NCLEX CRUSADE ACADEMY TEST - 10 CARE OF PATIENTS WITH CHEST TUBE TEST

1. According to NCLEX prioritization strategy, what is the first question a nurse should ask?. What medication is due next?. Is the patient in distress?. What is the lab value?. What equipment is needed?.

2. If a patient is in acute distress, the nurse should: Gather more data. Assess thoroughly first. Implement immediate action. Document the findings.

3. According to Maslow's hierarchy applied to nursing care, the highest priority is: Psychosocial needs. Safety needs. Physiological needs. Educational needs.

4. Which physiological priority comes first in emergency situations?. Circulation. Airway. Nutrition. Mobility.

5. A chronic condition becomes a priority when: The patient has had it for years. It is stable. There is a sudden or acute change. The patient complains frequently.

6. When should the Rapid Response Team be activated?. Heart rate above 100. Systolic BP less than 90 mmHg. Temperature above 100F. Mild anxiety.

7. A respiratory rate below 8 or above 28 breaths per minute indicates: Normal variation. Anxiety. Need to call Rapid Response Team. Need for patient education.

8. Oxygen saturation below what level despite oxygen therapy may trigger RRT?. 95%. 93%. 90%. 85%.

9. Urine output below what level may indicate instability?. <100 mL in 4 hours. <50 mL in 4 hours. <200 mL in 4 hours. <500 mL in 4 hours.

10. A sudden change in level of consciousness suggests: Stable condition. Dehydration. Neurological instability. Normal aging.

11. A patient with asthma has RR 10 and O2 saturation 88%. The nurse should: Call Rapid Response. Increase oxygen immediately. Document findings. Recheck vitals in one hour.

12. Pneumothorax chest tubes are typically placed in: 5th intercostal space. 2nd intercostal space. 8th intercostal space. 10th intercostal space.

13. Hemothorax chest tubes are typically inserted around: 2nd intercostal space. 4th intercostal space. 8th or 9th intercostal space. 3rd intercostal space.

14. In a chest drainage system, the chamber that controls suction is: Collection chamber. Water seal chamber. Suction control chamber. Air leak chamber.

15. The water seal chamber functions as: A measurement container. A one-way valve preventing air return. Oxygen reservoir. Fluid storage.

16. Gentle bubbling in the suction control chamber is: Dangerous. Expected and normal. A system leak. Evidence of obstruction.

17. Continuous bubbling in the water seal chamber indicates: Normal lung expansion. A leak in the system. Fluid accumulation. Tube obstruction.

18. Tidaling in a chest tube system refers to: Fluid accumulation. Air leak. Rise and fall of water with respiration. Tube obstruction.

19. If tidaling suddenly stops, the nurse should: Immediately remove the tube. Assess tubing and patient. Increase suction. Clamp the tube.

20. Chest tubes should NEVER be: Monitored. Milked or stripped. Positioned below the chest. Connected to suction.

21. If a chest tube becomes dislodged from the patient, the nurse should: Clamp the tube. Cover the site with sterile occlusive dressing taped on 3 sides. Push the tube back in. Ignore it.

22. If the drainage system breaks, the nurse should: Clamp the tube permanently. Submerge tube end in sterile water. Remove the tube. Ignore it.

23. Chest tube drainage greater than what amount per hour is a red flag?. 20 mL/hr. 40 mL/hr. 70100 mL/hr. 200 mL/hr.

24. Bright red drainage in chest tube output suggests: Normal drainage. Infection. Active bleeding. Air leak.

25. In carbon monoxide poisoning, pulse oximetry readings may appear: Very low. Normal despite hypoxia. Zero. Extremely high.