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 client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?

Correct answer: D

Rationale: Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.

3. A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: In hypertension management, it is crucial for clients to limit or avoid alcohol consumption, not just refrain from excess. Alcohol can raise blood pressure and interfere with the effectiveness of antihypertensive medications, making it a key lifestyle modification for individuals with hypertension.

4. A client has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: Atelectasis is a condition where the alveoli in the lungs collapse, leading to impaired gas exchange. As a result, the client may experience increasing dyspnea (difficulty breathing) due to the decreased lung capacity for oxygen exchange. Facial flushing, decreasing respiratory rate, and friction rub are not typically associated with atelectasis.

5. What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?

Correct answer: B

Rationale: The correct answer is B. A nurse should ask the client if they have any chronic breathing problems when the anteroposterior (AP) chest diameter is the same as the lateral chest diameter. This finding indicates a barrel chest, which can be associated with chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) or emphysema. Assessing for chronic breathing problems can help the nurse further evaluate the client's respiratory status and provide appropriate care.

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