a nurse is caring for a client post surgery with a chest tube what is the most important assessment
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Nursing Elites

ATI LPN

PN ATI Comprehensive Predictor

1. A client post-surgery has a chest tube. What is the most important assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the chest tube is functioning properly. This is crucial post-surgery to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube, positioning the client, or encouraging coughing are not appropriate assessments for a client with a chest tube post-surgery and could lead to serious issues if done incorrectly.

2. What are the complications of untreated deep vein thrombosis (DVT)?

Correct answer: A

Rationale: Corrected Rationale: Untreated DVT can lead to complications such as pulmonary embolism and stroke. Pulmonary embolism occurs when a blood clot from the leg travels to the lungs, potentially blocking blood flow and causing respiratory distress. Stroke can occur if a blood clot dislodges from the leg veins, travels to the brain, and obstructs a blood vessel, leading to brain tissue damage. Both of these complications are life-threatening if not managed promptly. The other choices (B, C, D) do not represent common complications of untreated DVT and are therefore incorrect.

3. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

4. What are the side effects of chemotherapy, and how should they be managed?

Correct answer: A

Rationale: The correct side effects of chemotherapy mentioned in this question are nausea and vomiting. These side effects are commonly managed with antiemetics to improve the quality of life for patients undergoing chemotherapy. Choice B (Hair loss and anemia) is incorrect as hair loss and anemia are potential side effects of chemotherapy but are not addressed in this question. Choice C (Diarrhea and fatigue) is also incorrect as it does not match the side effects provided. Choice D (Weight gain and high blood pressure) is inaccurate as these are not typical side effects of chemotherapy.

5. When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?

Correct answer: B

Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.

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