The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could the nurse delegate to the assistive personnel (AP)?

Assess patient pain level associated with the chest tube.

Check the water-seal chamber for the correct fluid level.

Document the amount of drainage every 8 hours.

Obtain samples of drainage for culture from the system.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing pain requires subjective interpretation and clinical judgment to gauge severity and response. This nursing task can’t be delegated, as assistants lack training to evaluate pain’s impact on respiratory status or intervention needs.

Choice B reason: Checking the water-seal chamber involves understanding pneumothorax mechanics and system integrity. This technical skill exceeds an assistant’s scope, requiring a nurse to ensure proper function and detect complications like air leaks.

Choice C reason: Documenting drainage volume is a routine task after RN measurement, involving recording observed data. It fits an assistant’s role, as it requires no analysis or intervention, making it a safe delegation for tracking output.

Choice D reason: Obtaining drainage samples involves sterile technique and system manipulation, risking infection or disruption. This skilled procedure remains a nursing duty, as assistants aren’t trained to handle invasive equipment safely.

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Correct Answer is C

Explanation

Choice A reason: Ceftriaxone treats infection, but giving it before cultures risks sterilizing samples, skewing results. It’s critical therapy, yet obtaining accurate diagnostics first ensures targeted treatment, delaying antibiotics briefly.

Choice B reason: Antipyretics reduce fever, a symptom, not the cause. Cultures take priority to identify pathogens before comfort measures, as fever management doesn’t alter diagnostic or treatment urgency in this case.

Choice C reason: Blood and sputum cultures identify the causative organism in suspected infection (e.g., pneumonia). They must be obtained first, before antibiotics, to ensure accuracy, guiding effective therapy and avoiding false negatives.

Choice D reason: Monitoring glucose is routine, not urgent in acute infection unless diabetic crisis is suspected. Cultures precede this, as identifying the pathogen drives treatment, while glucose can wait without immediate risk.

Choice E reason: Monitoring intake and output tracks fluid status, useful but secondary in acute infection. Cultures are the priority to diagnose and treat effectively, as I&O doesn’t alter initial management decisions.

A. Cardiac diet B. Cardiac assessment C. Medication education

Correct Answer is C

Explanation

Choice A reason: A cardiac diet (low sodium, low fat) supports blood pressure control long-term by reducing vascular strain. However, it’s less immediate than addressing adherence, as dietary change alone won’t correct current medication misuse driving the elevation.

Choice B reason: Cardiac assessment identifies complications like hypertrophy, useful for monitoring. It’s reactive, not proactive, and doesn’t address the root issue of inconsistent adherence, which directly impacts blood pressure control and outcomes now.

Choice C reason: Medication education tackles adherence, the primary cause of uncontrolled hypertension here. Teaching proper use ensures therapeutic levels, reducing pressure via vasodilation or fluid control, directly improving outcomes with evidence-based efficacy.

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The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could the nurse delegate to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Dr. Whitten just evaluated Ms. Sanchez and has written the following orders: Choose which order must be completed first.

Correct Answer is C

Explanation

Complete the following sentence: Given the patient’s elevated blood pressure and inconsistent medication adherence, the nurse should prioritize (intervention) to help improve blood pressure control and patient outcome

Correct Answer is C

Explanation

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