a nurse is caring for a client who has a pneumothorax and is being treated with a chest tube which of the following findings indicates that the lung h

ATI RN

ATI Exit Exam

1. A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

A. There is no fluctuation in the water seal chamber.
B. There is continuous bubbling in the suction control chamber.
C. There is tidaling in the water seal chamber.
D. The drainage system is positioned at the level of the client's chest.

Correct answer: A

Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.

2. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

A. Provide reality orientation throughout the day.
B. Limit the client's choices to prevent decision fatigue.
C. Encourage the client to participate in group therapy.
D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

3. What is the initial intervention for a patient with chest pain?

A. Administer aspirin
B. Administer nitroglycerin
C. Provide pain relief
D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

4. A healthcare professional is reviewing the laboratory results of a client who is receiving chemotherapy. Which of the following findings should the healthcare professional report immediately?

A. White blood cell count of 4,500/mmÂ³
B. Hemoglobin level of 8 g/dL
C. Platelet count of 90,000/mmÂ³
D. Serum potassium level of 3.5 mEq/L

Correct answer: C

Rationale: A platelet count of 90,000/mmÂ³ indicates thrombocytopenia, which increases the risk of bleeding and requires immediate intervention. Thrombocytopenia can lead to serious bleeding complications, so it is crucial to address this finding promptly. A low white blood cell count (choice A) may indicate neutropenia but is not as immediately life-threatening as severe thrombocytopenia. A hemoglobin level of 8 g/dL (choice B) would require intervention but is not as urgent as addressing a critically low platelet count. A serum potassium level of 3.5 mEq/L (choice D) is on the lower side of normal but does not pose an immediate risk to the client's safety compared to severe thrombocytopenia.

5. Which electrolyte imbalance is most concerning in a patient taking digoxin?

A. Monitor potassium levels
B. Monitor calcium levels
C. Monitor sodium levels
D. Monitor magnesium levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Patients taking digoxin are at risk of developing toxicity due to hypokalemia. Low potassium levels can potentiate the toxic effects of digoxin on the heart, leading to serious arrhythmias. Monitoring calcium levels (Choice B) is not the primary concern in patients taking digoxin. While calcium levels play a role in cardiac function, hypocalcemia is not directly associated with digoxin toxicity. Monitoring sodium levels (Choice C) is important for other conditions but is not the primary concern in a patient taking digoxin. Monitoring magnesium levels (Choice D) is also essential, but hypomagnesemia is not as directly linked to digoxin toxicity as hypokalemia.