Nursing EXAM 2 (2025 Version) Tested Questions and Accurate Answers Guaranteed score A.

Nursing EXAM 2 (2025 Version) Tested Questions and Accurate Answers Guaranteed score A. What do nurses need to be aware of regarding patient safety A safe environment reduces the risk for accidents Vulnerable groups require help to achieve a safe environment Nurses need to understand how changes in mobility, sensory function, and cognitive function affect patient safety .... as shown by research What are the basic human (patient) needs Oxygen Nutrition Temperature Humidity What is a nurses responsibility concerning oxygen? Be alert to important functioning equipment Make sure patient understand O₂ is an explosive Colorless and odorless, don't know it is running What is a nurses responsibility concerning Nutrition? Proper refrigeration, food storage, food preparation ..... are essential What is a nurses responsibility concerning Temperature? Comfort zone 65°F to 75°F Exposure to extreme heat and cold can cause injury What is a nurses responsibility concerning Humidity? Amount of water vapor in the air Added Humidity may be needed because O2 can dry out mucous membranes. What are physical Hazards In the home- inadequate lighting and physical barriers (doors, stairs, curbs, furniture) Poison - OTC drugs, cleaning agents, plants Home fires - #1 cause = smoking, matches (CO detectors are important) Natural disasters - earthquakes, hurricanes, floods, snowstorms Threat of bioterrorist attack - anthrax Concerns for the Transmission of Pathogens Hand hygiene - most effective way to limit spread of pathogens (gel in, gel out) Human immune deficiency virus (HIV) & Hep B remain high risk for incidence exposure Insects and rodents - primarily affect the homeless Inadequate human waste disposal - cause typhoid fever & hepatitis Immunization - very important, has helped to eradicate some disease, need for education on this topic Biohazard waste - chemotherapy is an example, dealt with at hospitals all the time Common developmental safety hazards for INFANT/TODDLER/PRESCHOOLER - balance is poor - prone to accidents - putting things in mouth, nose, ears - parent education * children not restrained in car seat * don't leave your kid alone on couch Common developmental safety hazards for SCHOOL-AGE CHILD Education about safe play Use of safety equipment for sports - helmets, shinguards, etc Common developmental safety hazards for ADOLESCENT Drug/alcohol use/abuse Smoking Motor vehicle accident Common developmental safety hazards for ADULT Issues related to lifestyle habits (mountain climbing, sky-diving, driving fast) Common developmental safety hazards for OLDER ADULT Age related physiological changes - vision, hearing, sense of touch, ability to perform fine motor tasks.... All diminish Effects of medications - slow reaction time & dull the senses Illness Accidents (more prone to trips & falls... throw rugs are a death trap) Other Issues/Risk Factors that are concerns for safety Lifestyle Impaired mobility Sensory impairments Cognitive impairments Safety awareness Falls Risks in the Health Care Agency Account for most patient accidents Inherent Accident Risks in the Health Care Agency (Normal everyday things that happen) Cuts Burns Ingestion Seizures Procedure Related Risks in the Health Care Agency Medication Fluid Hospital Staff Equipment Related Risks in the Health Care Agency Malfunction Disrepair Electrical Hazards The nursing process in regards to Safety Awareness Assessment Two pronged approach to assess the environment and the patient Nursing diagnosis Fall Risk, Impaired sensory perception Planning Implementation Evaluation Interventions for Fall Concerns Place call light within reach Safety light Clear Pathway to bathroom Exit alarms/pads when patient gets out of bed Use of Restraints for Safety Measure When a patient is a danger to themselves or tp stop them from pulling out catheters and other medical devices Regulated by TJC & CMS (centers for medicare/medicaid services) - flow sheet must be completed on every patient in retraint All four side rails up is considered a restraint Consider alternatives, such as ambualarm, rather than restraints What are Restraint Regulations Requires a physician order - physician must see and assess the patient every 24 hours and write a new order - Patient must be checked every 15 minutes - Must be told what they need to do in order to have restraints removed -Must be allowed to toilet, eat. & drink Concerns for Restraints Impaired skin integrity Altered neurovascular status to extremities (cyanosis, pallor, coldness of skin, tingling, pain, numbness) Patient releases the restraint and falls and injures him/herself Safety Concerns for FIRES Smoke detectors Home or health care facility Safety Concerns for POISONING Medications Cleaning Fluids Mercury Safety Concerns for BIOTERRORISM Biological Chemical Radiological What