23. A patient with a chest tube is being transported to the intensive care unit and
fluctuation is noted in the water seal chamber during inspiration and expiration. What
is the best action for the nurse to take?
A. Clamp the chest tube
B. Return to the emergency department
C. Assist ventilations with bag-mask device
D. Continue to the intensive care unit
Give this one a try later!
, D. Continue to the intensive care unit
7. A patient with a lower extremity fracture complains of severe pain and tightness in
his calf, minimally relieved by pain medications. Which of the following is the priority
nursing intervention?
A. Elevating the leg above the level of the heart
B. Repositioning the leg and applying ice
C. Elevating the leg to the level of the heart
D. Preparing the patient for ultrasound of the leg
Give this one a try later!
C. Elevating the leg to the level of the heart
Rationale: Musculoskeletal and Wounds\Musculoskeletal
This patient is exhibiting signs of possible compartment syndrome which is
a dangerous complication of fractured extremities. The pain is often out of
proportion to the injury and might not respond to pain medications. Elevate
the limb to the level of the heart to decrease dependent edema but not
above the heart, which can cause increased venous congestion and
pressure within the compartment.
4. You are caring for a patient who was thrown from a bike and was not wearing a
helmet. While performing the head-to-toe assessment, you note clear drainage from
the right ear. Which of the following is the most appropriate next step?
A. Clean the ear with a cotton-tipped applicator.
B. Pack the ear with gauze.
C. Notify the physician
D. Document and continue the exam.
Give this one a try later!
fluctuation is noted in the water seal chamber during inspiration and expiration. What
is the best action for the nurse to take?
A. Clamp the chest tube
B. Return to the emergency department
C. Assist ventilations with bag-mask device
D. Continue to the intensive care unit
Give this one a try later!
, D. Continue to the intensive care unit
7. A patient with a lower extremity fracture complains of severe pain and tightness in
his calf, minimally relieved by pain medications. Which of the following is the priority
nursing intervention?
A. Elevating the leg above the level of the heart
B. Repositioning the leg and applying ice
C. Elevating the leg to the level of the heart
D. Preparing the patient for ultrasound of the leg
Give this one a try later!
C. Elevating the leg to the level of the heart
Rationale: Musculoskeletal and Wounds\Musculoskeletal
This patient is exhibiting signs of possible compartment syndrome which is
a dangerous complication of fractured extremities. The pain is often out of
proportion to the injury and might not respond to pain medications. Elevate
the limb to the level of the heart to decrease dependent edema but not
above the heart, which can cause increased venous congestion and
pressure within the compartment.
4. You are caring for a patient who was thrown from a bike and was not wearing a
helmet. While performing the head-to-toe assessment, you note clear drainage from
the right ear. Which of the following is the most appropriate next step?
A. Clean the ear with a cotton-tipped applicator.
B. Pack the ear with gauze.
C. Notify the physician
D. Document and continue the exam.
Give this one a try later!
