction control chamber through an inlet, causing the excess suction to dissipate. Correct answer  Question 3 1 / 1 pts Evaporation of water in the water-seal chamber. Evaporation of water in the suction control chamber. Evaporation of fluid in the collection chamber. If the chest tube drainage system is tipped over. It is the level of water in the suction control chamber that maintains suction pressure. The nurse must be alert to the level of sterile water or normal saline in the water-seal or suction control chamber and be able to replace it as necessary to maintain proper functioning of the system. If the system is tipped or falls over, the integrity of the water-seal can be affected. The drainage system must remain upright to function properly. Correct answer  Question 4 1 / 1 pts After 2 to 3 days, tidaling stops. Gentle tidaling is present. Continuous bubbling is present in the diagnostic air-leak indicator. There is approximately 15 mL of fluid in the diagnostic air-leak indicator. Bubbling indicates the presence of an air leak, which must be identified and treated. The lung is reexpanding normally when a gentle tidaling is present in the diagnostic air-leak indicator. If after 2 to 3 days tidaling stops, the lung is usually reexpanded. The diagnostic air-leak indicator does require a small The nurse is monitoring the functioning of a three-chamber water-seal drainage system. Which of the following would negatively affect the functioning of this type of chest tube drainage system? (Select all that apply.) The nurse is assessing a waterless chest drainage system. Which of the following would be cause for concern?amount of fluid (e.g., 15 mL of fluid). This indicator is important for monitoring the function of the waterless system. Correct answer  Question 5 1 / 1 pts As the fluid level decreases with evaporation, the amount of suction declines. It prevents the suction from being so noisy as it bubbles. If the fluid level gets too low, the negative pressure created could cause damage to the pulmonary tissues. It is important to not let evaporation dry out the patient s lungs, which could impede reinflation. Sterile water is added several times a day because of evaporation. As the fluid level decreases, the amount of suction also declines. A prescribed amount of sterile fluid (e.g., 20 cm of water) is poured into the suction control chamber, which is then attached to a suction source by tubing. The amount of sterile water added depends on the manufacturer s recommendations. The chamber is filled to the set volume for the prescribed amount of suction. The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous, gentle bubbling. If the suction source delivers more negative pressure than the suction control chamber water level allows, there is no danger because atmospheric air is pulled into the suction control chamber through an inlet, causing the excess suction to dissipate. The extra air pulled into the chamber causes vigorous bubbling. If this occurs, lower the suction source setting to reduce noise and evaporation of the fluid. Correct answer  Question 6 1 / 1 pts Obtaining informed consent before the procedure. Removing the chest tube when the order is received. Setting up equipment, positioning the patient, and monitoring patient status. Inserting the chest tube, connecting it to a drainage system, and monitoring output. Health care providers are usually responsible for the insertion of chest tube catheters. The nurse is responsible for assisting during a chest tube insertion. This includes being responsible for equipment setup, positioning a patient, and monitoring the patient's status before, during, and after the procedure. It is the responsibility of the health care provider to obtain informed consent from the patient before inserting a chest tube. The nurse should verify the presence of a signed informed consent document What is the importance of keeping water at the prescribed centimeter level in the suction control chamber? Which of the following tasks associated with a chest tube is the responsibility of the nurse?before the start of the procedure. It is the responsibility of the health care provider to remove the chest tube. Correct answer  Question 7 1 / 1 pts The patient has had a stroke and is receiving anticoagulants. The patient has arthritis, which is being treated with aspirin. The patient regularly uses an antiplatelet agent. Regular caffeine use has been noted. The patient quit smoking 1 month ago. The patient has a hemoglobin value of 9 g per dL. A consent form lacks a signature. Anticoagulation therapy such as aspirin, warfarin, or heparin or platelet aggregation inhibitors such as ticlopidine can increase procedure-related blood loss. A low hemoglobin value is significant because it indicates that the patient has a lower oxygen-carrying capacity. Further bleeding could negatively affect the patient. The health care provider should be notified if a signed consent form is missing, because this procedure cannot be performed without a complete signed consent as a result of of the risks involved. It is unnecessary to notify the health care provider if the patient is a smoker or uses caffeine regularly because these factors have little impact on this procedure. Correct answer  Question 8 1 / 1 pts Shallow respirations at a rate greater than 20 breaths per minute. Anxious and restless. Diaphoretic. Cyanotic. Chest pain. Normal depth of breathing at a rate less than 20 breaths per minute. Pulse oximetry reading greater than 95%. Shallow, rapid respirations would be expected for the patient requiring a chest tube. The patient who is in need of a chest tube is usually in respiratory distress and has abnormal respiration rate and depth. The During assessment of a patient's record, what items are areas of concern that should be brought to the attention of the health care provider before chest tube insertion? (Select all that apply.) What clinical signs and symptoms should a nurse expect in a patient who requires chest tube insertion for a pneumothorax? (Select all that apply.)patient being anxious and restless and possibly cyanotic before chest tube insertion may indicate a lack of oxygen. A patient in respiratory distress is often sweating. Chest pain is associated with a pneumothorax, indicating that the patient needs a chest tube. Correct answer  Question 9 1 / 1 pts Temperature 98.0° F, pulse 80, respiration 20, blood pressure 124/80, pulse oximetry 93%. Drainage changing to serous color. Temperature 98.0° F, pulse 124, respiration 28, blood pressure 80/50, pulse oximetry 85%. Bubbling in water-seal chamber immediately after chest tube insertion. Bright red drainage 8 hours after insertion in the collection chamber. 