ATI RN
ATI Fundamentals
1. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?
- A. Encourage the client to cough every 2 hours.
- B. Check for continuous bubbling in the suction chamber.
- C. Strip the drainage tubing every 4 hours.
- D. Obtain a chest x-ray
Correct answer: C
Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.
2. A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?
- A. Oxygen
- B. Sterile water
- C. Enclosed hemostat clamps
- D. Indwelling urinary catheter
Correct answer: D
Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.
3. A healthcare provider is caring for a client following a thoracentesis. Which of the following manifestations should the healthcare provider NOT recognize as risks for complications?
- A. Dyspnea
- B. Localized bloody drainage on the dressing
- C. Fever
- D. Hypotension
Correct answer: B
Rationale: After a thoracentesis, some expected complications include dyspnea, fever, and hypotension. Localized bloody drainage on the dressing is a common and expected finding post-thoracentesis due to the procedure's nature of puncturing the chest wall. Therefore, the healthcare provider should not consider this finding as a risk for complications.
4. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?
- A. Obtain a chest x-ray
- B. Apply sterile gauze to the insertion site
- C. Place tape around the insertion site
- D. Assess respiratory status
Correct answer: B
Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.
5. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?
- A. Assist-control
- B. Synchronized intermittent mandatory ventilation
- C. Continuous positive airway pressure
- D. Pressure support ventilation
Correct answer: A
Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.
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