are body mechanics? Coordinated efforts of the musculoskeletal and nervous systems Maintain balance, posture, and body alignment Mandatory for Lifting, bending, and moving Performing activities of daily living Four characteristics of Body Mechanics Body Alignment Body Balance Coordinated Body Movement Friction What is Good Nursing Body Alignment Relationship of one body part to another - don't twist Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, and contributes to balance. What is Good Nursing Body Balance Achieved by a low center of gravity Enhanced by a wide base of support What is Good Nursing Coordinated Body Movement Must overcome an object's weight and be aware of it's center of gravity. - can be determined by having a person stand and just look to see if a person is wobbly What is Friction in Nursing Body Mechanics? The force that occurs in a direction to oppose movement. The greater the surface area of the object that is moved, the greater the friction. Effect of rubbing or resistance when a moving body meets a surface when turning Physiology & Regulation of Movement SKELETAL SYSTEM Provides attachments for muscles and ligaments and the leverage necessary for movement: Bones, joints, ligaments, tendons, cartilage Physiology & Regulation of Movement SKELETAL MUSCLE Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. Due to ability to contract and relax are the working elements of movement. Movement Posture Groups Synergistic - A synergist muscle is a muscle which works in concert with another muscle to generate movement. These muscles can work with the so-called agonists or prime movers which surround a joint, or the antagonistic muscles, which move in the opposite direction Antigravity - postural movement Physiology & Regulation of Movement NERVOUS SYSTEM Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. Pathological influences on body alignment, exercise, & activity Congenital Defects - Osteogenesis imperfecta - Scoliosis Disorders of Bones, Joints, & Muscles - Osteoporosis - Inflammatory & noniflamm joint disease CNS Damage - damage to any component that regulates voluntary movements Musculoskeletal Trauma - Bruises/Contusions - Sprains - Fractures Describe some of the body changes throughout the life span: Newborn - spine is flexed, lacks curves that adult has Toddler - swayed back, less coordination, budda belly 3 yrs Continue to develop & grow and gain fine motor skills Aging - muscle-skeletal changes occur - peripheral arterial disease - interferes with blood supply to lower extremities due to intermittent claudication (claudication = limping, relieved by a short period of rest) How are body alignment and mobility assessed? Body alignment: Standing Sitting Recumbent Mobility: Range of motion Gait Exercise Activity tolerance Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance Risk for activity intolerance Disturbed body image Impaired physical mobility Acute pain Chronic pain Impaired skin integrity Risk for impaired skin integrity Nursing process: Planning for a patient that is immobile Goals and outcomes Setting priorities Collaborative care Describe proper lifting techniques Place object close to center of gravity Bend knees Use stronger leg muscles Avoid twisting Tighten abdominal muscles and tuck in the pelvis Maintain an erect trunk Bed Position Techniques Fowler/semi-Fowler - Head of bed elevated, support and align hips and spine Supine - Lying on back, support with pillows, trochanter rolls, or splints Prone - Face down - amputations Lateral - lying on side with proper spine alignment SIMS - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle Transfer Techniques Patient safety - 1st priority Nurse safety - 2nd priority GET HELP Assess for orthostatic hypotension ROM Exercises Active - patient can move joints on own Passive - The nurse moves the patient's joints Active Assist - patient moves joints with help from nurse Assisted devices for walking Walker - only come in one width. Usually used in aging and rehab Canes - personal preference as to what side use on, although usually used on weaker side. Helps balance. Crutches - 3 fingertips below the armpit and arms should be at an angle with the hand grip. "up to heaven, down to hell" means that you lead with good foot when going up the stairs and lead with bad leg when going down the stairs" Assisting a Falling Patient Slide patient down knee Avoid the big thump Protect your own body * Try to strategically plan how far walking by having a chair available nearby. Use of hand rails or wall nearby. Nursing Process: Evaluation Patient care Patient expectations Why use medications? treat cure prevent pain relief diagnose 3 parts of a medication name chemical name - compound that makes up the drug generic name - official name trade or brand name - what company will market by What does classification mean and list some The effect that the drug has on the