a nurse is assessing a client who has a chest tube and drainage system in place which of the following is an expected finding

ATI RN

ATI Fundamentals

1. During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Drainage system positioned upright at chest level
D. Exposed sutures without dressing

Correct answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

2. A client requests the creation of a living will. Which of the following actions should the nurse take?

A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client's understanding of life-sustaining measures.
C. Determine the client's preferences about post-mortem care.
D. Request a conference with the client's family

Correct answer: B

Rationale: When a client requests the creation of a living will, the nurse's priority is to evaluate the client's understanding of life-sustaining measures. This involves ensuring that the client comprehends the implications of various life-sustaining interventions and can make informed decisions about their care preferences in the event they are unable to communicate them later. It is crucial for the nurse to assess the client's comprehension to ensure that the living will accurately reflects the client's wishes and values.

3. What is the appropriate needle size for insulin injection?

A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long

Correct answer: D

Rationale: The appropriate needle size for insulin injection is 25G, 5/8” long. This size allows for accurate and comfortable insulin administration in subcutaneous tissue.

4. What is the most common psychogenic disorder among elderly individuals?

A. Depression
B. Sleep disturbances (e.g., bizarre dreams)
C. Inability to concentrate
D. Decreased appetite

Correct answer: A

Rationale: Depression is the most common psychogenic disorder among elderly individuals. It can manifest as persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyed. Elderly individuals may also experience changes in appetite, sleep disturbances, and difficulty concentrating. Detecting and addressing depression in the elderly is crucial for their overall well-being and quality of life.

5. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

A. High platelets
B. Hypertension
C. Lower platelets
D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.