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 is the first action when continuous bubbling is observed 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 system
D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the first action should be to tighten the connections of the chest tube system. This step is crucial as it can often resolve an air leak causing continuous bubbling. Clamping the chest tube or replacing the chest tube system would not address the underlying issue of loose connections and may not be necessary. Continuing to monitor the chest tube without taking corrective action may lead to complications if the air leak is not addressed promptly.

3. What are the dietary recommendations for a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bedtime
C. Consume liquids with meals
D. Avoid NSAIDs

Correct answer: A

Rationale: The correct answer is to avoid mint and spicy foods for a patient with GERD. These foods can increase gastric acid secretion and worsen symptoms of GERD. Choice B is incorrect because eating large meals before bedtime can exacerbate GERD symptoms due to increased gastric pressure when lying down. Choice C is also incorrect as consuming liquids with meals can lead to increased gastric distention, potentially triggering GERD symptoms. Choice D, avoiding NSAIDs, though important for some patients with GERD due to their potential to irritate the stomach lining, is not a general dietary recommendation for all GERD patients.

4. What are the common manifestations of a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and confusion
D. Seizures and convulsions

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. A thrombotic stroke is characterized by a gradual onset of symptoms due to interrupted blood flow in the brain. This interruption results in manifestations such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache, confusion, seizures, and convulsions are more commonly associated with conditions other than thrombotic strokes.

5. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

A. Axillary temperature 37.2°C (99°F)
B. Apical pulse 100/min
C. Respiratory rate 30/min
D. Blood pressure 140/84 mm Hg

Correct answer: C

Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.