ATI RN MEDICAL SURGICAL EXAM QUESTIONS AND ANSWERS /MEDICAL SURGICAL RN ATI EXAM |LATEST VERSION ALREADY GRADED A+

A nurse is caring for a client who is to have his chest tube removed. Which fo the following actions should the nurse take? - Cover the insertion site with a hydrocolloid dressing after removal. - Provide pain medication immediately after removal. - Instruct the client to perform the Valsalva maneuver during removal. - Delegate removal of the chest tube to a licensed practical nurse (LPN). -ANS- Instruct the client to perform the Valsalva maneuver during removal. The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space. A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? - Provide oxygen. - Place the client in a side-lying position. - Provide privacy. - Lower the client to the floor. -ANS- Lower the client to the floor. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury.