New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
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A nurse is assessing a client who has a closed chest
tube drainage system. The nurse notes constant
bubbling in the water seal chamber. What actions
should the nurse take? (Select all that apply).
Clamping the chest
tube Changing the
drainage system
Assessing the system for an
external air leak Reducing
the degree of suction being
applied
Documenting assessment findings, actions taken, and client
response
Rationale: Constant bubbling in the water seal chamber of
a closed chest tube drainage system may indicate the
presence of an air leak. The nurse would assess the chest
tube system for the presence of an external air leak if
constant bubbling were noted in this chamber. If an
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
,New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
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external air leak is not present and the air leak is a new
occurrence, the physician is notified immediately, because
an air leak may be present in the pleural space. Leakage
and trapping of air in the pleural space can result in a
tension pneumothorax. Clamping the chest tube is
incorrect.
Additionally, a chest tube is not clamped unless this has
been specifically prescribed in the agency’s policies and
procedures. Changing the drainage system will not
alleviate the problem. Reducing the degree of suction
being applied will not affect the bubbling in the water seal
chamber and could be harmful. The nurse would
document the assessment findings and interventions
taken in the client’s medical record.
Test-Taking Strategy: Use the process of elimination and
your knowledge regarding the priority actions in the care of
a closed chest tube drainage system. Focus on the data in
the question, noting that there is bubbling in the water seal
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
,New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
chamber. Recalling that this may indicate an air leak will
direct you to the correct options. Review the nursing actions
to be taken immediately in the event that complications of a
closed chest tube drainage system occur if you had difficulty
with this question.
A nurse performing nasopharyngeal suctioning and suddenly
notes the presence of bloody secretions. The nurse would
first:
Continue suctioning to
remove the blood Check the
degree of suction being
applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and
begin vigorous suctioning through the mouth
Rationale: The return of bloody secretions is an
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
, New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
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unexpected outcome of suctioning. If it occurs, the nurse
should first assess the client and then determine the
degree of suction being applied. The degree of suction
pressure may need to be decreased. The nurse must also
remember to apply intermittent suction and perform
catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the
mouth will result in increased trauma and therefore
increased bleeding. Suctioning is normally performed on
clients who are unable to expectorate secretions. It is
therefore unlikely that the client will be able to cough out
the bloody secretions.
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
A nurse is assessing a client who has a closed chest
tube drainage system. The nurse notes constant
bubbling in the water seal chamber. What actions
should the nurse take? (Select all that apply).
Clamping the chest
tube Changing the
drainage system
Assessing the system for an
external air leak Reducing
the degree of suction being
applied
Documenting assessment findings, actions taken, and client
response
Rationale: Constant bubbling in the water seal chamber of
a closed chest tube drainage system may indicate the
presence of an air leak. The nurse would assess the chest
tube system for the presence of an external air leak if
constant bubbling were noted in this chamber. If an
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
,New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
external air leak is not present and the air leak is a new
occurrence, the physician is notified immediately, because
an air leak may be present in the pleural space. Leakage
and trapping of air in the pleural space can result in a
tension pneumothorax. Clamping the chest tube is
incorrect.
Additionally, a chest tube is not clamped unless this has
been specifically prescribed in the agency’s policies and
procedures. Changing the drainage system will not
alleviate the problem. Reducing the degree of suction
being applied will not affect the bubbling in the water seal
chamber and could be harmful. The nurse would
document the assessment findings and interventions
taken in the client’s medical record.
Test-Taking Strategy: Use the process of elimination and
your knowledge regarding the priority actions in the care of
a closed chest tube drainage system. Focus on the data in
the question, noting that there is bubbling in the water seal
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
,New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
chamber. Recalling that this may indicate an air leak will
direct you to the correct options. Review the nursing actions
to be taken immediately in the event that complications of a
closed chest tube drainage system occur if you had difficulty
with this question.
A nurse performing nasopharyngeal suctioning and suddenly
notes the presence of bloody secretions. The nurse would
first:
Continue suctioning to
remove the blood Check the
degree of suction being
applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and
begin vigorous suctioning through the mouth
Rationale: The return of bloody secretions is an
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
, New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
unexpected outcome of suctioning. If it occurs, the nurse
should first assess the client and then determine the
degree of suction being applied. The degree of suction
pressure may need to be decreased. The nurse must also
remember to apply intermittent suction and perform
catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the
mouth will result in increased trauma and therefore
increased bleeding. Suctioning is normally performed on
clients who are unable to expectorate secretions. It is
therefore unlikely that the client will be able to cough out
the bloody secretions.
New 2022/2023 Update NURSING 428 Med
Surge HESI Review Test Questions and Answers
Correct/Verified with rationales Graded A+
Guaranteed Success
