A community health nurse is preparing to administer a Mantoux skin test.

The nurse selects which syringe to administer

AR: B A Mantoux test is a skin test to determine exposure to tuberculosis. The nurse uses a tuberculin or a small hypodermic syringe for skin testing. 2. A nurse caring for a client with pneumothorax and who has had chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?

a. Do nothing, because this is an expected finding

b. Immediately clamp the chest tube and notify the physician

c. Check for an air leak because the bubbling should be intermittent

d. Increase the suction pressure so that the bubbling becomes vigorous.

AR: A Continuous gentle bubbling should be noted in the suction control chamber. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).

3. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate. a. Inform the physician b. Continue to monitor the client c. Reinforce the occlusive dressing d. Encourage the client to deep-breathe. AR: B The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent look exists, if the suction is not working properly, or if the lung has reexpanded. 4. A nurse is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Occasional pink-tinged sputum b. A few basilar lung crackles on the right c. Respiratory rate of 24 breaths/min d. Stridor AR: D The nurse reports stridor to the physician immediately. This is a highpitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. The prime danger after removal of an artificial airway is the clients ability to maintain a patent airway and breathe independently. 5. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? a. Face tent b. Aerosol mask

c. Venturi mask d. Trachaeostomy collar AR: C The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration.