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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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?

A. Encourage the client to cough every 2 hours.
B. Check for continuous bubbling in the suction chamber.
C. Strip the drainage tubing every 4 hours.
D. Obtain a chest x-ray

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Rationale: Stripping the drainage tubing is an outdated practice and can cause complications.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. After routine patient contact, how long should hand washing last at least?

A. 30 seconds
B. 1 minute
C. 2 minutes
D. 3 minutes

Correct answer: A

Rationale: Proper hand washing for 30 seconds is recommended after routine patient contact as it effectively removes pathogens. This duration ensures thorough cleaning without excessive time consumption, promoting infection control and prevention.

3. In which of the following organs does the exchange of gases take place?

A. Kidneys
B. Lungs
C. Liver
D. Heart

Correct answer: B

Rationale: The exchange of gases, specifically oxygen and carbon dioxide, occurs in the lungs. In the lungs, oxygen from the air we breathe enters the bloodstream, while carbon dioxide is removed from the bloodstream and exhaled. This process is essential for respiration and supplying the body with oxygen for energy production. The kidneys filter waste from the blood to produce urine and regulate fluid balance (Choice A). The liver is involved in detoxification, protein synthesis, and producing bile (Choice C). The heart is responsible for pumping blood throughout the body to deliver oxygen and nutrients (Choice D).

4. The client was asked to read the Snellen chart. Which of the following is being tested?

A. Optic
B. Olfactory
C. Oculomotor
D. Trochlear

Correct answer: A

Rationale: The correct answer is A: Optic. The Snellen chart is used to test visual acuity, which assesses the function of the optic nerve responsible for vision. Choices B, C, and D are incorrect. Olfactory relates to the sense of smell, oculomotor controls eye movement, and trochlear controls certain eye muscles. Therefore, the only option related to vision testing in this context is the optic nerve.

5. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.