a nurse is assessing a client who has a pneumothorax with a chest tube in place for which of the following findings should the nurse notify the provid
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Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?

Correct answer: A

Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.

2. A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

Correct answer: D

Rationale:

3. The healthcare provider is caring for a client who has heart failure and a history of asthma. The provider reviews the orders and recognizes that clarification is needed for which of the following medications?

Correct answer: B

Rationale: The correct answer is Fluticasone. Carvedilol, Captopril, and Isosorbide dinitrate are commonly used in heart failure management and do not typically pose significant risks for clients with a history of asthma. However, Fluticasone is a corticosteroid used to manage asthma but can potentially worsen heart failure symptoms due to its anti-inflammatory effects. Therefore, the nurse should seek clarification regarding the prescription of Fluticasone for a client with heart failure and a history of asthma.

4. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Correct answer: B

Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.

5. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Correct answer: D

Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.

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