a nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x ray department which of
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ATI Detailed Answer Key Medical Surgical

1. A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

2. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

3. A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?

Correct answer: C

Rationale: Following a thoracentesis, it is crucial for healthcare professionals to monitor for potential complications. Increased heart rate can indicate hypovolemia or other serious issues, such as bleeding or pneumothorax, and requires immediate attention to prevent further complications. Serosanguineous drainage from the puncture site is a common expected finding post-procedure. Discomfort at the puncture site is also common and can be managed with appropriate interventions. Decreased temperature is not typically associated with complications following a thoracentesis. Therefore, the correct answer is increased heart rate as it signifies a potential serious complication that needs prompt medical evaluation.

4. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?

Correct answer: B

Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.

5. A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?

Correct answer: C

Rationale: Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.

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