a nurse is assessing a client who has a chest tube following a thoracotomy which of the following findings requires intervention by the nurse
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ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

Correct answer: C

Rationale: The correct answer is C. There should be 2 cm of water in the water seal chamber of the chest tube system. A level of 1 cm may indicate a leak or compromised functionality that requires intervention. Choices A, B, and D are not findings that necessarily require immediate intervention. Tidaling with spontaneous respirations is an expected finding, the drainage collection chamber being 1/3 full is within normal limits, and a suction chamber pressure of -20 cm H2O indicates appropriate suction for chest drainage.

2. A client who has a new prescription for simvastatin is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Grapefruit juice can increase the risk of toxicity with simvastatin, so clients should avoid consuming it while on the medication. Choice A is incorrect because the timing of medication administration should be based on healthcare provider instructions. Choice C is incorrect because simvastatin is prescribed to lower cholesterol levels. Choice D is incorrect as monitoring kidney function is not specifically related to simvastatin therapy.

3. A client with burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals with burn injuries. Support groups can provide emotional support, promote acceptance of altered appearance, and help the client cope with the changes. Choice A is incorrect because it may not address the client's emotional needs. Choice B is incorrect as suggesting a timeline for cosmetic surgery may not be appropriate without considering the client's physical and emotional readiness. Choice C is incorrect as reconstructive surgery may not completely restore the client's previous appearance and may set unrealistic expectations.

4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure?

Correct answer: A

Rationale: The correct answer is A, Propofol. Propofol is a short-acting anesthetic medication commonly used to induce moderate sedation for procedures like a colonoscopy. This medication provides rapid onset and recovery, making it an ideal choice for such procedures. Choice B, Pancuronium, is a neuromuscular blocking agent used for muscle relaxation during surgery and would not be appropriate for sedation during a colonoscopy. Choice C, Promethazine, is an antihistamine used for nausea and motion sickness, not for anesthesia. Choice D, Pentoxifylline, is a medication used to improve blood flow in patients with circulation problems and is not indicated for anesthesia during a colonoscopy.

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