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ATI Detailed Answer Key Student Success.N4581 Airway. Chest Tube Mgmt A+ LATEST 2023 R185,97   Add to cart
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ATI Detailed Answer Key Student Success.N4581 Airway. Chest Tube Mgmt A+ LATEST 2023
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ATI Detailed Answer Key Student Success.N4581 Airway. Chest Tube Mgmt A+ LATEST 2023 1. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the n...

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  • October 16, 2023
  • 31
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

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  • ati nursing education
  • 2023
  • ati detailed
  • n4581 airway
  • ssatipracticeassessmentanswerkeyforairwayctmgmt
  • ati detailed answer key student successn4581 airwa

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NURS 258 FINAL

NURS 258 FINAL
A nurse is observing the closed chest drainage system of a client who is 24 hours post
thoracotomy. Thenurse notes slow, steady bubbling in the suction control chamber. What action
should the nurse take?
- Continue to monitor the client’s respiratory status
- (slow steady bubbling in the suction control chamber is an expected finding)


A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of
the prostate (TURP). The nurse notes that the patients indwelling catheter has not drained in the
past hour.What action would the nurse take first?
- Check the tubing for kinks
- (Use the least restrictive intervention first)


A nurse in monitoring a client who was admitted with a severe burn injury and is receiving IV
fluid resuscitation therapy. The nurse should identify a decrease in which of the following
findings as an indication of adequate fluid replacement?
- Heart rate
- (When a clients circulating fluid volume is low, the heart rate increases to maintain
adequate blood pressure. Therefore the nurse should identify a decrease in heart rate
as in indication ofadequate fluid replacement.


A nurse in caring for a client who has cancer and a new prescription for odansetron tp treat
chemotherapyinduced nausea. Which of the following adverse effects should the nurse monitor?
- Headache
- (This is a common adverse effect of this medication)


A nurse is caring for a client who has active pulmonary TB and is to be started on intravenous
rifampin therapy. The nurse should instruct the client that this medication can cause which of the
following adverse effects?
- Body secretions turning a red orange color
- (Rifampin is used in combination with other medicines to treat TB. Rifampin will cause
the urine,stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-
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, NURS 258 FINAL
brown.)


A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a
fractured tibia.Which of the following is the priority action for the nurse to take?
- Perform a neurovascular assessment
- (The greatest risk to the client is neurovascular injury. Therefore, the priority action is to
perform aneurovascular assessment. This consists of assessing the involved extremity
(the lower leg) at the most distal point (the foot) for circulation (color), motion
(movement), and sensation, and can be remembered by the acronym "C-M-S check.")


A nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy. The client
reports a tingling sensation in the hands, the soles of the feet and around the lips. For which of the
following should the nurse assess the client?
- Chvostek’s sign
- The nurse should suspect that the client has hypocalcemia, a possible complication
following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness
and tingling in the hands, the soles of the feet, and around the lips, typically appearing
between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the
client's face at a point just below and in front of the ear. A positive response would be
twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular
excitability due to hypocalcemia.


A nurse is caring for a client who was admitted with bleeding esophageal varices and has a
esophagogastric balloon Tamponade with sengstaken-blakeore tube to control the bleeding. What
action should the nurse take?
- Provide frequent oral and nares care
- A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the
client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If
the client is not alert, gentle suctioning of the oral cavity and nares might be required to
remove secretions.




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, NURS 258 FINAL

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of
clear drainage coming from the client’s right nostril. Which of the following actions should the
nurse take first?
- Test the drainage for glucose
- This is the priority nursing action. Because of the high risk of cerebral spinal fluid
(CSF) leak in clients with basal skull fractures, the nurse should realize there is a
possibility that the clear fluid coming from the client's nostril is CSF, which will test
positive for glucose.


A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several
treatments, the client reports fatigue. Which of the following actions should the nurse take?
- Check the results of the clients most recent CBC
- The client might have anemia as a result of myelosuppression (bone marrow
suppression) from the chemotherapy. If so, she might require treatment for the anemia
(transfusion, medication) andthe provider might have to delay further chemotherapy until
her blood counts are higher.


A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client
asks the nurse several questions about what the provider might be planning to do. Which of the
following nursingresponses should the nurse make?
- Encourage the client to write down questions to ask the provider.
- The nurse does not know the answers to the client's questions, so helping the client to
preparequestions for the provider addresses the client's needs.


A nurse is teaching the partner of a client who had an acute MI about the reason blood was
drawn from the client. Which of the following statements should the nurse make regarding
cardiac enzyme studies?
- Test tests help to determine the degree of damage to the heart tissues
- Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the
degree of damage to the myocardium. The enzymes most commonly measured are CPK
and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may


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, NURS 258 FINAL

take 4 hr or more after the onset of manifestations for the test to become abnormal and up
to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal.
Consequently, serial blood tests must be taken from the client to document and evaluate
enzyme levels.


A nurse is caring for a client who has returned from the surgical suite following surgery for a
fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture.
Which of the followingactions is the priority for the nurse to take?
- Prevent aspiration
- When using the airway, breathing, circulation approach to client care, the nurse should
determinethat the priority goal is to prevent the client from aspirating. Because the
client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the client
should be given medication for nausea, and wire cutters should be kept at the bedside in
case of vomiting.


A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous
IV. Theclient asks the nurse how long it will take for the heparin to dissolve a clot. Which of
the following responses should the nurse give?
- Heparin does not dissolve a clot is prevents new ones from forming
- This statement accurately answers the client's question.


A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the
followingmanifestations should the nurse monitor?
- Weakness
- Generalized weakness of the diaphragmatic and intercostal muscles may produce
respiratorydistress or predispose the client to respiratory infections.


A nurse is assessing a client who has fluid overload. Which of the following findings should the
nurseexpect?
- increased heart rate
- increased blood pressure
- Increased RR
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