a nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right sided pneumothorax the client complains of chest
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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 wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?

Correct answer: D

Rationale: When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.

2. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct answer: A

Rationale: In a closed chest drainage system, slow, steady bubbling in the suction control chamber is an expected finding, indicating proper functioning of the system. There is no immediate need for intervention as this indicates the system is working as intended. The nurse should continue to monitor the client's respiratory status for any signs of distress or changes. Checking tubing connections for leaks or clamping the chest tube are unnecessary actions based on the information provided. Checking the suction control outlet on the wall is also not indicated in this scenario.

3. A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?

Correct answer: C

Rationale: Following a thoracentesis, it is crucial for healthcare professionals to monitor for potential complications. Increased heart rate can indicate hypovolemia or other serious issues, such as bleeding or pneumothorax, and requires immediate attention to prevent further complications. Serosanguineous drainage from the puncture site is a common expected finding post-procedure. Discomfort at the puncture site is also common and can be managed with appropriate interventions. Decreased temperature is not typically associated with complications following a thoracentesis. Therefore, the correct answer is increased heart rate as it signifies a potential serious complication that needs prompt medical evaluation.

4. A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?

Correct answer: C

Rationale: Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.

5. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

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