a student nurse is providing tracheostomy care what action by the student requires intervention by the instructor
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?

Correct answer: C

Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.

2. The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

Correct answer: A

Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.

3. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

4. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

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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