500 mL of drainage in 24 hours. Asymmetrical chest movement. After the procedure, the patient's vital signs should move toward normal. You should notify the health care provider if the patient's blood pressure drops and pulse increases significantly because this may be an indication of bleeding. If the patient's respirations increase and the patient has more difficulty breathing, increased chest pain, decreased oxygen saturation, asymmetrical chest movement, or mediastinal shifting, the nurse should notify the health care provider because this indicates either a worsening of condition or development of a tension pneumothorax. The patient's drainage should change from a bloody appearance to a more serous color. The amount of drainage may be 500 to 1000 mL in the first 24 hours. You should report bright red drainage because this indicates active bleeding. When you initially connect the system to the patient, bubbles are expected from the water-seal chamber. These are from air that was present in the system and in the patient's intrapleural space. After a short time, this bubbling stops and tidaling is noted. Correct answer  Question 10 1 / 1 pts A patient with a hemothorax has a posterior chest tube located laterally in the fifth intercostal space connected to a water-seal drainage system. Preprocedure vital signs were: temperature 98.6° F, pulse 110, respiration 26 and shallow, blood pressure 94/52, and oxygen saturation 87%. The nurse is evaluating the patient's outcome. The health care provider should be notified of which of the following findings? (Select all that apply.) A nursing student is helping care for a patient with a chest tube. The nursing student asks the staff nurse what determines the level of suction in the chest tube. What is the correct response? (Select all that apply.)"The depth of fluid in the suction control chamber of a water-seal system determines the highest amount of negative pressure that can be present within the system." "The setting of the wall suction determines the amount of negative pressure present within the water-seal system." "The suction float ball indicates the amount of suction the patient's intrapleural space is receiving in a waterless system." "Whether it is a two-chamber or three-chamber system determines the level of suction. Three-chamber systems have more area to collect drainage, creating a greater negative intrapleural pressure." In a water-seal system, the depth of fluid dictates the amount of negative pressure. For example, 20 cm of water is approximately 20 cm of water pressure. Any additional negative pressure applied to the system is vented into the atmosphere through the suction control vent. The setting of the wall suction is unrelated to the amount of negative pressure within the water-seal system. In a water-seal system, turning the wall suction up higher will only make the system noisier without increasing the amount of suction on the patient's intrapleural space. In a waterless system, the suction float ball dictates the amount of suction in the system. The float ball allows only the level of suction dictated by its setting. The amount of drainage a drainage system can hold is unrelated to the level of suction in the chest tube. Correct answer  Question 11 1 / 1 pts Every 15 minutes for the first 2 hours. Every 10 minutes for the first hour. Every 15 minutes for the first hour, then every 30 minutes for the next hour, then every hour for the next 4 hours. Every 15 minutes times 2, then every hour times 4, then every 4 hours. Every 15 minutes for the first 2 hours is a minimum and assumes that the patient's vital signs remain stable and/or improve. Correct answer  Question 12 1 / 1 pts Shallow, rapid respirations. Asymmetrical chest movement. Diaphoretic. Which postprocedure chest tube insertion vital sign schedule meets the minimum needs of a postoperative patient? What is a normal expected outcome after insertion of a chest tube?Cyanotic. Increased chest pain. Normal rate and depth of breathing. The patient should be breathing more easily and at a normal rate (12 to 20 breaths per minute) and depth after the procedure. The patient who is free of respiratory distress should appear calm. The patient who is free of respiratory distress should have warm, dry skin of a normal skin tone for the patient. The patient should be free of chest pain. Chest pain or asymmetrical chest movement may indicate a possible tension pneumothorax. Correct answer  Question 13 1 / 1 pts Delegate assisting the health care provider in chest tube insertion to the NAP so the RN can take report on a new admission. Delegate milking the chest tube to the NAP while the RN administers pain medication to the patient. Delegate to the NAP clamping the chest tube while ambulating the patient in the hall 3 times a day. Delegate to the NAP informing the nurse if there is disconnection of the chest tube system or sudden bleeding. The NAP should be instructed to inform the nurse if there is disconnection of system, change in type and amount of drainage, sudden bleeding, or sudden cessation of bubbling. Only a nurse may assist health care providers with chest tube insertion because of the level of skill required. Milking chest tubes should be done only when there is a health care provider's order and an organizational policy covering this practice. Although assisting with ambulation may be delegated, chest tubes are never routinely clamped when the patient is ambulating and/or during transportation to another location. Correct answer  Question 14 1 / 1 pts The nurse performed all steps correctly. An RN and an NAP are caring for a group of patients. Which of the following would be an appropriate action for the nurse? The nurse is assisting the health care provider with the insertion of a chest tube. Before the procedure, the nurse prepares the drainage system to ensure that it will operate correctly. The nurse opens the drainage system and adds sterile water to the suction control chamber according to the manufacturer’s directions. The nurse then connects the tubing to the suction control chamber and to the suction source. The nurse clamps the tube that will go to the patient and turns the suction on to check the system for any air leaks. Because no air leaks are found, the nurse unclamps the tube and leaves the suction on so that it is ready to be connected to the patient. W