the nurse is caring for a client with a chest tube following a thoracotomy which assessment finding requires immediate intervention the nurse is caring for a client with a chest tube following a thoracotomy which assessment finding requires immediate intervention
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which requires immediate intervention to prevent complications such as pneumothorax. An air leak can lead to ineffective lung expansion, respiratory distress, and compromised gas exchange. Therefore, prompt action is necessary to maintain the integrity of the closed drainage system and prevent further complications. Choices B, C, and D are incorrect because serosanguineous drainage is an expected finding post-thoracotomy, intermittent bubbling in the suction control chamber is normal, and having the chest tube secured to the client's chest wall is essential for stability and proper functioning.

2. A client with a new diagnosis of type 2 diabetes mellitus inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information?

Correct answer: D

Rationale: The correct answer is D: American Diabetes Association. The American Diabetes Association is a reputable source that provides credible information on managing diabetes. While family members can offer support, they may not have the specialized knowledge on oral antidiabetic agents. Pharmacists are knowledgeable about medications but may not provide comprehensive information on diabetes management. Dietitians can offer valuable advice on nutrition but may not cover specific details about oral antidiabetic agents. Therefore, referring the client to the American Diabetes Association ensures access to accurate and detailed information related to their condition.

3. A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

4. Major nutrients supplied by foods in the Vegetables group of MyPlate include:

Correct answer: A

Rationale: The correct answer is A: potassium and vitamin A. Vegetables are an excellent source of potassium and vitamin A, both essential for maintaining overall health. Iron and vitamin C (choice B) are commonly found in foods from the Protein and Fruits groups, respectively. Calcium and vitamin B12 (choice C) are more abundant in dairy products and animal-based foods. Sodium and vitamin E (choice D) are not the major nutrients typically supplied by vegetables.

5. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

Correct answer: A

Rationale: The correct answer is A: Yankauer catheter. The Yankauer catheter is specifically designed for oral suctioning, making it the most appropriate choice for this task. Choice B, the Bulb syringe, is typically used for suctioning small amounts of liquid from the nose or mouth. Choice C, the Suction catheter, is more commonly used for deep suctioning in the trachea or bronchi. Choice D, Sterile gloves, are necessary for infection control but are not the primary supply used for oral suctioning.

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