a nurse assesses a client who has a mediastinal chest tube which symptoms require the nurses immediate intervention select all that apply
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

2. A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

Correct answer: C

Rationale: Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.

3. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?

Correct answer: A

Rationale: In chronic obstructive pulmonary disease (COPD), clients often develop a barrel chest, characterized by an increased anterior-posterior diameter of the chest due to hyperinflation of the lungs. This change in chest shape is a common finding in COPD. Decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typical findings associated with COPD.

4. Prior to a thoracentesis, what intervention should the nurse complete?

Correct answer: D

Rationale: Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.

5. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

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