a nurse is planning care for a client following the insertion of a chest tube and drainage system which of the following should not be included in the
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Nursing Elites

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ATI Fundamentals

1. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?

Correct answer: C

Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.

2. Which of the following interventions promotes patient safety?

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

3. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

Correct answer: D

Rationale: Leukocytosis is defined as an increase in the total white blood cell count. A normal WBC count typically ranges from 4,500 to 10,000/mm³. A WBC count of 25,000/mm³, as indicated in choice D, is significantly higher than the normal range and clearly indicates leukocytosis.

4. A client is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct answer: B

Rationale: Dehydration can lead to an imbalance in electrolytes and cause uterine irritability, potentially leading to preterm contractions. It is essential for the nurse to educate the client on the importance of adequate hydration to reduce the risk of preterm labor. The statement 'Dehydration can increase the risk of preterm labor' directly addresses the client's condition and provides relevant information for their understanding and management of the situation.

5. During discharge teaching, a client informs the nurse about a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching?

Correct answer: C

Rationale: Taking prednisone with meals can help reduce the risk of gastrointestinal upset and irritation. It is important for the client to understand how to take the medication correctly to maximize its effectiveness and minimize potential side effects. Monitoring for weight loss or changes in stools may be important but does not directly relate to the administration of the medication with meals.

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