a nurse is planning care for a client who has a chest tube which of the following interventions should the nurse include
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A client has a chest tube. Which of the following interventions should the nurse include?

Correct answer: B

Rationale: Maintaining the chest tube drainage system below the client's chest level is crucial to ensure proper drainage and prevent complications. Clamping the chest tube can lead to a tension pneumothorax, stripping the chest tube is an outdated practice that can cause damage to the tissues, and keeping the collection device at the level of the client's chest can impede proper drainage and lead to fluid accumulation.

2. A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.

3. A client is 24 hours postoperative following a right-sided mastectomy. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: Elevating the client's right arm on a pillow is essential post-mastectomy to reduce swelling and promote circulation. Placing the client in the supine position may not be comfortable or ideal after a mastectomy. Encouraging the client to lift objects with the right arm can strain the surgical site and hinder healing. Measuring the client's blood pressure on the right arm should be avoided to prevent disruption to the area and inaccurate readings.

4. A nurse is planning assignments for a licensed practical nurse (LPN) during a staffing shortage. Which client should be delegated to the LPN?

Correct answer: C

Rationale: The correct answer is C because the client postoperative following a bowel resection with an NG tube set to continuous suction requires routine postoperative care, which an LPN can manage. Choice A involves administering blood products, which typically requires assessment and monitoring by a registered nurse. Choice B indicates a potentially serious neurological condition that requires assessment by a higher-level provider. Choice D suggests a client experiencing respiratory distress, which requires immediate assessment and intervention by a registered nurse or physician.

5. A nurse is reviewing the medical record of a client who has a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L is below the normal range, indicating hypokalemia. Before administering potassium chloride, which is used to treat low potassium levels, the nurse should report this finding to the provider for further evaluation and potential adjustment of the treatment plan. Choices A, B, and D are within normal ranges and do not directly relate to the need for potassium chloride administration.

Similar Questions

A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider recommend?
A client is 2 hours postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?
A client is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?
A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect?
A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses