Chest Tubes Chap 26 and Chap 43

Question 1

The nurse is caring for a patient who is comatose and on a ventilator. When she enters the room, she notices that the patient’s trachea has shifted toward the left side of the patient’s neck, and he has become tachycardic. She assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having recognized that the patient has developed which of the following conditions?

a. Hemothorax
b. Pneumothorax on the left side
c. Pneumothorax on the right side
d. Myocardial infarction

Answer 1

ANS: C
A tension pneumothorax occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. If left untreated, the lung on the affected side collapses, and the mediastinum and the trachea shift to the opposite (unaffected) side. The patient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction.

Question 2

For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located?

a. Second to third intercostal space (apical), anterior
b. Fifth to sixth intercostal space, posterior
c. Fifth to sixth intercostal space, lateral
d. Mediastinal area

Answer 2

ANS: A
Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in the case of a pneumothorax. Chest tubes are placed low (usually in the fifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in the mediastinum, just below the sternum. This tube drains blood or fluid, preventing its accumulation around the heart. A mediastinal tube commonly is used after open heart surgery.

Question 3

The patient’s chest tube is attached to a one-way flutter valve that allows air to escape the chest cavity and prevents air from reentering. How does the nurse document this finding?

a. Heimlich chest drain valve
b. Pneumovax
c. Water seal
d. Pleurovac

Answer 3

ANS: A
The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is the brand name of a water-seal set.

Question 4

The nurse is caring for a patient who has a chest tube connected to a water seal. The patient is not on a ventilator. Which of the following would the nurse consider normal?

a. The fluid level in the water seal rises with inspiration.
b. The fluid level in the water seal falls with inspiration.
c. Constant bubbling occurs in the water seal.
d. The fluid level in the water seal falls with expiration 3 days after insertion.

Answer 4

ANS: A
Observe the water seal for intermittent bubbling from its U tube or for a rise and fall of fluid that is synchronous with respirations. (For example, in a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. When a patient is on a mechanical ventilator, the opposite occurs.) In a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded.

Question 5

The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage contains a large amount of pus. What does the presence of the pus indicate?

a. Malignancy
b. Pulmonary infarction
c. Empyema
d. Hemothorax

Answer 5

ANS: C
Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus colored. Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax.

Question 6

What is indicated by continuous bubbling in the water-seal chamber with no bubbles noted in the suction control chamber of the drainage system?

a. A leak in the system
b. Normal functioning
c. A drainage obstruction
d. Insufficient suction pressure

Answer 6

ANS: A
Continuous bubbling in the water-seal chamber with an absence of bubbles in the suction control chamber indicates that there is a leak in the system. Normal functioning is indicated by gentle, continuous bubbling in the suction chamber and occasional bubbling in the water seal, with fluctuations on inspiration and expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in the suction chamber.

Question 7

What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure?

a. Pneumonitis
b. Tube displacement
c. A myocardial infarction
d. A tension pneumothorax

Answer 7

ANS: D
Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over the chest tube insertion site. Myocardial infarction pain is expressed as “crushing” or “pressure” over the sternal area.

Question 8

Which of the following is an expected outcome of chest tube insertion?

a. Mild chest pain is maintained.
b. Breath sounds are auscultated in all lobes.
c. Drainage from the pleural cavity increases over time.
d. Lung expansion is increased beyond the unaffected side.

Answer 8

ANS: B
When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO2) is stable or improved, and respirations are nonlabored. Chest pain is not an expected outcome. Treatment is effective when the patient reports no chest pain. Drainage from the pleural cavity decreases over time with reexpansion of the lung. Lung expansion would be equal to preinjury status.

Question 9

What should the nurse do to establish a two-chamber waterless chest tube system?

a. Add sterile water to the suction chamber
b. Add sterile solution to the water seal
c. Set the float ball to the correct drainage pressure
d. Connect directly to the chest tube and add nothing

Answer 9

ANS: D
The waterless two-chamber system is ready for connecting to the patient’s chest tube after the wrappers have been opened. The waterless system’s principles are similar to those of the water-seal system, except that fluid is not required for setup. Because water is not used, accidentally tipping over the system does not compromise the patient’s condition. The suction chamber does not depend on water. Instead, it contains a float ball, which is set by a suction control dial after the suction source is turned on.

Question 10

Which of the following represents appropriate technique when providing care for a patient with chest tubes?

a. Applying an occlusive dressing over the site
b. “Stripping” the tube on a regular basis
c. Assessing the patient hourly after insertion
d. Keeping excess loops of tubing from hanging over the side of the bed

Answer 10

ANS: D
Lay excess tubing horizontally on the mattress next to the patient. Secure with a rubber band and safety pin or with the system’s clamp. This prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage could collect in the loop and occlude the drainage system. Physician responsibility in chest tube placement includes covering the insertion site with sterile petroleum gauze, 4 × 4-inch gauze, and a large dressing to form an occlusive dressing supported with an elastic bandage. Strip or milk the chest tube only if indicated (this means compressing the tube to encourage clots to press through the tube). Stripping may cause complications because it creates excessive negative intrapleural pressure. Check agency policy. Monitor vital signs, SaO2, and the insertion site every 15 minutes for the first 2 hours.

Question 11

Which of the following is the correct positioning for a patient after a chest tube has been inserted for a hemothorax?

a. Supine
b. Side-lying
c. Semi-Fowler’s
d. High-Fowler’s

Answer 11

ANS: D
After the tube is placed, assist the patient to a comfortable position. Supine does not facilitate drainage or removal of air or fluid, and side-lying does not facilitate lung expansion. The high-Fowler’s position is used to evacuate air (pneumothorax).

