a nurse is caring for a client who has a chest tube and drainage system in place the nurse observes that the chest tube was accidentally removed which
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Nursing Elites

ATI RN

ATI Fundamentals

1. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?

Correct answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

2. Parenteral penicillin can be administered as an:

Correct answer: A

Rationale: Penicillin can be administered intramuscularly or intravenously.

3. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

Correct answer: C

Rationale: Immobility, diaphoresis, and avoidance of deep breathing or coughing are common signs of pain.

4. A client requests the creation of a living will. Which of the following actions should the nurse take?

Correct answer: B

Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.

5. A client with depression reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

Correct answer: A

Rationale: When St. John's wort, an herbal supplement, is taken with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of serotonin syndrome. Serotonin syndrome is a serious condition that can occur when there is an excess of serotonin in the body, leading to symptoms such as confusion, hallucinations, rapid heart rate, increased body temperature, and more. Monitoring for serotonin syndrome is crucial when these substances are taken together to prevent any potential harm to the client.

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