body! - Anticoagulants - Analgesic (pain) - Antipyretic (fever) - Anti Inflammatory Forms of Medications Tablets Capsules Nasal Sprays Transdermal patches Eyedrops/eardrops Injectibles Supositories Elixirs Topical Government Regulation of Medication - To protect our patients and each state must abide by these laws - The gov't must also regulate off-label use of medications what does the state nurse practice act define? Defines the scope of nurses' professional functions and responsibilities. The act protects patients from unskilled, undereducated and unlicensed personnel. Nurse is responsible for following legal provisions for administering opioids which are carefully controlled through federal and state guidelines How are Non-therapeutic meds abused? overuse, underuse, eratic use, abuse, improper use What are Pharmacokinetics? The study of how medications enter the body, reach the site of action, metabolize and exit the body ...In order for meds to be useful they have to get to the area that needs to be treated. What are the factors that influence absorption? Absorption is the passage of medications into the blood from the site of administration 1. Route of administration (fastest I.V.) 2. Ability of the medication to dissolve 3. Blood flow from the area of absorption (poor blood flow leads to decreased effectiveness) 4. Body surface area 5. Lipid solubility of the medication (fat-soluble/water-soluble) Rate of dissolve for Meds (1) Enteric Coated - won't dissolve right away. Most of the time it passes through the stomach and dissolves in the intestines (2) Sustained Release - a longer time to dissolve What factors Influence Medication Distribution Circulation - Clot in blood vessel and narrow blood vessels can impede circulation Membrane permeability - may need assistance to cross the blood brain barrier - Protein binding Med chemicals bind to proteins to help meds get to where they need to go Metabolism of the medication Can only occur after the medication reaches the site of action Biotransformation occurs when enzymes detoxify, degrade, and remove active chemicals - Occurs in liver (major site of drug metabolism) people having trouble with this are older adults or people with liver diseases. - other places: lungs, kidneys, blood, and intestines ** people in liver failure are at ↑ rate of liver failure b/c metabolism of meds is very poor Excretion of Meds After metabolism, excretion occurs through Kidneys, liver, bowel, Lungs - alcohol, nitrous oxide and exocrine glands - Chemical structure of medication determines where excretion occurs - Some drugs can cross the placenta and should not be administered to pregnant women Types of Medication Action Therapeutic Effects Side Effects Adverse Effects Toxic Effects Idiosyncratic Reactions Allergic Reactions Anaphalaxsis Medication Interactions Medication Dose Responses Therapeutic Effects Intended effects Side Effects expected effects that don't contribute to helping the patient these are annoying, but not usually harmful Adverse Effects these are unwanted effects that are more harmful to the body Toxic Effects life threatening effects of the drug Idiosyncratic Reactions Causes something that you didn't expect Allergic Reactions can be minor all the way up to life threatening Anaphalaxsis Grandfather of all allergic reactions Medication Interactions some drugs can interact and cause physical changes Ex: Dilaudid mixed with D₅W will go through a physical change Medication Dose Responses at one dose do one thing and at another dose do another thing that is better or harmful Ex: Dopamine at a low dose will improve renal perfusion. At a middle dose, will raise blood pressure. At a higher dose, it raises blood pressure at the expense of the kidneys Routes of Administration of Meds Oral - by mouth - Sublingual: under the tongue - Buccal: by the cheek Parenteral: Subcut, IV, ID, IM Topical: anything you can put on the skin, to include patches Inhalation: via the mouth or nasal passages (breathed in) Intraocular: eye drops or eye ointment (intraopthalmic) Via epideral Intraperiteneal Intracardiac Inrapleural Intra arterial Intra articular - into a joint Intra osseous - narrow space of long bone Systems of Medication Administration Metric system - A decimal system organized into units of 10 Household measurements - Drops, teaspoons, tablespoons, cups, pints, quarts Solutions - Concentrations in units of mass per units of volume Clinical Calculations Conversions within one system - Grams to milligrams (or vice versa) Conversions between systems - 2 t to milliliters Dosage calculations Pediatric dosages - Approximation based on the adult dose. Sometimes based on weight or body surface area Administration of Meds: Who can prescribe? MD, PA (co-signed by MD), NP Administration of Meds: Types of Orders Standing - give once a day for the rest of life PRN - as needed / per requested Single one time dose