The nurse is caring for a client with a chest tube following a thoracotomy. Which finding requires immediate intervention by the nurse?

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ATI Vital Signs Test 58 Questions Quizlet Questions

Question 1 of 5

The nurse is caring for a client with a chest tube following a thoracotomy. Which finding requires immediate intervention by the nurse?

Correct Answer: A

Rationale: Continuous bubbling in the water seal chamber (A) indicates an air leak, requiring immediate intervention. Fluctuation (B) is normal, 50 mL/hour drainage (C) is acceptable, and no crepitus (D) is expected.

Question 2 of 5

Which nursing actions are appropriate when caring for a client with dementia? Select one that apply..

Correct Answer: A

Rationale: Reorienting the client (A) is appropriate. Correcting the client about hallucinations (C) can cause distress and is not helpful.

Question 3 of 5

With which clients is the nurse especially vigilant in actions to prevent infection? Select one that apply..

Correct Answer: B

Rationale: Chemotherapy (B) increase infection risk due to immunosuppression or chronic illness. Fractures (A) no flu vaccine (C) and allergies (D) are lower risk.

Question 4 of 5

What is the normal pulse rate of a newborn infant?

Correct Answer: A

Rationale: The normal pulse rate for a newborn is 100-150 beats per minute as their heart rate is faster than adults due to higher metabolic demands. Options B C and D are more typical for older children or adults.

Question 5 of 5

Of all the physiological needs

Correct Answer: D

Rationale: Oxygen is the most essential need as humans can survive only minutes without it per Maslow's hierarchy. Food (A) water (B) and elimination (C) are important but less immediately critical.

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