Question 12

What is the expected amount of drainage for an adult patient with a mediastinal chest tube?

a. Less than 100 mL/hr during the immediate postoperative period
b. Less than 10 mL/hr during the immediate postoperative period
c. 1000 mL/hr during the first 24-hour period
d. 200 mL/hr during the first 24-hour period

Answer 12

ANS: A
In the adult, less than 50 to 200 mL/hr is drained immediately after surgery in a mediastinal chest tube. No standard is known for 10 mL/hr in the immediate postoperative period. Expected drainage in the adult with a mediastinal chest tube is approximately 500 mL in the first 24 hours.

Question 13

What is the expected amount of drainage for an adult patient with a posterior chest tube?

a. 100 to 300 mL during the first 3 hours
b. 10 to 50 mL during the first 2 hours
c. 200 mL during the first 24 hours
d. 400 to 500 mL during the first 24 hours

Answer 13

ANS: A
In the adult, between 100 and 300 mL of fluid may drain from a posterior tube during the first 3 hours after insertion. The 24-hour rate is 500 to 1000 mL.

Question 14

A nurse determines that there may be a leak in the chest tube system. Clamps are applied near the patient’s chest, and the nurse finds that the bubbling stops. What should the nurse do next?

a. Change the tubing.
b. Change the drainage container.
c. Move the clamps farther down the chest tube.
d. Reinforce the dressing and notify the physician.

Answer 14

ANS: D
Assess for the location of the air leak by clamping the chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site. Unclamp the tube, reinforce the dressing, and notify the physician immediately. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing toward the patient. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system.

Question 15

During assessment of a patient, the chest tube becomes dislodged. What should the nurse do first?

a. Have an assistant apply an occlusive gauze dressing and tape on all four sides.
b. Clamp the chest tube.
c. Attempt to gently reinsert the tube.
d. Apply pressure over the insertion site.

Answer 15

ANS: D
If the chest tube becomes dislodged, immediately apply pressure over the chest tube insertion site. The nurse should first stabilize the patient to the best of his or her ability before calling the physician. Applying gauze to all four sides of an occlusive dressing would not allow for the escape of any air from the pleural space and could lead to a tension pneumothorax. Because the chest tube has become dislodged, it is outside of the body. Clamping the tube at this point would be useless. Nurses are not allowed to reinsert chest tubes. Immediately apply pressure over chest tube insertion site. Have an assistant apply gauze dressing and tape three sides. Notify the health care provider.

Question 16

What does the expected role of the nurse include during chest tube removal?

a. Prepares an occlusive dressing
b. Performs clipping of the sutures
c. Provides support and assessment of the patient
d. Removes the chest tube firmly and quickly

Answer 16

ANS: C
The nurse supports the patient physically and emotionally while the physician or an advanced practice nurse (APN) removes the dressing and clips the sutures. A physician or an APN prepares an occlusive dressing of petroleum gauze on a pressure dressing, sets it aside on a sterile field, and applies sterile gloves; removes the dressing and clips the sutures; and pulls out the chest tube.

Question 17

Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is noted when the nurse:

a. Hangs the reinfusion lower than the usual intravenous (IV) bag
b. Uses a microaggregate filter on the reinfusion bag
c. Maintains 500 mm Hg pressure in the gravity blood cuff
d. Keeps the clamps open on the drainage tubing during bag transfer

Answer 17

ANS: B
Use a new microaggregate filter to reinfuse each autotransfusion bag. Hang the bag on an IV pole and continue to prime the tubing until all air is gone. Clamp the tubing, attach it to the patient’s IV access, and adjust the clamp to deliver the reinfusion at the appropriate rate. Reinfusion is delivered by gravity or by application of a blood cuff (not to exceed 150 mm Hg pressure) or a blood-compatible IV pump. Connect the red and blue connectors on top of the initial collection bag, and remove it by lifting it from the side hook and then from the foot hook. This maintains a closed system within the bag and removes it for use in autotransfusion.

Question 18

Of the following nursing assessments, which should be reported to the primary care provider immediately by the nurse?

a. Bloody drainage from a patient with a hemothorax
b. Subcutaneous emphysema is noted on assessment
c. Bubbling in the water seal stops on a patient with a pneumothorax
d. Over 300 mL of drainage has been collected in the system in the past hour

Answer 18

ANS: D
Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if the patient has a hemothorax. Cessation of bubbling in the water seal indicates that the air has been evacuated in the patient with a pneumothorax. Although the finding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency.

Question 19

The nurse is providing care for a patient with a pneumothorax. She anticipated removal of the chest tube because of the absence of an air leak for the past _____ hours.

a. 6 to 8
b. 12 to 16
c. 18 to 24
d. 48 to 72

Answer 19

ANS: C
One of the signs that indicate that the chest tube may be removed is lack of an air leak for 24 to 48 hours. Lack of an air leak for less than 24 hours is usually not long enough, and there is no need to wait 4 days. Other findings that indicate that the chest tube may be removed include a chest x-ray showing lung reexpansion, minimal tube drainage, and lack of water-seal tidaling.

Question 20

The nurse is caring for a patient with blood collecting in the pleural space. The nurse documents this as:

a. pleural effusion.
b. hemothorax.
c. pulmonary hemorrhage.
d. pneumothorax.

