a nurse is caring for a client who has a chest tube and drainage system in place the nurse observes that the chest tube was accidentally removed which

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ATI Fundamentals

1. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?

A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess respiratory status

Correct answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

2. 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.

3. What is the most common injury among elderly persons?

A. Atherosclerotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

Correct answer: D

Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.

4. When preparing to administer eye drops to a school-age child, what actions should a nurse take?

A. 52341
B. 53241
C. 35241
D. 14325

Correct answer: A

Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.

5. A client reports that the medication the nurse is administering appears different than what they take at home. Which of the following responses should the nurse take?

A. Did the doctor discuss with you that there was a change in this medication?
B. I recommend that you take this medication as prescribed
C. Do you know why this medication is being prescribed to you?
D. I will call the pharmacist now to check on this medication

Correct answer: A

Rationale: When a client reports that the medication appears different than what they take at home, it is crucial for the nurse to ensure the safety and accuracy of the medication being administered. The most appropriate action for the nurse to take in this situation is to call the pharmacist to verify the medication, dosage, and any potential changes. This proactive step helps prevent medication errors and ensures the client's safety and well-being.