a nurse is assessing a client who has a pneumothorax with a chest tube in place for which of the following findings should the nurse notify the provid
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Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?

Correct answer: A

Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.

2. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

Correct answer: B

Rationale: The client joining a book club that meets outside the home and requires him or her to go out in public is the best indicator that goals for Impaired Self-Esteem are being met. This social activity indicates an improvement in self-confidence and willingness to engage with others, which are essential aspects of self-esteem. The other choices, while positive, do not directly address self-esteem concerns related to social interaction and confidence.

3. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

Correct answer: C

Rationale:

4. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

5. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

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