a nurse is caring for a client who has a chest tube which of the following findings should the nurse report to the provider
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: Continuous bubbling in the water seal chamber should be reported to the provider as it can indicate an air leak. This finding suggests that air is escaping from the pleural space, which can lead to lung collapse or pneumothorax. Drainage of 75 mL in the past 24 hours is within the expected range for a client with a chest tube and is not a cause for concern. Intermittent bubbling in the water seal chamber is a normal finding that indicates the system is functioning properly. Tidaling in the water seal chamber is also an expected finding that shows the fluctuation of fluid with the client's breathing and is not alarming.

2. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?

Correct answer: B

Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.

3. A nurse is caring for a client who is at risk for pressure ulcers. Which of the following interventions should the nurse implement?

Correct answer: A

Rationale: The correct intervention for preventing pressure ulcers in a client at risk is to turn the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and preventing tissue damage. Using a donut-shaped cushion can actually increase pressure on the skin and worsen the risk of pressure ulcers. Elevating the head of the bed to 45 degrees is beneficial for preventing aspiration in some cases but does not directly address pressure ulcer prevention. Massaging reddened areas can further damage the skin and increase the risk of pressure ulcer development by causing friction and shearing forces.

4. A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'You may experience a persistent cough while taking this medication.' Lisinopril is known to cause a persistent cough as a common side effect. It is essential for the nurse to educate the client about this potential side effect, as it should be reported to the healthcare provider. Choice A is incorrect because lisinopril is usually taken once daily, but not necessarily at bedtime. Choice C is incorrect because lisinopril can actually increase potassium levels, so taking it with a potassium supplement may lead to hyperkalemia. Choice D is incorrect because antacids may reduce the effectiveness of lisinopril, so it should not be taken with them.

5. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?

Correct answer: D

Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.

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