a nurse is assisting a provider with the removal of a chest tube which of the following should the nurse instruct the client to do

ATI RN

ATI Fundamentals

1. During the removal of a chest tube, what should the nurse instruct the client to do?

A. Lie on their left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

2. A client has diaper dermatitis. Which of the following actions should the nurse take?

A. Apply zinc oxide ointment to the irritated area.
B. Wipe stool from the skin using store-bought baby wipes.
C. Apply talcum powder to the irritated area.
D. None of the above

Correct answer: A

Rationale: Diaper dermatitis, also known as diaper rash, is a common condition in babies or clients who wear diapers. The primary intervention for diaper dermatitis is to apply a protective barrier cream, such as zinc oxide ointment, to the irritated area. This helps to protect the skin from irritants and promotes healing. Wiping stool from the skin using baby wipes may further irritate the skin, and talcum powder is no longer recommended due to potential respiratory risks when inhaled. Therefore, the correct action for the nurse in this scenario is to apply zinc oxide ointment to the irritated area.

3. What is the abbreviation for micro drop?

A. µgtt
B. gtt
C. mdr
D. mgts

Correct answer: A

Rationale: The correct abbreviation for micro drop is 'µgtt,' where the symbol 'µ' represents micro and 'gtt' stands for drop. Choice B, 'gtt,' is the abbreviation for drop, not specifically for micro drop. Choice C, 'mdr,' and Choice D, 'mgts,' are not standard abbreviations for micro drop and are incorrect.

4. What is required for effective hand washing?

A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above

Correct answer: A

Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.

5. For a rectal examination, the patient can be directed to assume which of the following positions?

A. Genupectoral
B. Sims
C. Horizontal recumbent
D. All of the above

Correct answer: B

Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.