a nurse is assessing a client who has a chest tube and drainage system in place which of the following is an expected finding

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ATI Fundamentals

1. During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Drainage system positioned upright at chest level
D. Exposed sutures without dressing

Correct answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

2. How many milliliters are equal to 20 cc?

A. 2
B. 20
C. 2000
D. 20000

Correct answer: B

Rationale: 1 cc (cubic centimeter) is equal to 1 ml. Therefore, 20 cc is equal to 20 ml. To convert between cubic centimeters (cc) and milliliters (ml), the values are equivalent since they both measure volume in the metric system. Choice A (2) is incorrect as it does not account for the direct conversion between cc and ml. Choice C (2000) and choice D (20000) are incorrect as they represent conversions based on a misunderstanding of the relationship between cc and ml.

3. A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

A. Prime IV tubing with 0.9% sodium chloride
B. Use a 24-gauge IV catheter
C. Obtain filterless IV tubing
D. Place blood in the warmer for 1 hr

Correct answer: A

Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.

4. A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

A. Platelet count
B. Potassium level
C. Creatinine clearance
D. Prealbumin

Correct answer: A

Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.

5. Which of the following is not a cause of tachycardia?

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.