a nurse is caring for a client who has a chest tube in place to a closed chest drainage system which of the following findings should indicate to the
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

2. A client with tuberculosis is starting medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.

3. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

4. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?

Correct answer: C

Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.

5. Prior to a cardiac catheterization, what is the most important action for the nurse to take?

Correct answer: D

Rationale: Assessing the client for allergies, particularly to iodine or shellfish, is crucial before a cardiac catheterization because the contrast dye used during the procedure can lead to allergic reactions. Identifying any allergies beforehand allows the healthcare team to take necessary precautions to prevent potential adverse reactions and ensure the client's safety.

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