a nurse is caring for a client who has a chest tube which of the following actions should the nurse take
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. What action should the healthcare provider take for a patient with a chest tube?

Correct answer: D

Rationale: Ensuring the water seal chamber is filled to the prescribed level is essential for the chest tube's effective functioning. This maintains the integrity of the system, prevents air from entering the pleural space, and facilitates proper drainage. Stripping the drainage tubing, keeping the drainage system below the chest level, or clamping the chest tube during ambulation are not recommended practices and can lead to complications.

2. During postoperative teaching following a hip arthroplasty, which instruction should the nurse include?

Correct answer: C

Rationale: The correct instruction for the nurse to include during postoperative teaching following a hip arthroplasty is to 'Place a pillow between your legs when turning.' Placing a pillow between the legs when turning is crucial as it helps prevent dislocation of the hip prosthesis. This position aids in maintaining proper alignment and stability, thereby reducing the risk of complications after hip arthroplasty surgery. Choices A, B, and D are incorrect because they do not directly address the specific action needed to protect the hip prosthesis and prevent complications.

3. When providing teaching to a client with a new prescription for digoxin, which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for a client with a new prescription for digoxin is to take their pulse before taking the medication. Digoxin can lead to bradycardia as a side effect, and monitoring the pulse helps in assessing the heart rate prior to medication administration. This precaution allows for the identification of any significant changes in heart rate that may require medical attention.

4. A client has tuberculosis, and the nurse is planning care. Which of the following isolation precautions should the nurse implement?

Correct answer: C

Rationale: The correct answer is C: Airborne. Tuberculosis is transmitted through the air, making it an airborne disease. Airborne precautions are crucial to prevent the spread of tuberculosis to others. These precautions include placing the client in a negative pressure room, wearing an N95 respirator mask, and ensuring proper ventilation to minimize the risk of transmission to healthcare workers and other clients. Choice A, Protective environment, is used for clients with compromised immune systems. Choice B, Contact precautions, are used for diseases spread by direct or indirect contact. Choice D, Droplet precautions, are for diseases transmitted through respiratory droplets, like influenza or pertussis.

5. A healthcare professional is assessing a client who has fluid volume overload. Which of the following findings should the healthcare professional expect?

Correct answer: C

Rationale: Crackles in the lungs are a classic sign of fluid volume overload. When there is an excess of fluid in the lungs, it can manifest as crackling sounds upon auscultation. This finding indicates the accumulation of fluid in the alveoli and interstitial spaces of the lungs, which is a common manifestation of fluid volume overload.

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