Adv. Nursing Skills Exam 2 ATI Questions with Latest Update
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Course
Advanced RN math ability
Institution
Advanced RN Math Ability
A nurse is planning education for a patient who has a chest tube in place attached to a closed-chest drainage system following surgery for lung cancer. Which of the following should the nurse emphasize to the patient when he is ready to ambulate freely? - Answer-Keep the collection device upright a...
Adv. Nursing Skills Exam 2 ATI
Questions with Latest Update
A nurse is planning education for a patient who has a chest tube in place attached to a
closed-chest drainage system following surgery for lung cancer. Which of the following
should the nurse emphasize to the patient when he is ready to ambulate freely? -
Answer-Keep the collection device upright at all times
*The closed-chest drainage system must be upright at all times to ensure that the tubing
drains optimally and the system functions correctly.
A patient who sustained trauma from a motor vehicle crash is transported to an
emergency department. The provider determines the need for immediate central venous
access for fluid and blood replacement and prophylactic antibiotic therapy. The
appropriate central venous access device of this patient is: - Answer-a non tunneled
percutaneous central catheter.
A nurse is performing a nasogastric intubation. Which of the following actions should the
nurse take immediately after inserting the tube to the predetermined length?
A) Inspect the oropharynx with a penlight and a tongue blade
B) Obtain an x-ray examination of the chest and abdomen
C) Tape the tube securely in place with a tube holder device
D) Aspirate Gastric contents - Answer-A) Inspect the oropharynx with a penlight and a
tongue blade
To prevent a common complication of continuous enteral tube feedings, a nurse should
- Answer-limit the time the formula hangs to 4 hours
A type of protein the immune system produces to neutralize a threat of some kind, such
as an incompatible substance in the blood, is called an: - Answer-antibody
A nurse is caring for a patient who has a chest tube in place attached to water-seal
drainage. Which of the following abservations about the drainage should be reported if
found 5 hr after insertion? - Answer-About 150 mL/hr over the past 2 hr
*After the first fer hours, the nurse should report drainage that exceeds 70 mL/hr.
Patients who lose as much as 100 mL of blood every 15 min might require
autotransfusion within 6 hr.
You started a transfusion of packed RBC about 1 hour ago. Your patient has suddenly
developed shaking chills, muscle stiffness, and a temperature of 101.4 F (38.6 C). He
appears flushed and reports a headache and "nervousness." Your patient has most
likely developed which type of transfusion reaction? - Answer-febrile nonhemolytic
, A nurse is preparing to obtain a blood sample from a patient who has a triple lumen
central catheter in place for multiple therapies. Which of the following is an appropriate
action for the nurse to take? - Answer-turn off the distal infusions for 1 to 5 minutes
before obtaining the blood sample.
A nurse is caring for a patient who has a nasogastric tube connected to suction. Which
of the following should indicate to the nurse that the tube has become occluded?
A) active bowel sounds
B) passing flatus
C) Increase gastric secretions
D) Patient's report of nausea - Answer-Patient's report of nausea (Tubes connected to
suction decompress the GI tract. This is needed when peristalsis is absent. If gastric
secretions are unable to move through the GI tract and if the nasogastric tube is unable
to evacuate the stomach due to an occlusion, nausea and vomiting will result.)
A nurse inserting a nasogastric tube asks the pt to flex her head toward her check after
the tube passes through the nasopharynx. The action facilitates proper insertion of the
tube by - Answer-closing off the glottis
During report, a nurse is informed that a patient has a nasogastric tube connected to
continuous suction. The nurse should recognize that this patient must have which of the
following types of tube?
A) Levin
B) Sengstaken-Blakemore
C) Salem Pump
D) Ewald - Answer-Salem sump (A salem sump is the only type of tube that allows for
continuous suction. The tube has two lumens; one removes gastric contents and the
other serves as an air vent. The vent allows air to enter the stomach, allowing the tube
to float freely and preventing damage to the gastric mucosa.)
To prevent aspiration during the administration of an enteral tube feeding, a nurse
should - Answer-place the patient in Fowler's position (or elevate the bed at 30 degrees)
A nurse is assessing a patient who has a chest tube in place attached to a closed-chest
water-seal drainage system. When the nurse palpates the area around the chest-tube
insertion site, she is checking for - Answer-Subcutaneous emphysema
*Palpating the area surrounding the insertion site helps identify crepitus, a dry,
crackling, or grating sound. This is the classic manifestation of subcutaneous
emphysema, which indicates that air is leaking into the subcutaneous tissue
surrounding the chest-tube insertion site.
A nurse is caring for a patient who has a central venous catheter. When flushing the
catheter, the nurse uses a 10 ml syringe to prevent which of the following complications
associated with central vascular access devices? - Answer-catheter rupture.
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