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ATI PN Comprehensive Predictor 2023 Quizlet
1. What is the priority for the nurse when caring for a patient with a chest tube?
- A. Ensure tube patency and observe for air leaks
- B. Maintain sterile technique during dressing changes
- C. Monitor drainage and record output
- D. Observe for signs of infection and monitor for subcutaneous emphysema
Correct answer: A
Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.
2. How should a healthcare professional assess and manage a patient with ascites?
- A. Monitor abdominal girth and administer diuretics
- B. Administer pain relief and monitor fluid intake
- C. Restrict fluid intake and encourage bed rest
- D. Administer albumin and check electrolyte levels
Correct answer: A
Rationale: Correct! When managing a patient with ascites, monitoring abdominal girth is crucial as it helps assess the extent of fluid retention. Administering diuretics is also essential to help reduce fluid buildup in the body, thereby managing ascites effectively. Option B is incorrect as pain relief is not the primary intervention for ascites. Option C is incorrect as restricting fluid intake can worsen the condition by causing dehydration and further fluid imbalances. Option D is incorrect as administering albumin and checking electrolyte levels are not first-line interventions for managing ascites; these interventions may be considered in specific cases but are not the initial steps in managing ascites.
3. How should a healthcare professional care for a patient with a central venous catheter?
- A. Monitor for infection and change the dressing regularly
- B. Ensure the catheter is patent and flush as needed
- C. Educate the patient on self-care and proper hygiene
- D. Monitor blood glucose levels and administer IV fluids
Correct answer: A
Rationale: Corrected Rationale: Regular monitoring for infection and dressing changes are essential aspects of caring for a patient with a central venous catheter. Infections are a significant risk with these catheters, so vigilant monitoring and timely dressing changes help prevent complications. Choice B is important too, but ensuring catheter patency and flushing are more focused on maintaining the functionality of the catheter rather than infection prevention. Choice C is also important for patient education, but the immediate concern for a healthcare professional is monitoring and preventing infections related to the catheter. Choice D is not directly related to the care of a central venous catheter.
4. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?
- A. Assess for bladder distention after 2 hours
- B. Encourage the client to try urinating in a sitting position
- C. Pour warm water over the client's perineum
- D. Restrict the client's fluid intake
Correct answer: C
Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.
5. What is the most important intervention when managing a client with delirium?
- A. Administer a sedative to reduce agitation
- B. Identify any reversible causes of delirium
- C. Increase environmental stimulation
- D. Limit noise and provide a calm environment
Correct answer: B
Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.
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