A patient with congestive heart failure is at risk of excess ﬂuid volume. Which intervention will best determine if the patient is beginning to have excess ﬂuid volume?

Daily intake and output recordings

Daily weights

Daily blood pressure and heart rate checks

Daily CMP lab draw

Answer and Explanation

The Correct Answer is B

Daily weights provide a reliable and accurate measure of ﬂuid balance in the body. An increase in weight can indicate ﬂuid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most eﬀective way to monitor for excess ﬂuid volume in this situation.

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Correct Answer is C

Explanation

: Chest tube placement is done to remove air or ﬂuid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.

It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the ﬂow of air or ﬂuid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the ﬂuid will not drain properly, which can cause the ﬂuid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.

Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.

A. Vesicular sounds B. Wheezing sounds C. Crackles sounds D. Bronchovesicular sounds

Correct Answer is B

Explanation

When someone has asthma, their lungs may produce a wheezing sound when they breathe in and out. Narrowed airways and restricted air movement through the lungs may be responsible for the wheezing sound.

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A patient with congestive heart failure is at risk of excess ﬂuid volume. Which intervention will best determine if the patient is beginning to have excess ﬂuid volume?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?

Correct Answer is C

Explanation

The nurse provides care for the client with an asthma crisis experiencing hypoxia. Which lung sound would the nurse expect to auscultate on the physical assessment?

Correct Answer is B

Explanation

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