how should a nurse manage a patient with a chest tube

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. How should a healthcare professional manage a patient with a chest tube?

A. Ensuring the chest tube is secured properly and functioning
B. Checking for air leaks and ensuring drainage is working
C. Ensuring chest tube drainage is below chest level
D. Ensuring proper documentation of chest tube output

Correct answer: D

Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.

2. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?

A. Taking two medications ensures a faster recovery.
B. The medications work best together to improve your immune system.
C. Taking the 2 medications together keeps you from becoming resistant to either of them.
D. These medications target different parts of the virus.

Correct answer: C

Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.

3. Which patient should the nurse see first?

A. A 1-month-old infant looking at a shiny, round battery just out of arm's reach.
B. A 56-year-old patient with oxygen and a lighter on the bedside table.
C. A 56-year-old patient with oxygen using an electric razor for grooming.
D. A bedridden patient who has a reddened area on the buttocks and needs to be turned.

Correct answer: B

Rationale: The correct answer is B because the patient with oxygen and a lighter on the bedside table is at immediate risk of fire. Oxygen promotes combustion, and having a lighter nearby poses a serious safety hazard. This situation requires urgent attention to prevent a potential disaster. Choices A, C, and D do not present immediate life-threatening risks compared to the patient with oxygen and a lighter nearby.

4. While reviewing notes from a previous shift, a nurse finds incomplete documentation. What is the most appropriate action?

A. Complete the missing documentation
B. Notify the nurse manager of the issue
C. Ask the nurse to complete the documentation
D. Confront the nurse about the incomplete notes

Correct answer: B

Rationale: The most appropriate action when finding incomplete documentation is to notify the nurse manager of the issue. This ensures that accurate records are maintained and the situation can be addressed properly. Completing the missing documentation on behalf of someone else may lead to inaccuracies, asking the nurse to complete it may not guarantee timely correction, and confronting the nurse could create a confrontational situation that is not conducive to effective teamwork.

5. Which intervention is most effective in preventing postoperative complications?

A. Encourage the patient to drink fluids.
B. Ambulate the patient as soon as possible.
C. Perform deep breathing exercises with the patient.
D. Encourage the patient to perform range of motion exercises.

Correct answer: B

Rationale: The most effective intervention in preventing postoperative complications is to ambulate the patient as soon as possible. Early ambulation helps prevent complications like deep vein thrombosis and pneumonia by enhancing circulation and preventing respiratory issues. Encouraging the patient to drink fluids, perform deep breathing exercises, or range of motion exercises are beneficial interventions, but ambulation is the priority due to its overall impact on preventing various postoperative complications.