STAT - give immediately Now - give it now, without breaking neck to do so ** Prescriptions are often being done electronically Administration of Meds: Nurses Role Double-Check right patient right drug right dose Administration of Meds: Pharmacist's Role Interaction with other drugs Correct dosage Fill prescription Distribution Systems Unit dose - A single dose to be given at a specific time Automated medication dispensing systems in the hospital Nurse's role - Administer medication correctly - Monitor side effects - Assess ability for patient self medication - Patient and family education Rights of Medication 1. Right medication 2. Right dose 3. Right patient Two forms of identification: name and birthdate Safety check to protect you... waiting to see if you change your name 4. Right route 5. Right time - allowed an hour window of time How do your prioritize if patient misses two doses of meds due to a long procedure? Look at when next due dose is? 6. Right documentation 7. Right to refuse (try to educate patient, document and notify provider) Maintaining patient's rights Nursing Process in Med Admin: Assessment History Allergies, medication, diet Patient's perspectives Current condition Attitudes about medication use Knowledge and understanding of medication use Learning needs Expectations Nursing Process in Med Admin: Diagnose & Plan NANDA-I list Knowledge deficit Risk for injury Setting goals Establishing outcomes Nursing Process in Med Admin: Implementation Patient and family teaching Receiving, transcribing, and communicating medication orders Accurate dosage calculation and measurement Correct administration Recording medication administration Document in a timely fashion Prevention of Needle Sticks Person on the blunt end of the needle is responsible for the sharp end of the needle Use needleless systems/ avoid use of needles NEVER recap needle Plan disposal of needle and syringe prior to procedure Immediately dispose of needle in sharps container Document injury Special Considerations for Administering Medications to Infants and Children Age, weight, surface area Ability to absorb, metabolize, and excrete Toddlers have a much higher metabolic rate. It slows down in pre-school Special Considerations for Administering Medications to Older Adults Polypharmacy - patient on many drugs. Are drugs interacting, does patient know why taking the drug? Medication reconciliation: whenever a patient transfers to a new hospital, or new floor, or is discharged Swallowing - patient may not be able to swollow and patient should sit upright when taking meds Reading - can patient read the label Arthritis - can patient get lid off container? If not, container tends to be left off and pets or children can get into it. Herbal drugs can interact negatively with prescribed meds. St.Johns Wart is the worst. Medication Error Errors include - Inaccurate prescribing - Wrong medication, route, and time - Extra doses or failing to administer Reporting procedures Written report within 24 hours of occurrence Medication Reconciliation Comparison of medications taken at home and prescribed when in the health care setting Evaluation of the Medication Change in patient's condition Is patient better or worse? Ask the patient Desired effect Adverse reactions Observation of physiological measures Check vitals in response to the medication Changes in laboratory values Endogenous Produced by your own pancreas Exogenous Given from the outside Who requires insulin? Everyone! - the body requires insulin in order to convert sugar into energy. Most people get insulin from endogenous means. Who requires exogenous insulin Type I diabetes Some type II diabetes people who are overly stressed may require insulin to regulate blood glucose for a short period of time. EX: Sometimes post surgery a patient can be put on a insulin drip as a therapy to control the cortisol release from the stress-response syndrome as surgery, anesthesia, and issues that brought patient to hospital can cause a great deal of stress. Advantages of insulin pen Advantages of insulin pen: Portable Don't require refrigeration Metered dose Reusability Clear insulin is the short acting insulin Steps to use Insulin Pen Remove cap Roll in hand make sure enough insulin Rub injection site w/ alcohol swab Screw on needle Prime insulin pen Set your dose Hold pen with thumb ready to depress Pinch skin Insert needle at 90⁰ angle Press plunger down until reads zero Keep needle in skin for 10 sec Mixing Insulin Clean the vials Roll the vials Put air into the cloudy vial first Then put air into clear vial Pull out clear insulin Draw out cloudy insulin Injection is given subcut Regular Insulin = CLEAR aka, short-acting insulin Long acting insulin = CLOUDY aka, NPH * prevent contamination of short-acting insulin with long acting Why do we draw clear before cloudy? prevent contamination of short-acting insulin with long acting