Answer 20

ANS: B
A hemothorax is a collection of blood in the pleural space. A pneumothorax is the collection of air in the pleural space. A pulmonary hemorrhage is bleeding inside the lung. A pleural effusion is the collection of fluid within the pleura.

Question 21

The nurse knows that _______________ is the proper term to describe that the patient’s water seal is fluctuating up and down with each breath.

a. bubbling
b. tidaling
c. fluttering
d. alternating

Answer 21

ANS: B
The term for the fluctuation of the water-seal chamber when the patient breathes is tidaling. Bubbling is different from tidaling, because bubbling is the presence of gas moving through the chamber, whereas tidaling is an up and down movement that correlates with the patient’s breathing. Fluttering and alternating reflect incorrect terminology.

Question 22

The nurse is caring for a patient with a chest tube connected to water-seal drainage. The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)?

a. Changing the chest tube drainage system
b. Milking the chest tube
c. Measuring chest tube output
d. Turning and positioning the patient

Answer 22

ANS: D
The NAP may turn and position the patient as long as the nurse ensures that the NAP understands how to manipulate the tubing safely and what signs and symptoms should be reported immediately. Care of the chest tube, including milking the tube if ordered, measuring chest tube output, and changing the chest tube drainage system, should never be delegated to unlicensed assistive personnel.

Question 23

The patient has a chest tube for a pneumothorax. Assessment revealed no continuous bubbling in the water-seal chamber. The nurse finds no loose connections. After the chest tube near the patient is clamped, the bubbling stops. The nurse’s first action should be to:

a. apply pressure to the dressing around the chest tube insertion site.
b. move the clamp farther down the tube and note whether bubbling resumes.
c. replace the entire collection tubing and system.
d. increase suction control until bubbling does not resume when the clamp is removed.

Answer 23

ANS: A
If bubbling stops when the chest tube is clamped between the collecting system and the body, the leak is at the insertion site or inside the patient. Applying pressure to the dressing will determine which of the sites is leaking. If bubbling continues after the chest tube is clamped, the leak is below the clamp, and the next step would be to move the clamp farther away from the patient and reassess. Only if the bubbling never stops after the clamp is moved all the way down the tubing should the collection system be replaced. Turning the suction device higher will increase bubbling in the suction chamber and will not affect bubbling in the water-seal chamber.

Question 24

A pneumothorax can be caused by which of the following? (Select all that apply.)

a. Trauma
b. Rupture of a blister
c. Emphysema
d. Dyspnea

Answer 24

ANS: A, B, C
A variety of mechanisms can cause a pneumothorax. A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing or a case of the chest striking the steering wheel in an automobile accident. A spontaneous or primary pneumothorax sometimes occurs from the rupture of a small bleb (blister) on the surface of the lung or from an invasive procedure, such as insertion of a subclavian IV line. Secondary pneumothorax occurs because of underlying disease, such as emphysema. A patient with a pneumothorax usually feels pain as atmospheric air irritates the parietal pleura. Dyspnea is a symptom of pneumothorax, not a cause.

Question 25

The nurse is caring for a patient with a chest tube connected to wall suction. To keep the tube patent, the nurse should implement which of the following? (Select all that apply.)

a. Routinely “milk” the drainage tubing.
b. Avoid dependent loops of the drainage tubing.
c. Lift and clear the tube every 15 minutes.
d. Coil the drainage tubing to prevent dependent loops.

Answer 25

ANS: B, C
Chest tube milking or stripping usually is contraindicated because it does not improve catheter patency. Careful management of chest tube drainage prevents the need to milk the chest tube. Institute nursing interventions to maintain tube patency. These interventions include avoiding dependent loops of the drainage tube, or, when these loops cannot be avoided, such as when the patient is sitting, lifting and clearing the tube every 15 minutes. If the tubing is coiled, looped, or clotted, drainage is impeded, and this can result in a tension pneumothorax.

Question 26

The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage is blood-tinged. What might this indicate to the nurse? (Select all that apply.)

a. Malignancy
b. Pulmonary infarction
c. Empyema
d. Hemothorax

Answer 26

ANS: A, B
Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus-colored. Frank blood indicates a hemothorax.

Question 27

The nurse is preparing to assist the physician in removal of a chest tube. What should the nurse do to prepare the patient? (Select all that apply.)

a. Assess the patient’s need for pain medication.
b. Instruct the patient about the process.
c. Teach the patient to take a deep breath and hold it.
d. Clamp the chest tubes.

Answer 27

ANS: A, B, C
The nurse should prepare the patient for chest tube removal by (1) assessing the need for pre-removal analgesia and obtaining the required medication orders, and (2) instructing the patient about the process and what will be requested of the patient. During removal of the chest tube, it is important to instruct the patient to take a deep breath and hold it until the tube is removed. This maneuver prevents air from being sucked into the chest as the tube is pulled out and an occlusive dressing is applied. Although clamping of the chest tubes is done to determine whether the chest tube can be eliminated, this is not part of the immediate chest tube removal procedure.

Question 28

The nurse is caring for a patient who has a chest tube. Attached to the top of the patient’s bed are two shodded hemostats. In which situations would these be used? (Select all that apply.)

a. To assess an air leak
b. To quickly empty or change disposable systems
c. To quickly seal off the lungs if the system becomes disconnected
d. To assess whether the patient is ready to have the chest tube removed

Answer 28

ANS: A, B, D
Chest tubes are clamped only under the following specific circumstances, per health care provider order or nursing policy and procedure: to assess air leak, to quickly empty or change disposable systems, or to assess whether the patient is ready to have the chest tube removed (which is done by a health care provider’s order). Clamping an open system could lead to a tension pneumothorax.

