what is the nurses priority when caring for a patient with a chest tube
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 Quizlet

1. What is the priority for the nurse when caring for a patient with a chest tube?

Correct answer: A

Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.

2. What intervention is key when managing a client with delirium?

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

3. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?

Correct answer: D

Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.

4. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

Correct answer: A

Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.

5. What is the most appropriate safety measure for a client using home oxygen?

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright at all times. This is important to prevent the tanks from falling over, which can lead to injuries or tank damage. Choice A is incorrect because oxygen tanks should not be stored in a closet when not in use, as this can lead to poor ventilation and potential hazards. Choice C is incorrect because smoking near oxygen tanks poses a significant fire risk. Choice D is incorrect because while it is important to keep oxygen equipment away from heat sources, ensuring the tanks are kept upright is a more critical safety measure.

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