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: Strip the drainage tubing every 4 hours.

Rationale: Stripping the drainage tubing is an outdated practice and can cause complications.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. A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

A. Non-rebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask

Correct answer: B: Venturi mask

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

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

A. Dehydration is treated with calcium supplements.
B. Dehydration can increase the risk of preterm labor.
C. Dehydration is associated with gastroesophageal reflux.
D. Dehydration is caused by decreased hemoglobin and hematocrit.

Correct answer: Dehydration can increase the risk of preterm labor.

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.

4. What is the most common injury among elderly persons?

A. Atherosclerotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

Correct answer: D

Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.

5. Which of the following procedures always requires surgical asepsis?

A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation

Correct answer: B

Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.