Question 29

The nurse is performing an initial assessment of a patient with a chest tube placed in the eighth intercostal space. Which of the following findings would the nurse need to assess further? (Select all that apply.)

a. Respiratory rate of 18 breaths per minute
b. Continuous bubbling in the water-seal chamber
c. The presence of subcutaneous emphysema
d. Complaints of pain at the insertion site
e. Serous drainage on the chest tube dressing the size of a bean

Answer 29

ANS: B, C, D
Continuous bubbling in the water-seal chamber could indicate a leak in the system and should be assessed further. The presence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at the chest tube insertion site. Complaints of pain at the insertion site can be expected but should be fully assessed before analgesics are administered. A respiratory rate of 18 breaths per minute falls within the normal range and does not, by itself, indicate a need for further assessment. A small amount of drainage on the chest tube dressing can be expected and serous drainage would be normal; however, it should be monitored for any change in appearance.

Question 30

The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse begins her shift assessment, she should ensure that what equipment is at the bedside? (Select all that apply.)

a. Two rubber-tipped clamps
b. Plain gauze 4 × 4
c. Sterile petroleum gauze
d. Extra drainage system
e. A sterile chest tube of the same size as the one inserted in the patient

Answer 30

ANS: A, B, C, D
The nurse should ensure that two rubber-tipped clamps are at the bedside to clamp the tubing in case of emergency, as well as a plain gauze 4 × 4 and sterile petroleum gauze to make an occlusive dressing should the chest tube become dislodged, and an extra drainage system, should the current system become full. There is no need to keep a spare chest tube in most instances because it could be obtained while waiting for the primary care provider to arrive and reinsert.

Question 31

How should the nurse identify a patient before obtaining a laboratory specimen from him?

a. Use at least two patient identifiers.
b. Look at the chart before entering the room.
c. Ask the patient his name.
d. Check the patient’s armband twice.

Answer 31

ANS: A
Before obtaining a laboratory specimen, use at least two identifiers such as checking the identification number on the admission armband and asking the patient’s name. Patients who are confused or who have a language barrier may smile and not understand the question. The patient could also have the wrong armband on; checking it twice would not change that.

Question 32

When discussing the collection of a clean-voided urine specimen, it is important for the nurse to instruct the patient to:

a. use a clean specimen cup.
b. collect 100 to 150 mL of urine for testing.
c. void some urine first and then collect the sample.
d. wash the perineal area with soap and water immediately before voiding.

Answer 32

ANS: C
After the patient has initiated a urine stream, pass the urine specimen container into the stream and collect 90 to 120 mL of urine. A sterile specimen container is used. Pour antiseptic solution over cotton balls. A cotton ball or gauze is used to cleanse the perineum.

Question 33

The nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from a patient who has an indwelling catheter. The catheter was placed the night before. What must the nurse do to obtain the specimen?

a. Obtain the urine from the drainage bag.
b. Clamp the drainage tubing for 10 to 15 minutes.
c. Draw urine using a 20-mL syringe.
d. Insert the needle into the silicone catheter.

Answer 33

ANS: B
Clamp the drainage tubing with a clamp or rubber band for 30 minutes to permit collection of fresh, sterile urine in the catheter tubing rather than draining into the bag. Do not collect a urine specimen for culture tests from a urine drainage bag unless it is the first urine to drain into a new sterile bag. Draw urine into a 3-mL syringe (for culture), or draw urine into a 20 mL-syringe (for routine urinalysis). Proper volume is needed to perform the test. Do not puncture Silastic, silicone, or plastic catheters. These are not self-sealing.

Question 34

What should the nurse do first if a patient is unable to void on demand for a clean-voided specimen?

a. Perform Credé’s procedure for the suprapubic area.
b. Catheterize the patient to obtain the specimen.
c. Offer fluids, if allowed, and wait about 30 minutes.
d. Notify the physician that the test cannot be completed.

Answer 34

ANS: C
If the patient is unable to urinate on demand, offer fluids if permitted. Allow more time for urine to accumulate in the bladder. Try obtaining a specimen after 30 minutes. If the patient has no urine in the bladder, Credé’s would not be useful. The risk for infection precludes the use of catheterization simply to obtain a specimen. If the patient is unable to void after several hours, the physician may need to be called to obtain an order for catheterization.

Question 35

What must the nurse do to collect a midstream urine sample from an infant?

a. Apply a sterile plastic collection bag to the perineum.
b. Wring out diapers and collect the urine in a specimen container.
c. Have the infant sit facing the back of the toilet.
d. Catheterize the infant and collect the urine using sterile procedure.

Answer 35

ANS: A
Use a sterile plastic urine collecting bag that adheres to the perineum of a non–toilet-trained child. Special considerations for boys: Place the penis and scrotum inside the bag. Diapers may be contaminated. Seating on a toilet generally is not realistic for an infant. Catheterization should be used as a last resort only.

Question 36

What should the nurse do when a patient is required to provide a timed urine specimen?

a. Save all urine from the time the test began.
b. Leave the collection bottle on the floor near the patient’s bed.
c. Send notices along with the patient when leaving the unit to have all urine saved and returned to the unit.
d. Remove contaminants such as toilet paper from the urine before transferring it to the collection bottle.

Answer 36

ANS: C
Place signs on the patient’s door and toileting area, indicating that a timed urine specimen collection is in progress. If the patient leaves the unit for a test or procedure, be sure that personnel in that area collect and save all urine. The nurse discards the first specimen and then collects every successive specimen until the time period has ended. Place a specimen collection container in the bathroom and, if indicated, in a pan of ice. The urine specimen is not to be contaminated with feces or toilet tissue.

Question 37

What instructions does the nurse provide to the patient to obtain a double-voided urine specimen?

a. Save two separate specimens from the first voiding in the morning.
b. Add two specimens together from the morning voiding and the evening voiding.
c. Discard the first sample, then wait a half hour and void again.
d. Void first and then self-catheterize to obtain the specimens.

Answer 37

ANS: C
A fresh specimen should be used because stagnant urine that has been in the bladder for several hours will not accurately reflect the serum glucose level at the time of testing. Ask the patient to collect a random urine specimen and discard, drink a glass of water, and collect another specimen 30 to 45 minutes later.

Question 38

An appropriate procedure for urine testing with reagent strips for chemical properties of the sample is to:

a. obtain the first voided specimen in the morning.
b. immerse the test strip in the urine and remove immediately.
c. add a chemically active tablet to the urine and then test it with a reagent strip.
d. wipe the strip with a sterile gauze after dipping.

Answer 38

ANS: B
Immerse the strip briefly in the urine sample, and then remove it and tap it gently on the side of the container; prolonged exposure to excess urine can dilute reagents. Stagnant urine stored in the bladder overnight or for long periods does not reveal quantities of glucose and ketones excreted by the kidney at the time of testing. Kits that contain tablets do not also use strips; the tablet contains the reagent and changes color to indicate chemical properties of the urine. Tap the strip gently against the side of the container to shed excess urine; do not wipe it.

Question 39

A patient is concerned because her first guaiac test is positive. What information should the nurse share with the patient?

a. The patient probably has colorectal cancer.
b. The test needs to be repeated after she eats some red meat.
c. The test needs to be repeated at least 3 times.
d. The patient needs a low-residue diet to reduce intestinal abrasions.

Answer 39

ANS: C
A single positive test result does not confirm bleeding or indicate colorectal cancer. For confirmed positive results, the test must be repeated at least 3 times while the patient is on a meat-free, high-residue diet. More in-depth diagnosis is needed with a positive result.

Question 40

When teaching a patient about home testing for occult blood, the nurse instructs the patient that:

a. positive results are indicative of bleeding.
b. poultry and fish should be eaten before testing.
c. testing should be done carefully during the menstrual cycle.
d. two samples should be obtained from the same part of the stool specimen.

Answer 40

ANS: C
Specimens will be positive if contaminated by menstrual blood or hemorrhoidal blood or povidone-iodine. A single positive test result does not confirm bleeding or indicate colorectal cancer. Diets rich in meats; green, leafy vegetables; poultry; and fish may produce false-positive results. Obtain a second fecal specimen from a different portion of the stool.

Question 41

A patient asks what food may be eaten before a stool specimen is obtained for occult blood. What food should the nurse allow the patient to eat?

a. Fish
b. Apples
c. Red meats
d. Green, leafy vegetables

Answer 41

ANS: B

Diets rich in meats; green, leafy vegetables; poultry; and fish may produce false-positive results.

Question 42

The nurse evaluates that an expected outcome for analysis of gastric secretions is:

a. inability of the patient to discuss the rationale for the test.
b. negative occult blood.
c. the presence of clumps or clots.
d. the presence of brown, “coffee-ground” secretions.

Answer 42

ANS: B
An expected outcome after completion of the procedure is the test for occult blood. If frank red blood is observed or coffee-ground materials are seen, report these findings immediately. This is an unexpected finding.

Question 43

An appropriate technique for the nurse to implement when obtaining throat cultures is to:

a. have the patient lie flat in the bed.
b. do the culture before meals or an hour after meals.
c. avoid touching the swab to any of the inflamed areas.
d. place pressure on the tongue blade along the back of the tongue.

Answer 43

ANS: B
Plan to do the culture before mealtime or at least 1 hour after eating. This procedure often induces gagging; timing will decrease the patient’s chances of vomiting. Ask the patient to sit erect in bed or on a chair facing the nurse. Gently but quickly swab the tonsillar area from side to side, making contact with inflamed or purulent sites. Depress the anterior third of the tongue only; placement of a tongue blade along the back of the tongue is more likely to initiate a gag reflex.

Question 44

What step should the nurse take to obtain a vaginal specimen for a culture?

a. Apply sterile gloves.
b. Assist the patient to a side-lying position.
c. Collect discharge from the perineum on the same swab.
d. Insert the swab to 1 inch into the orifice and rotate before removal.

Answer 44

ANS: D
Gently insert the swab to 1 inch into the vaginal orifice and rotate before removal. Apply clean disposable gloves. The patient should be in dorsal recumbent position. If a discharge near the vagina appears different from the discharge along the perineum, collect separate specimens from each area.

Question 45

When using a commercially prepared tube to collect a culture, the nurse should:

a. take the swab and mix it in the reagent to check for color changes.
b. place the swab into the culture tube and then add a special reagent to the tube.
c. crush the ampule at the end of the tube and put the tip of the swab into the solution.
d. place the swab into the tube, close it securely, and keep it warm until it is sent to the laboratory.

Answer 45

ANS: C

Immediately squeeze the end of the tube to crush the ampule, and push the tip of the swab into fluid medium.

Question 46

A nurse suspects that the patient may have tuberculosis. She sends a sputum sample to the lab for testing. When the following tests are compared, which will best support the diagnosis of possible tuberculosis?

a. Acid-fast bacilli
b. General cytology
c. Chemical analysis
d. Culture and sensitivity

Answer 46

ANS: A
Sputum specimens are collected to identify cancer cells, for culture and sensitivity (C&S) to identify pathogens and determine the antibiotics to which they are sensitive, and for acid-fast bacilli to diagnose pulmonary tuberculosis. Cytological or cellular examinations of sputum may identify aberrant cells or cancer. Chemical analysis would indicate chemicals within the blood, not sputum. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms and to determine which antibiotics are most sensitive. A definitive diagnosis of TB also requires a sputum culture and sensitivity.

Question 47

The patient has come to the emergency department complaining of coughing up bloody sputum. The patient has a 30-year history of smoking and has lost 15 pounds in the last month. What will the nurse expect the sputum specimen to be evaluated for?

a. Culture and sensitivity
b. AFB
c. Cytology
d. Chemical analysis

Answer 47

ANS: C
The patient is showing signs of cancer. Sputum specimens are collected to identify cancer cells.
Sputum collected for culture and sensitivity testing is used to identify specific microorganisms. The AFB is used to support the diagnosis of tuberculosis. Chemical analysis would indicate chemicals within the blood, not sputum.

Question 48

An appropriate technique that the nurse can tell the patient to implement before obtaining a sputum specimen is to:

a. use mouthwash before the collection.
b. splint the surgical incision before coughing.
c. try to obtain a sample immediately after eating.
d. take a deep breath, cough hard, and expectorate.

Answer 48

ANS: B
If the patient has a surgical incision or localized area of discomfort, have the patient place hands firmly over the affected area, or place a pillow over the area. Splinting of painful areas minimizes muscular stretching and discomfort during coughing and thus makes cough more productive. The patient should not use mouthwash or toothpaste because it may decrease viability of microorganisms and culture results. Have the patient wait 1 to 2 hours after eating. After a series of deep breaths, ask the patient to cough after full inhalation.

Question 49

During a sputum collection, the patient becomes hypoxic. What action should the nurse take?

a. Suction the patient thoroughly.
b. Continue to complete the procedure quickly.
c. Stop the procedure and provide oxygen, if ordered.
d. Have the patient lie down and take deep breaths before continuing with the specimen collection.

Answer 49

ANS: C
If the patient becomes hypoxic, discontinue the procedure until stable and provide oxygen therapy as needed, if ordered. Suctioning can decrease usable oxygen to the patient.

Question 50

The nurse has delegated ADL care of a patient with a large wound that is draining. Which of the follow should the nurse instruct the nurse assistant to report back to her?

a. The wound has a foul odor.
b. Drainage is decreased.
c. The patient’s temperature is slightly below normal.
d. The patient does not complain of discomfort.

Answer 50

ANS: A

Report a foul odor, increased drainage, and increased temperature or complaints of discomfort.

Question 51

An appropriate technique for the nurse to use when culturing wound drainage that is suspected to contain anaerobic bacteria is to:

a. use older secretions for the specimen.
b. add exudate from the skin to the wound specimen.
c. aspirate 5 to 10 mL of exudate from a deep cavity wound.
d. swab carefully and slowly in a back-and-forth motion across the wound.

Answer 51

ANS: C
Take a swab from a special anaerobic culture tube, swab deeply into the draining body cavity, and rotate gently. Remove the swab and return it to the culture tube, or insert the tip of a syringe into the tube, and aspirate 5 to 10 mL of exudate. Cleanse the area around the wound edges with an antiseptic swab. This removes old exudate and skin flora, preventing possible contamination of the specimen. Never collect exudate from the skin unless it is a separate culture and is labeled as such.

Question 52

The patient is diagnosed with suspected bacteremia. The physician has ordered blood cultures from two different sites. The patient is complaining of chills and has an elevated temperature. What action should the nurse take in the presence of these symptoms?

a. Delay drawing the blood cultures until symptoms subside.
b. Draw blood from only one site to prevent further discomfort.
c. Draw the blood cultures as ordered.
d. Draw blood from the patient’s intravenous (IV) catheter.

Answer 52

ANS: C
Because bacteremia may be accompanied by fever and chills, blood cultures should be drawn when the patient is experiencing these clinical signs. It is important that at least two culture specimens be drawn from two different sites. Bacteremia exists when both cultures grow the infectious agent. Because blood culture specimens obtained from an IV catheter are frequently contaminated, tests that use them should not be performed unless catheter sepsis is suspected.

Question 53

When blood specimens are drawn, which of the following is true?

a. Draw cryoglobulin levels using test tubes placed on ice.
b. To test ammonia and ionized calcium levels, warm the test tubes.
c. To draw for lactic acid levels, do not use a tourniquet.
d. To draw for vitamin levels, use light to determine density.

Answer 53

ANS: C
Some specimens have special collection requirements before or after specimen collection, for example, for lactic acid levels, do not use a tourniquet. For cryoglobulin levels, use pre-warmed test tubes. For ammonia and ionized calcium levels, place the tube in ice for delivery to the laboratory. For vitamin levels, avoid exposure of the test tube to light.

Question 54

A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What should the nurse do when given this information?

a. Use pre-warmed test tubes.
b. Keep the specimen out of the light.
c. Avoid use of a tourniquet during the procedure.
d. Place the samples on ice before sending them to the lab.

Answer 54

ANS: D
Some specimens have special collection requirements before or after specimen collection. For ammonia levels, tubes must be placed on ice for delivery to the laboratory. For cryoglobulin levels, use pre-warmed test tubes. For vitamin levels, avoid exposure of the test tube to light. For lactic acid levels, do not use a tourniquet.

