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 healthcare provider is caring for a client following a thoracentesis. Which of the following manifestations should the healthcare provider NOT recognize as risks for complications?

A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension

Correct answer: B

Rationale: After a thoracentesis, some expected complications include dyspnea, fever, and hypotension. Localized bloody drainage on the dressing is a common and expected finding post-thoracentesis due to the procedure's nature of puncturing the chest wall. Therefore, the healthcare provider should not consider this finding as a risk for complications.

3. What is the primary purpose of handwashing?

A. To promote hand circulation
B. To prevent the transfer of microorganisms
C. To avoid touching the client with a dirty hand
D. To provide comfort

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.

4. Which of the following patients is at greatest risk for developing pressure ulcers?

A. An alert chronic arthritic patient treated with steroids and aspirin
B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed

Correct answer: B

Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.

5. 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.