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. What is the most appropriate action for handling hazardous drugs?

A. Wear gloves and wash hands after handling.
B. Store the drugs according to manufacturer instructions.
C. Discard unused drugs in regular trash.
D. Wear personal protective equipment (PPE) when handling hazardous drugs.

Correct answer: D

Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.

3. What is an appropriate parenting technique for time-out disciplining in children with mental health issues?

A. Provide positive reinforcement for minor infractions
B. Remove all privileges for at least one week following a violation
C. Limit the child's time outside of the home environment
D. Time-out should only be used in severe situations

Correct answer: B

Rationale: The correct answer is B: 'Remove all privileges for at least one week following a violation.' When dealing with children with mental health issues, it is essential to have consistent consequences for their actions. Providing positive reinforcement for minor infractions (choice A) may not effectively address inappropriate behaviors that require disciplinary action. Limiting the child's time outside the home environment (choice C) does not directly address the behavioral issue. Using time-out only in severe situations (choice D) may not provide consistent consequences for the child's behavior and can lead to escalation before interventions are used.

4. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

A. Hold the cane with your left hand
B. Move the cane forward 18 inches with each step
C. When walking, move your left foot forward first
D. Keep your elbow straight when you hold the cane

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

5. A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?

A. The client has a do-not-resuscitate order.
B. The client has a continuous IV of lactated Ringer's.
C. The client was straight catheterized for 350 mL 2 hours ago.
D. The client has Medicare insurance.

Correct answer: A

Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.