Question 55

The nurse is preparing to perform a venipuncture on a patient. Which of the following is an appropriate action for the nurse to take?

a. Apply the tourniquet until the distal pulse is no longer felt.
b. Remove the tourniquet after 1 minute.
c. Instruct the patient to vigorously open and close the fist.
d. Do not use veins that rebound.

Answer 55

ANS: B
Do not keep a tourniquet on the patient longer than 1 minute. Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration. Palpate the distal pulse (e.g., brachial) below the tourniquet. If the pulse is not palpable, reapply the tourniquet more loosely. Ask the patient to open and close the fist several times, finally leaving the fist clenched. Instruct the patient to avoid vigorous opening and closing of the fist. Palpate for a firm vein that rebounds; a patent, healthy vein is elastic and rebounds on palpation.

Question 56

An appropriate technique for the nurse to implement when preparing for a venipuncture is to:

a. tie the tourniquet in a knot.
b. tie the tourniquet so it can be easily removed.
c. place the tourniquet 6 to 8 inches above the selected site.
d. make the tourniquet tight enough to occlude the distal pulse.

Answer 56

ANS: B
Apply the tourniquet by encircling the extremity and pulling one end of the tourniquet tightly over the other, looping one end under the other so it can be removed by pulling the end with a single motion. Apply the tourniquet 2 to 4 inches above the venipuncture site selected. Palpate the distal pulse below the tourniquet; if the pulse is not palpable, reapply the tourniquet more loosely.

Question 57

The nurse is drawing blood from a patient to determine the blood alcohol level. Which step is an appropriate action for the nurse to take?

a. Swab the area with an antiseptic swab.
b. Swab the area with an alcohol swab.
c. Do not swab the area at all.
d. Apply the tourniquet for 5 minutes.

Answer 57

ANS: A
If drawing a sample for a blood alcohol level or blood culture, use only an antiseptic swab, not an alcohol swab. Do not keep a tourniquet on the patient longer than 1 minute.

Question 58

When performing a venipuncture, the nurse should:

a. inject with the needle at a 45-degree angle.
b. select a vein that is rigid and cordlike, and that rolls when palpated.
c. perform the needle insertion immediately after cleansing the skin with alcohol.
d. place the thumb of the nondominant hand about 1 inch below the site and pull the skin taut.

Answer 58

ANS: D
Place the thumb or forefinger of the nondominant hand 1 inch below the site and gently pull the skin taut. Stretch the skin down until the vein is stabilized. Hold a syringe and needle at a 15- to 30-degree angle from the patient’s arm with the bevel up. Palpate for a firm vein that rebounds. Do not use veins that feel rigid or cordlike; a thrombosed vein is rigid, rolls easily, and is difficult to puncture. Allowing alcohol to dry completes its antimicrobial task and reduces the “sting” of venipuncture. Alcohol left on the skin can cause hemolysis of the sample.

Question 59

When obtaining a venipuncture sample for a blood culture, the nurse should:

a. recap the needles.
b. shake the culture bottles well.
c. use two different sites to draw samples.
d. inoculate the aerobic culture bottle first.

Answer 59

ANS: C
Collect 10 to 15 mL of venous blood by venipuncture in a 20-mL syringe from each venipuncture site. Culture specimens must be obtained from two sites. Dispose of needles, syringe, and soiled equipment in the proper container. Do not cap the needles. Mix gently after inoculation. If both aerobic and anaerobic cultures are needed, inoculate the anaerobic culture first.

Question 60

When teaching about the procedure for capillary puncture, the nurse instructs a patient to:

a. hold the finger upright.
b. use the central tip of the finger.
c. allow the antiseptic to dry completely.
d. vigorously squeeze the end of the finger.

Answer 60

ANS: C
Clean the site with an antiseptic swab, and allow it to dry completely. Alcohol left on the skin can cause hemolysis of the sample. Hold the finger to be punctured in a dependent position while gently massaging the finger toward the puncture site to increase blood flow to the area before puncture. Select the lateral side of the finger; be sure to avoid the central top of the finger, which has a more dense nerve supply.

Question 61

Which of the following is the site of choice for obtaining samples for ABG?

a. Radial artery
b. Brachial artery
c. Femoral artery
d. Popliteal artery

Answer 61

ANS: A
The radial artery is the safest, most accessible site for puncture; it is superficial, is not adjacent to large veins, and usually has adequate collateral circulation by the ulnar artery. Its use is relatively painless if the periosteum is avoided, and it is used when Allen’s test is positive. The brachial artery has reasonable collateral blood flow but is less superficial, is more difficult to palpate and stabilize, and carries increased risk for venous puncture; its use results in increased discomfort. The femoral artery should not be used by nurses without specialized training. The popliteal artery usually is not used.

Question 62

An appropriate technique for the nurse to implement when obtaining an ABG specimen is to:

a. insert the needle at a 45-degree angle.
b. use a 19-gauge, 1-inch needle.
c. leave 0.5 mL of heparin in the syringe.
d. aspirate blood after the puncture.

Answer 62

ANS: A
Hold the needle bevel up, and insert the needle at a 45-degree angle into the artery. Use a 23- to 25-gauge needle. Aspirate 0.5 mL sodium heparin into a syringe, and then eject all heparin in the barrel out of the syringe. Allow arterial pulsations to pump 2 to 3 mL of blood into the heparinized syringe slowly to reduce the presence of air bubbles.

