the nurse is caring for a client with a chest tube which assessment finding requires immediate intervention
Logo

Nursing Elites

ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

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

Correct answer: C

Rationale: Crepitus (subcutaneous emphysema) around the insertion site can indicate air leakage, requiring immediate intervention to prevent complications such as pneumothorax. This assessment finding suggests that there may be a break in the chest tube system, leading to air entering the pleural space. Prompt intervention is crucial to prevent respiratory compromise and further complications.

2. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?

Correct answer: D

Rationale: The correct answer is D: Hyperglycemia. Risperidone (Risperdal) can lead to metabolic side effects, such as hyperglycemia, which requires monitoring. Choice A, Hypertension, is incorrect because risperidone is not typically associated with hypertension. Choice B, Weight loss, is less common with risperidone use as it can lead to weight gain. Choice C, Hyperactivity, is not a common side effect of risperidone; instead, it is more known for sedative effects.

3. The nurse is administering sevelamer (RenaGel) during lunch to a client with end-stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?

Correct answer: B

Rationale: Sevelamer (RenaGel) binds with phosphorus in foods to prevent its absorption, which is why it should be taken with meals. By taking RenaGel with meals, it can effectively bind with phosphorus from food, reducing the amount of phosphorus absorbed by the body, thus helping to manage hyperphosphatemia in clients with ESRD. Choices A, C, and D are incorrect because RenaGel's primary action is to bind with phosphorus in foods, not related to preventing indigestion, promoting stomach emptying, or buffering hydrochloric acid.

4. An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer?

Correct answer: B

Rationale: In this scenario, the immediate need is to provide passive immunity to the adolescent patient. Gamma globulin contains antibodies against hepatitis B, which can offer immediate protection. The hepatitis B vaccine provides active immunity over time but is not immediate. Fresh frozen plasma and corticosteroids are not indicated for immediate protection against hepatitis B infection. Therefore, the correct choice is Gamma globulin as it can provide immediate passive immunity against hepatitis B.

5. A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?

Correct answer: A

Rationale: The priority nursing action for a patient with type 1 diabetes mellitus admitted with diabetic ketoacidosis (DKA) is to administer regular insulin intravenously. Insulin helps to lower blood glucose levels and correct acidosis, which are critical in managing DKA. Administering oral hypoglycemic agents is not appropriate in the acute setting of DKA as they may not work quickly enough compared to intravenous insulin. While sodium bicarbonate may be used to correct acidosis, insulin administration is the priority to address both hyperglycemia and acidosis simultaneously. Providing a high-calorie diet is not suitable initially in DKA management; the main focus is on stabilizing the patient's condition through insulin therapy and fluid/electrolyte correction.

Similar Questions

When assessing a client with a chest tube connected to suction, which observation indicates that the chest tube is functioning properly?
A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?
The healthcare provider is caring for a client with Guillain-Barré syndrome. Which assessment finding requires the healthcare provider's immediate action?
A client with a history of asthma is prescribed salmeterol (Serevent). Which instruction should the nurse provide?
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses