Which finding is the most concerning and should prompt immediate action by the nurse?

Potassium level of 4.8 mEq/L

Episodes of dizziness and blurred vision

Chest x-ray showing mild left ventricular hypertrophy

Blood pressure of 168/98 mmHg

Answer and Explanation

The Correct Answer is B

Choice A reason: Potassium of 4.8 mEq/L is within normal range (3.5-5.0 mEq/L), posing no immediate threat. Hyperkalemia risks arrhythmias, but this level doesn’t warrant urgent action, as it’s stable and unlikely to disrupt cardiac function acutely.

Choice B reason: Dizziness and blurred vision suggest cerebral hypoperfusion or stroke, potentially from hypertension or embolism. These neurologic symptoms demand immediate action to assess and treat, as they indicate acute risk to brain function or life.

Choice C reason: Mild left ventricular hypertrophy on x-ray reflects chronic hypertension adaptation, not an acute emergency. It’s a stable finding requiring management, but it doesn’t necessitate immediate intervention compared to symptomatic neurologic changes.

Choice D reason: Blood pressure of 168/98 mmHg is elevated (stage 2 hypertension), risking long-term damage. Without acute symptoms, it’s less urgent than dizziness and vision changes, which signal immediate compromise needing rapid response.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Repositioning may ease discomfort but won’t address severe pain (7/10) or reduced breath sounds post-thoracotomy. It risks dislodging tubes and doesn’t improve atelectasis or bleeding, lacking urgency for this acute scenario.

Choice B reason: Incentive spirometry prevents atelectasis, but pain limits participation. Decreased breath sounds suggest collapse, yet without pain control, this intervention is ineffective, delaying relief and lung expansion needed post-surgery.

Choice C reason: Clamping a chest tube risks tension pneumothorax by trapping air or blood, worsening breathing. With 100 mL drainage, it’s functioning; clamping is contraindicated unless ordered, making it dangerous here.

Choice D reason: Morphine reduces severe pain (7/10), enabling deeper breathing to reverse atelectasis. It addresses the primary barrier to recovery post-thoracotomy, improving ventilation and comfort, aligning with acute pain management protocols.

A. Assess patient pain level associated with the chest tube. B. Check the water-seal chamber for the correct fluid level. C. Document the amount of drainage every 8 hours. D. Obtain samples of drainage for culture from the system.

Correct Answer is C

Explanation

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which finding is the most concerning and should prompt immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage. Which action would the nurse take?

Correct Answer is D

Explanation

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)?

Correct Answer is C

Explanation

Which patient statement supports a history of intermittent claudication?

A patient comes to the doctor’s office with the following complaints: Moderate to severe pain over the nose, eyes, and forehead, purulent nasal drainage, fever, and malaise. The nurse suspects the patient is suffering from ___________.

Nursing management of patients with tracheostomies includes collaboration with other healthcare team members. Match the Health care team member with the correct collaborative task.

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is important to communicate to the health care provider?

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?

Which instruction will the nurse plan to include in discharge teaching for a patient who was admitted with a sickle cell crisis?

Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

Which nursing intervention is important when providing care for a patient in sickle cell crisis?