Adult Medical Surgical ATI

Correct Answer: D

Rationale: The development of subcutaneous emphysema is a concerning finding that requires immediate intervention. Subcutaneous emphysema results from air leaking into the tissues, which can lead to respiratory compromise. It is important to address this issue promptly to prevent further complications. The other options are normal or expected findings in a chest tube drainage system. Chest tube eyelets not being visible may indicate dislodgement, continuous bubbling in the suction control chamber indicates proper functioning, and the presence of tidal fluctuation in the water seal chamber demonstrates appropriate drainage and lung re-expansion.

Correct Answer: A

Rationale: In a client with a three-chamber closed chest tube system, a rise in the water seal chamber with client inspiration is an expected finding. The nurse should continue to monitor the client as this indicates that the system is functioning correctly. There is no need to notify the healthcare provider, reposition the client, or clamp the chest tube as these actions are not indicated in response to a rise in the water seal chamber.

Correct Answer: D

Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.

Correct Answer: A

Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.

Correct Answer: C

Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.