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. While reviewing the laboratory results of a group of clients, which infection should the nurse in a provider's office report?

Correct answer: D

Rationale: Chlamydia is a sexually transmitted infection that requires notification and intervention due to its public health implications and potential complications if left untreated. Reporting Chlamydia is crucial to initiate appropriate treatment, prevent further spread of the infection, and provide necessary counseling to affected individuals. While other infections like herpes simplex, human papillomavirus, and candidiasis are also significant, Chlamydia is particularly important to report in this context.

3. While teaching a newly hired nurse about varicella, a nurse in a pediatric clinic should include which of the following information?

Correct answer: A

Rationale: Children with varicella (chickenpox) are contagious until all vesicles are crusted over. The contagious period starts 1-2 days before the rash appears and continues until all lesions are dried and crusted. It is important to educate healthcare providers about the contagious period to prevent the spread of the virus to susceptible individuals.

4. What is the most common cause of dementia among elderly persons?

Correct answer: D

Rationale: Alzheimer’s disease is the most common cause of dementia among elderly persons. It is a progressive neurodegenerative disorder that affects memory, thinking, and behavior. While Parkinson’s disease, multiple sclerosis, and amyotrophic lateral sclerosis are serious conditions, they are not typically associated with dementia in the same way Alzheimer’s disease is. Therefore, the correct answer is D.

5. Which type of illness is characterized by severe symptoms of relatively short duration?

Correct answer: B

Rationale: The correct answer is B: Acute Illness. Acute illnesses are characterized by the sudden onset of severe symptoms that typically last for a short duration. These conditions usually resolve within a defined period, unlike chronic illnesses that persist over a longer time frame. Choices C and D, Pain and Syndrome, are not specific types of illnesses but rather symptoms or clinical manifestations that can occur in various health conditions.

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