a nurse is caring for a patient admitted with an air leak in a chest tube system what action should the nurse take

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 does continuous bubbling in the chest tube water seal chamber indicate?

A. An air leak
B. Normal chest tube function
C. A blocked chest tube
D. Continuous drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This occurs when air is entering the system from the outside, preventing the lung from fully re-expanding. Choice B is incorrect because continuous bubbling is not a sign of normal chest tube function. Choice C is incorrect because a blocked chest tube would typically exhibit no bubbling or fluctuation in the water seal chamber. Choice D is incorrect as continuous drainage would not cause bubbling in the water seal chamber.

3. What are the expected signs in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Fever and infection
C. Localized redness and swelling
D. Loss of sensation in the affected area

Correct answer: A

Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.

4. What dietary modifications are recommended for a patient with pre-dialysis kidney disease?

A. Limit phosphorus intake to 700 mg/day
B. Increase sodium intake to 3 g/day
C. Restrict protein intake to 0.55-0.60 g/kg/day
D. Eat three large meals per day

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. Patients with pre-dialysis kidney disease should limit phosphorus intake to prevent further kidney damage. Excessive phosphorus can lead to mineral and bone disorders. Choice B is incorrect because increasing sodium intake is not recommended in pre-dialysis kidney disease. Choice C is incorrect as protein restriction is a common recommendation in advanced kidney disease, not pre-dialysis. Choice D is incorrect as eating three large meals per day is not a specific dietary modification for pre-dialysis kidney disease.

5. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?

A. Monitor blood glucose levels
B. Monitor for respiratory distress
C. Monitor for hypertension
D. Monitor for hyperkalemia

Correct answer: A

Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.