ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. A patient is admitted with an air leak in a chest tube system. What action should the nurse take?
- A. Tighten the connections of the chest tube system
- B. Continue monitoring the patient
- C. Replace the chest tube system
- D. Clamp the chest tube
Correct answer: A
Rationale: When caring for a patient with an air leak in the chest tube system, the nurse should tighten the connections of the chest tube system. This action can help resolve the air leak by ensuring there are no loose connections or leaks in the system. Continuing to monitor the patient (Choice B) is important, but addressing the air leak is a priority. Replacing the chest tube system (Choice C) may not be necessary if tightening the connections resolves the issue. Clamping the chest tube (Choice D) is not appropriate as it can lead to tension pneumothorax.
2. What is the initial nursing action for a patient with chest pain and acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Check the patient's urine output
- C. Check cardiac enzymes
- D. Obtain IV access
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority initial action for a patient with chest pain and acute coronary syndrome. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart muscle and reducing chest pain. Checking the patient's urine output (choice B) and cardiac enzymes (choice C) are important assessments but are not the first priority when managing acute chest pain. Obtaining IV access (choice D) is essential for administering medications and fluids, but administering sublingual nitroglycerin takes precedence in the initial management of chest pain in acute coronary syndrome.
3. What should the nurse do when continuous bubbling is seen in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Replace the chest tube
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.
4. A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?
- A. Gentle bubbling in the suction chamber
- B. Crepitus around the insertion site
- C. Constant bubbling in the water seal chamber
- D. Absence of breath sounds on the right side
Correct answer: A
Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.
5. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
- A. The dressing was changed 7 days ago
- B. The circumference of the client's upper arm has increased by 10%
- C. The catheter has not been used in 8 hours
- D. The catheter has been flushed with 10 mL of sterile saline after medication use
Correct answer: B
Rationale: An increase in the circumference of the client's upper arm by 10% could indicate deep vein thrombosis, which is a serious condition. Deep vein thrombosis can impede blood flow and potentially lead to life-threatening complications. Therefore, the nurse should notify the provider immediately about this finding. Choice A is not an immediate concern as PICC dressing changes are usually done every 7 days. Choice C is a normal finding as catheters may not be used for certain periods. Choice D is a correct procedure for maintaining catheter patency after medication use.
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