what intervention is needed for a patient with a chest tube and an air leak

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What intervention is needed for a patient with a chest tube and an air leak?

A. Tighten the connections of the chest tube system
B. Replace the chest tube
C. Clamp the chest tube
D. Continue to monitor the chest tube

Correct answer: A

Rationale: The correct intervention for a patient with a chest tube and an air leak is to tighten the connections of the chest tube system. This step helps prevent air leaks and ensures the proper functioning of the chest tube. Choice B, replacing the chest tube, is not necessary as tightening the connections should be attempted first. Clamping the chest tube (Choice C) is not recommended as it can lead to complications by obstructing the drainage system. Continuing to monitor the chest tube (Choice D) without taking action may result in worsening of the air leak. Therefore, the priority intervention is to tighten the connections of the chest tube system.

2. A patient is admitted with an air leak in a chest tube system. What action should the nurse take?

A. Tighten the connections of the chest tube system
B. Continue monitoring the patient
C. Replace the chest tube system
D. Clamp the chest tube

Correct answer: A

Rationale: When caring for a patient with an air leak in the chest tube system, the nurse should tighten the connections of the chest tube system. This action can help resolve the air leak by ensuring there are no loose connections or leaks in the system. Continuing to monitor the patient (Choice B) is important, but addressing the air leak is a priority. Replacing the chest tube system (Choice C) may not be necessary if tightening the connections resolves the issue. Clamping the chest tube (Choice D) is not appropriate as it can lead to tension pneumothorax.

3. What dietary recommendations are given to a patient with pre-dialysis end-stage kidney disease?

A. Reduce phosphorus intake to 700 mg/day
B. Increase sodium intake
C. Restrict protein intake to 0.55-0.60 g/kg/day
D. Increase protein intake

Correct answer: A

Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. Excessive phosphorus intake can be harmful to individuals with kidney disease as their kidneys may not be able to excrete it efficiently. Choice B is incorrect because increasing sodium intake is generally not recommended for patients with kidney disease, as it can contribute to fluid retention and high blood pressure. Choice C is incorrect as protein restriction is commonly advised for individuals with advanced kidney disease to reduce the workload on the kidneys. Choice D is also incorrect as increasing protein intake can further burden the kidneys.

4. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

A. Place several pillows behind the client's head
B. Place the client in a Sim's position
C. Keep the client's neck in a midline position
D. Maintain flexion of the client's hips at a 90° angle

Correct answer: C

Rationale: Keeping the client's neck in a midline position is crucial for managing increased intracranial pressure. This position helps optimize blood flow and minimizes the risk of further increasing ICP. Placing several pillows behind the client's head (Choice A) may inadvertently elevate the head, potentially worsening ICP. Placing the client in a Sim's position (Choice B) or maintaining flexion of the client's hips at a 90° angle (Choice D) are not directly related to managing increased ICP.

5. What are the expected ECG changes in hypokalemia?

A. Flattened T waves
B. ST elevation
C. Wide QRS complex
D. Tall T waves

Correct answer: A

Rationale: Flattened T waves are the most common ECG change seen in patients with hypokalemia. Hypokalemia leads to a decrease in serum potassium levels, affecting the repolarization phase of the cardiac action potential. This results in T wave flattening or inversion. ST elevation is typically seen in conditions like myocardial infarction, not in hypokalemia. Wide QRS complex is more associated with hyperkalemia than hypokalemia. Tall T waves are often seen in hyperkalemia, not hypokalemia.