a nurse is planning care for a client following the insertion of a chest tube and drainage system which of the following should not be included in the

ATI RN

ATI Fundamentals

1. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?

A. Encourage the client to cough every 2 hours.
B. Check for continuous bubbling in the suction chamber.
C. Strip the drainage tubing every 4 hours.
D. Obtain a chest x-ray

Correct answer: C

Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.

2. Which of the following is not a cause of tachycardia?

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

3. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

4. During a client's first hospitalization, which of the following actions ensures the safety of the client?

A. Keep unnecessary furniture out of the way
B. Keep the lights on at all times
C. Keep side rails up at all times
D. Keep all equipment out of view

Correct answer: A

Rationale: During a client's first hospitalization, it is essential to keep unnecessary furniture out of the way to prevent obstacles and ensure a safe environment. This action helps reduce the risk of accidents or falls, promoting the client's safety and well-being. Keeping the lights on at all times may not be necessary and can disrupt the client's rest. Keeping side rails up at all times can restrict the client's movement and independence unnecessarily. Keeping all equipment out of view may hinder the healthcare team's ability to monitor and access necessary tools for providing care.

5. What is the primary goal of performing a bed bath?

A. To cleanse, refresh, and provide comfort to the client who must remain in bed
B. To expose the necessary parts of the body
C. To develop skills in bed bath
D. To check the body temperature of the client in bed

Correct answer: A

Rationale: The primary goal of performing a bed bath is to cleanse, refresh, and provide comfort to clients who are unable to leave their bed. This helps maintain their hygiene, promotes skin health, and enhances their overall well-being. Choice B is incorrect as the primary purpose is not to expose body parts but to provide hygiene and comfort. Choice C is incorrect as the main goal is client care, not skill development. Choice D is incorrect as checking body temperature is not the main purpose of a bed bath.