PrepU
Clinical Skills
Q&A
2024
,1. A nurse is caring for a patient who has a chest tube
connected to a water-seal drainage system. The nurse
notices that there is continuous bubbling in the water-seal
chamber. What should the nurse do next?
a) Clamp the chest tube and notify the physician.
b) Check the system for air leaks and tape any connections
that are loose.
c) Document the finding and continue to monitor the
patient.
d) Increase the suction pressure to remove the excess air.
*Answer: b) Check the system for air leaks and tape any
connections that are loose.*
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak in the system, which can compromise
the drainage of fluid and air from the pleural space and
increase the risk of tension pneumothorax. The nurse
should check the system for air leaks and tape any
connections that are loose. Clamping the chest tube can
cause a buildup of pressure in the pleural space and worsen
the patient's condition. Documenting the finding and
continuing to monitor the patient is not enough to address
the problem. Increasing the suction pressure will not stop
the air leak and may cause damage to the lung tissue.
2. A nurse is preparing to administer an intramuscular
injection to a patient who has a history of anaphylaxis. The
nurse has drawn up 0.3 mL of epinephrine 1:1000 in a
syringe. What is the most appropriate site for the injection?
a) Deltoid muscle
, b) Vastus lateralis muscle
c) Ventrogluteal muscle
d) Dorsogluteal muscle
*Answer: b) Vastus lateralis muscle*
Rationale: The vastus lateralis muscle is the preferred site
for intramuscular injections of epinephrine in patients who
have a history of anaphylaxis, because it has a large surface
area, is easily accessible, and has fewer major blood
vessels and nerves than other sites. The deltoid muscle is
not recommended because it has a smaller surface area and
may not absorb the medication as quickly. The
ventrogluteal and dorsogluteal muscles are not
recommended because they are located near major blood
vessels and nerves and have a higher risk of injury.
3. A nurse is performing a head-to-toe assessment on a
patient who was admitted with abdominal pain and
vomiting. The nurse palpates the patient's abdomen and
finds that it is rigid, tender, and distended. What should the
nurse do next?
a) Auscultate the abdomen for bowel sounds.
b) Measure the patient's abdominal girth and document it.
c) Elevate the head of the bed to 30 degrees and apply a
warm compress.
d) Notify the physician and prepare for emergency surgery.
*Answer: d) Notify the physician and prepare for
emergency surgery.*
Rationale: A rigid, tender, and distended abdomen is a sign
of acute abdominal emergency, such as perforation,
obstruction, or ischemia, which requires immediate surgical
Clinical Skills
Q&A
2024
,1. A nurse is caring for a patient who has a chest tube
connected to a water-seal drainage system. The nurse
notices that there is continuous bubbling in the water-seal
chamber. What should the nurse do next?
a) Clamp the chest tube and notify the physician.
b) Check the system for air leaks and tape any connections
that are loose.
c) Document the finding and continue to monitor the
patient.
d) Increase the suction pressure to remove the excess air.
*Answer: b) Check the system for air leaks and tape any
connections that are loose.*
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak in the system, which can compromise
the drainage of fluid and air from the pleural space and
increase the risk of tension pneumothorax. The nurse
should check the system for air leaks and tape any
connections that are loose. Clamping the chest tube can
cause a buildup of pressure in the pleural space and worsen
the patient's condition. Documenting the finding and
continuing to monitor the patient is not enough to address
the problem. Increasing the suction pressure will not stop
the air leak and may cause damage to the lung tissue.
2. A nurse is preparing to administer an intramuscular
injection to a patient who has a history of anaphylaxis. The
nurse has drawn up 0.3 mL of epinephrine 1:1000 in a
syringe. What is the most appropriate site for the injection?
a) Deltoid muscle
, b) Vastus lateralis muscle
c) Ventrogluteal muscle
d) Dorsogluteal muscle
*Answer: b) Vastus lateralis muscle*
Rationale: The vastus lateralis muscle is the preferred site
for intramuscular injections of epinephrine in patients who
have a history of anaphylaxis, because it has a large surface
area, is easily accessible, and has fewer major blood
vessels and nerves than other sites. The deltoid muscle is
not recommended because it has a smaller surface area and
may not absorb the medication as quickly. The
ventrogluteal and dorsogluteal muscles are not
recommended because they are located near major blood
vessels and nerves and have a higher risk of injury.
3. A nurse is performing a head-to-toe assessment on a
patient who was admitted with abdominal pain and
vomiting. The nurse palpates the patient's abdomen and
finds that it is rigid, tender, and distended. What should the
nurse do next?
a) Auscultate the abdomen for bowel sounds.
b) Measure the patient's abdominal girth and document it.
c) Elevate the head of the bed to 30 degrees and apply a
warm compress.
d) Notify the physician and prepare for emergency surgery.
*Answer: d) Notify the physician and prepare for
emergency surgery.*
Rationale: A rigid, tender, and distended abdomen is a sign
of acute abdominal emergency, such as perforation,
obstruction, or ischemia, which requires immediate surgical