What is an insulin pump? An insulin pump is a small battery-operated device about the size of a small cell phone. It continuously delivers small amounts of insulin through an infusion line placed under the skin. The infusion set must be changed every few days. What are the advantages of the pump? System much more like the beta cells of your pancreas Some of the pumps monitors your blood glucose level How do insulin pumps work? Has a reservoir that is filled with insulin and a microcomputer that allows you to adjust how much insulin is to be delivered. Pumps only use buffered short-acting or rapid-acting insulin (not long- or intermediate-acting insulin). Basal insulin is delivered continuously over 24 hours to keep blood sugar levels in range between meals and overnight. You can program different amounts of insulin for different times of the day and night. When your patient eats, you use buttons on the pump to give additional or "bolus" insulin to cover the carbohydrates in the meal. Glucose monitors Monitor determined by the physician as well as the frequency AC = before meals HS = at bedtime Hourly Machines vary from facility to facility Glucose monitoring test requires alcohol wipe lancet test strip machine Glucose monitoring test sites Finger tip forearm palm IV collection Steps for doing a glucose monitoring wash hands turn on machine and assure calibration cleanse selected collection site use lancet to perform stick express blood from site collect blood in test strip read & record results wash hands Glucose monitoring reporting Daily record taken to provider Reported to provider at time of test Documented on patient medical record Ventilation Movement of air in and out of the lungs Diffusion Movement of gases between air spaces and blood stream Respiration Exchange of gases; O₂ and CO₂ Perfusion Movement of blood into and out of the lungs to organs and tissues We need to get O₂ to the cells throughout the body!! In order for perfusion to occur, must have ventilation, diffusion & respiration What are the regulators of ventilation Neural Chemical O₂ transport CO₂ transport Neural Regulators CNS sends signal to chest wall to control rate, depth, and rhythm Chemical Regulators Carbon dioxide and hydrogen ions affect rate and depth of ventilation Oxygen Transport Influences ventilation and perfusion Carbon Dioxide Transport Dissolved in plasma, carbamino compounds, bicarbonate ** acid--base regulation What motivates COPD patient to breathe? O₂ motivates - body has become used to CO₂ build-up, therefore excess CO₂ does not motivate to breathe - low O₂ motivates COPD patient to breathe - BUT we cannot give too much O₂ because they do not have functioning alveoli to carry out the O₂ transport, so the O₂ build-up causing high level of O₂ resulting in no motivation to breathe What factors affect ventilation and O₂ transport? Hypoxia Hypoventilation Hyperventilatiom Hypoxia Inadequate tissue oxygenation at the cellular level - Mental confusion - Seizures - Cardiac arrest - Death Hypoventilation Inadequate ventilation to meet the body's demand - Atelectisis - Pulmonary edema ( no gas exchange with the lungs) - acid-base imbalance Hyperventilation Increase in respiratory rate - Pursed lip breathing to slow down breathing rate What is causing the quick breathing - anxiety attacks/pain/fear - acid-base imbalance Factors Affecting Oxygenation ↓ Oxygen carrying Capability Reduced hemoglobin, carbon monoxide, anemia ↓ Oxygen concentration Obstruction, decreased environmental oxygen ↑ Metabolic rate Hypercapnia, hypoxemia, fever, pregnancy, wound healing Chest wall movement - Musculoskeletal abnormality,- paralysis may take away respiratory drive - nervous system disease, -trauma Developmental Factors that impair oxygenation Premature infants - If too premature, it can be born before surfactant develops Infants and children - RSV (respiratory syncytial virus) - Airway obstruction due to swallowing small objects School-aged children and adolescents - Asthma - Teach kids and parents how to manage situations Young and middle-age adults - Smoking Older adults - Age-related changes: thickening of ventricular walls, reduction of cilia (the ability to capture things that can cause an infection) - Harder time fighting off infection Lifestyle Factors that Affect Oxygenation Nutrition/Hydration Exercise Cigarette smoking - Dialogue on how to quit Substance abuse Stress Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors) Nursing Process: Assessment Nursing history: Signs that may indicate poor oxygenation - Fatigue - Pain - Orthopnea - Wheezing - Cough - Respiratory infection - Medication use (drug interaction) Physical Exam - Cardiopulmonary status - Chest wall movement - Respiratory pattern - Airway patency (stridor) Diagnostic Test that may indicate poor oxygenation ECG - what is heart doing? If heart is not working properly then we don't get perfusion