,NU 189/NU189 Exam 3 – Medical-Surgical Nursing
II – Actual Q&A (GCN) (Updated PDF)
1. The nurse notes fluctuation of the water level in the water seal chamber of a
chest tube with each respiration. Which action is required?
A) Continue to monitor; this is a normal finding.
B) Clamp the chest tube immediately.
C) Notify the healthcare provider.
D) Prepare for chest tube removal.
Correct Answer: A) Continue to monitor; this is a normal finding.
Rationale: Tidaling in the water seal chamber indicates the chest tube is patent
and the drainage system is functioning properly. This is an expected finding and
requires no intervention. Clamping can cause a tension pneumothorax, notifying
the provider is unnecessary, and removal is not indicated. The nurse should
document the finding and continue routine monitoring.
2. A patient's chest tube becomes disconnected from the drainage system. What
is the priority action?
A) Clamp the chest tube immediately.
B) Place the end of the chest tube in a container of sterile water.
C) Reconnect the tube and tape it.
D) Notify the provider and prepare for new insertion.
Correct Answer: B) Place the end of the chest tube in a container of sterile
water.
,Rationale: Placing the disconnected end under sterile water creates an
underwater seal, preventing air from entering the pleural space and causing a
tension pneumothorax. Clamping can trap air and is not the first action.
Reconnection may follow, but the immediate priority is to restore the water
seal.
3. Which assessment is most important before a cardioversion procedure?
A) Check the INR level.
B) Verify the patient is NPO.
C) Determine if the patient has an artificial valve.
D) Assess capillary refill.
Correct Answer: C) Determine if the patient has an artificial valve.
Rationale: An artificial valve may require specific precautions and can affect the
cardioversion procedure. While INR and NPO status are important, identifying
an artificial valve is the most critical pre-procedure assessment. Capillary refill is
not a priority before cardioversion. This assessment guides safe procedural
planning.
4. A patient with an ICD is being discharged. Which statement by the patient
indicates a need for further teaching?
A) I will keep the insertion site clean for 4 days.
B) I will avoid exposure to magnets.
C) I will carry my ICD identification badge.
D) I can safely go through airport security without any concerns.
, Correct Answer: D) I can safely go through airport security without any
concerns.
Rationale: Patients with an ICD must inform airport security personnel because
security screening may interfere with the device. Keeping the insertion site
clean, avoiding magnets, and carrying an identification badge are correct
statements. This statement reflects a misunderstanding and requires further
teaching about device safety.
5. A patient with atrial fibrillation is prescribed warfarin. Which laboratory value
should the nurse monitor to evaluate therapy?
A) aPTT
B) INR
C) Platelet count
D) PT
Correct Answer: B) INR
Rationale: Warfarin effectiveness is monitored using the international
normalized ratio, with a therapeutic range of 2 to 3. Atrial fibrillation increases
clot and stroke risk, and warfarin prevents clot formation. The aPTT monitors
heparin, platelet count measures platelets, and PT is less standardized than INR.
6. Left pneumothorax results in which type of shock?
A) Obstructive shock
B) Hypovolemic shock
II – Actual Q&A (GCN) (Updated PDF)
1. The nurse notes fluctuation of the water level in the water seal chamber of a
chest tube with each respiration. Which action is required?
A) Continue to monitor; this is a normal finding.
B) Clamp the chest tube immediately.
C) Notify the healthcare provider.
D) Prepare for chest tube removal.
Correct Answer: A) Continue to monitor; this is a normal finding.
Rationale: Tidaling in the water seal chamber indicates the chest tube is patent
and the drainage system is functioning properly. This is an expected finding and
requires no intervention. Clamping can cause a tension pneumothorax, notifying
the provider is unnecessary, and removal is not indicated. The nurse should
document the finding and continue routine monitoring.
2. A patient's chest tube becomes disconnected from the drainage system. What
is the priority action?
A) Clamp the chest tube immediately.
B) Place the end of the chest tube in a container of sterile water.
C) Reconnect the tube and tape it.
D) Notify the provider and prepare for new insertion.
Correct Answer: B) Place the end of the chest tube in a container of sterile
water.
,Rationale: Placing the disconnected end under sterile water creates an
underwater seal, preventing air from entering the pleural space and causing a
tension pneumothorax. Clamping can trap air and is not the first action.
Reconnection may follow, but the immediate priority is to restore the water
seal.
3. Which assessment is most important before a cardioversion procedure?
A) Check the INR level.
B) Verify the patient is NPO.
C) Determine if the patient has an artificial valve.
D) Assess capillary refill.
Correct Answer: C) Determine if the patient has an artificial valve.
Rationale: An artificial valve may require specific precautions and can affect the
cardioversion procedure. While INR and NPO status are important, identifying
an artificial valve is the most critical pre-procedure assessment. Capillary refill is
not a priority before cardioversion. This assessment guides safe procedural
planning.
4. A patient with an ICD is being discharged. Which statement by the patient
indicates a need for further teaching?
A) I will keep the insertion site clean for 4 days.
B) I will avoid exposure to magnets.
C) I will carry my ICD identification badge.
D) I can safely go through airport security without any concerns.
, Correct Answer: D) I can safely go through airport security without any
concerns.
Rationale: Patients with an ICD must inform airport security personnel because
security screening may interfere with the device. Keeping the insertion site
clean, avoiding magnets, and carrying an identification badge are correct
statements. This statement reflects a misunderstanding and requires further
teaching about device safety.
5. A patient with atrial fibrillation is prescribed warfarin. Which laboratory value
should the nurse monitor to evaluate therapy?
A) aPTT
B) INR
C) Platelet count
D) PT
Correct Answer: B) INR
Rationale: Warfarin effectiveness is monitored using the international
normalized ratio, with a therapeutic range of 2 to 3. Atrial fibrillation increases
clot and stroke risk, and warfarin prevents clot formation. The aPTT monitors
heparin, platelet count measures platelets, and PT is less standardized than INR.
6. Left pneumothorax results in which type of shock?
A) Obstructive shock
B) Hypovolemic shock
