a nurse is reviewing the prescriptions for a client who has a pneumothorax which of the following actions should the nurse perform first
Logo

Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam Quizlet

1. When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?

Correct answer: B

Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.

2. When providing mouth care to an unconscious client, what is the best position for the client?

Correct answer: B

Rationale: The best position for an unconscious client when providing mouth care is the side-lying position. This position helps prevent aspiration by allowing fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure. The other options are not ideal for mouth care in an unconscious client: Fowler’s position may increase the risk of aspiration, the supine position can lead to aspiration as well, and Trendelenburg position is not recommended due to potential adverse effects on blood circulation and increased intracranial pressure.

3. What is the initial technique used when examining a client's abdomen?

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

4. 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?

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.

5. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?

Correct answer: C

Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.

Similar Questions

Which of the following patients is at greater risk for contracting an infection?
When preparing an in-service on malpractice issues in nursing, which of the following examples should the nurse include in the teaching?
Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?
If a patient's blood pressure is 150/96, what is his pulse pressure?
Which of the following blood tests should be performed before a blood transfusion?

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