Question 63

What should the nurse do after obtaining a sample for ABG?

a. Maintain pressure over the site for 3 to 5 minutes.
b. Check the artery proximal to or above the puncture site.
c. Place the syringe into a plastic bag, and send it to the lab.
d. Apply a cool compress to hematoma formation at the puncture site.

Answer 63

ANS: A
Maintain continuous pressure on and proximal to the site for 3 to 5 minutes. Palpate the artery below or distal to the puncture site to determine whether pulse quality has changed, indicating alteration in arterial flow. Place a syringe in a cup of crushed ice. Failure to do this may result in decreased pH, arterial oxygen pressure (PaO2), and oxygen saturation. Apply warm compresses to enhance the absorption of blood.

Question 64

When collecting specimens, the nurse should: (Select all that apply.)

a. wear gloves and perform hand hygiene.
b. handle excretions discreetly.
c. explain the procedure to the patient.
d. allow patients to collect their own urine specimens.

Answer 64

ANS: A, B, C, D
When collecting specimens, wear gloves, and perform hand hygiene. Also, handle excretions discreetly. Invasive collection procedures and fear of unknown test results often cause patients anxiety. Patients who receive a clear explanation about the purpose of the specimen and how the nurse will obtain it are more cooperative. Give patients proper instruction to collect their own specimens of urine, stool, and sputum, thus avoiding embarrassment.

Question 65

When obtaining laboratory specimens, the nurse needs to be aware that: (Select all that apply.)

a. specimen collection may cause anxiety and embarrassment.
b. sociocultural variations may affect a patient’s compliance.
c. contact isolation precautions are required for collection of blood.
d. two identifiers, including room number, must be used.

Answer 65

ANS: A, B
The nurse should recognize that specimen collection may cause anxiety, embarrassment, and/or discomfort. Cultural considerations are important when collecting specimens and performing diagnostic procedures. Culture and beliefs may affect a patient’s response and willingness to participate in specimen collection. Use of a patient’s room number is not an acceptable identifier, and the nurse should follow standard precautions when collecting specimens of blood or other body fluids.

Question 66

A timed urine collection can be used for which of the following? (Select all that apply.)

a. Glucose
b. Adrenocorticosteroids
c. Bacteria count
d. Color

Answer 66

ANS: A, B
Some tests of renal function and urine composition require urine to be collected over 2 to 72 hours. The 24-hour timed collection is most common. These tests measure for elements such as amino acids, creatinine, hormones, glucose, and adrenocorticosteroids, whose levels fluctuate throughout the day. A timed urine collection also can serve as a means to measure the concentration or dilution of urine. Bacteria count and color can be determined through a routine urinalysis.

Question 67

Hemoccult testing helps to reveal blood that is visually undetectable. This test is a useful diagnostic tool for which of the following conditions? (Select all that apply.)

a. Colon cancer
b. Upper gastrointestinal (GI) ulcers
c. Localized gastric parasites
d. Large polyps

Answer 67

ANS: A, B, C, D
This test is a useful diagnostic tool for conditions such as colon cancer, upper gastrointestinal ulcers, and localized gastric parasitic infection or intestinal irritation. The amount of bleeding increases with the size of the polyp and the stage of cancer. People with small polyps (less than 1 cm in diameter) bleed scarcely more than those without polyps.

Question 68

The nurse is caring for a patient who has had a craniotomy. The patient appears to need endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.)

a. Violent coughing
b. Aspiration of stomach contents
c. Increased intracranial pressure
d. Bradycardia or tachycardia

Answer 68

ANS: A, B, C, D
Sometimes suctioning provokes violent coughing, causes vomiting and aspiration of stomach contents, and induces constriction of pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may cause hypoxemia or vagal overload, resulting in cardiopulmonary compromise and increased intracranial pressure.

Question 69

In explaining to the patient about obtaining a sputum specimen to diagnose tuberculosis, the nurse explains which of the following? (Select all that apply.)

a. Specimens are best obtained in the early morning.
b. Acid-fast bacilli (AFB) smears require three consecutive morning samples.
c. Bacteria accumulate as secretions pool.
d. Specimens should be obtained at bedtime.

Answer 69

ANS: A, B, C
Specimens for AFB require three consecutive morning samples, and cultures can take up to 8 weeks. The ideal time to collect sputum is early morning because bronchial secretions tend to accumulate during the night. Bacteria also accumulate as secretions pool.

Question 70

Assessment of the chemical properties of urine is done by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The _____________ of the strip or tablet indicates the presence of any of unique chemical properties.

Answer 70

ANS:
change in color
You assess the chemical properties of urine by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The change in color of the strip or tablet indicates the presence of glucose, ketones, protein, and blood as well as pH of the urine.

Question 71

A common test performed on fecal material is the ________ test for fecal occult blood.

Answer 71

ANS:
guaiac
A common test performed on fecal material is the guaiac test for fecal occult blood.

Question 72

______________ is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.

Answer 72

ANS:
Suctioning
Suctioning is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.

Question 73

Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify _______________.

Answer 73

ANS:
wound infection
Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify wound infection.

Question 74

_______________ organisms grow in superficial wounds exposed to the air.

Answer 74

ANS:
Aerobic
Aerobic organisms grow in superficial wounds exposed to the air.

Question 75

The least traumatic method of obtaining a blood specimen is known as __________.

Answer 75

ANS:
skin puncture
capillary puncture
Skin puncture, also called capillary puncture, is the least traumatic method of obtaining a blood specimen.