Chest x-ray ABG CBC - infection? Stress test Pulmonary function Cardiac catheterization Dependent edema Nursing Diagnosis Activity intolerance- quality of life? Things they like doing but can't - Ex. "activity intolerance related to COPD as evidence by dyspenia when walking to car" Ineffective airway clearance Ineffective breathing patterns Decreased cardiac output Fatigue Impaired gas exchange Risk for infection Acute pain Nursing Process: Planning for patients with low oxygenation Goals and outcomes - We are helping this patient to heal and get out of the hospital - Make sure outcomes are measurable - Ex: "upon discharge, patient will be able to maintain air on own" Setting priorities - Do the goals matter to the patient? Collaborative care - Work with the families so that care is followed - Medicare is not going to pay if patient comes back to hospital w/in 30 days. 17-20% patients have to come back related to initial hospitalization. Nursing Process: IMPLEMENTATION for patients with low oxygenation Health Promotion: Influenza and pneumococcal vaccine - CDC: Annual influenza vaccines for those 6 months and those over 50 years of age - Pneumococcal for those over 65 or with chronic illnesses Environmental modifications - Exposure to second hand smoke - Fragrance free zones Acute Care: Dyspenia Management Medications - Mucolytics - Bronchodialators - Anti-anxiety drugs oxygen therapy, physical techniques and psychosocial techniques Maintenance and promotion of oxygenation Oxygen supply, methods of oxygen delivery, hydration, humidification, nebulization O2 is a drug and must have doctor's orders Some hospitals have standing orders up to 2L If sending patient home with O2, educate on no open flames. Post a sign at the house. O2 can be extremely drying. If over 5L you need to humidify the O2 Oxygen Delivery Nasal Cannula Simple Face Mask Non-rebreather Mask - Rates if 8-15 liters - bag must be full Venturi Mask - Air entrapment & is more precise - Specific prescribed amt. of O2 being given and does not dry out membranes What percentage is 2 liters of O₂ 2L is 28% and it increases 4% every liter CPAP Continuous positive airway pressure - Normally for sleep apnea BIPAP Higher level on inspiration and lower level on expiration - Severe sleep apnea or other respiratory problems - It is thought that bipap is easier on the patient, but it is noisier. Indications for Endotracheal Intubation Inability to maintain oxygenation/ ventilation Airway protection - protects against aspiration Nurse's Role in an Endotracheal Intubation Know the proper equipment and its use Anticipate the health provider's needs Position the patient Preoxygenate the patient Provide suction as necessary Monitor the patient Provide information and reassurance How to Document for Endotracheal Intubation Size of ET tube (width & length) - Document! Location of ET tube in airway (nose or mouth) Medications administered Patient's tolerance of procedure Coughing Techniques to prevent poor oxygenation Cascade A series of coughs throughout exhalations Deep breath in, hold for 2 seconds, as you exhale then cough-cough-cough Huff While exhaling, open the epiglottis by saying the word huff Quad Push the diaphragm inward and upward This is for parapalegics ** Patient should cough every two hours Suctioning Techniques Oropharyngeal and nasopharyngeal Orotracheal and nasotracheal Tracheal - This is sterile - Suction this first NonInvasive Maintenance and Promotion of Lung Expansion Positioning - Reposition every two hours to reduce the risk of infection - Move from side to side allows for secretions and expansion - Splinting - hold a pillow or blanket against lower ribs to help ease pain Incentive spirometry (IS) - Exhale, then have patient suck in and hold it. Reduce risk of collapse of alveoli Chest physiotherapy - Chest percussion - Vibration - Cupping your hand and pat the back creating a vibration to move fluids along Don't do this on rib fractures, bleeding disorders, old person with osteoporosis - Postural drainage Can position patient in order to encourage drainage. CPAP & BiPAP Invasive Maintenance and Promotion of Lung Expansion Chest tubes - Suction control - expect to see gentle bubbling that stops - Should be kept below the patient for the effect of gravity - Do not strip the tubing, need to milk it instead. - Nurse needs to know # of mLs and what to expect - Each hospital has its own policy tubing mgt, know it - Pneumothorax Completely black on CXR indicated a collapsed lung - Hemothorax Air or blood is trapped in the pleural space; Know signs and symptoms of respiratory distress - Asymmetrical chest tube - Hypotension, tachycardia (may indicate tension pneumothorax) Evaluation Respiration should be between 16-20 (can be as low as 12) What is comfort level (any pain?) Check with the dyspnea scale O2 saturation ABGs *** Need to get pre-op or baseline in order to evaluate.