ATI Detailed Answer Key Student Success.N4581 Airway. Chest Tube Mgmt

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 nurse take? Continue to monitor the client’s respiratory status. Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client’s respiratory status. A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/84 mmHg place him in which of the following categories? Prehypertension -A blood pressure of 124/84 mm Hg places this client in the prehypertension category. Prehypertension is indicated by a systolic pressure between 120 and 130 mm Hg and a diastolic pressure between 80- and 89-mm Hg. A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first? open the client's airway using a jaw-thrust maneuver - to protect the clients cervical spine. A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? Obtain an EKG. (The nurse should obtain an EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort.) !!! -Administer enteric-coated acetaminophen. (The nurse should administer a non-enteric coated aspirin to allow for more rapid absorption of the antiplatelet medication. Acetaminophen does not have antiplatelet properties.) -Administer ibuprofen. (The nurse should administer morphine IV to provide rapid pain relief. Decreasing the client's pain level will increase oxygen supply and decrease myocardial demands for oxygen.) -Maintain oxygen saturations greater than or equal to 92%. (The nurse should administer oxygen therapy as needed to maintain oxygen saturations greater than or equal to 95% to increase myocardial oxygen supply.) A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increases intracranial pressure (ICP) as indicated by which of the following findings? Elevated temperature. Fever, sometimes accompanied by chills, is a manifestation of bacterial infection. A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? Epinephrine. The priority action the nurse should take when using the airway, breathin