ATI RN
ATI Nursing Specialty
1. A client with chronic obstructive pulmonary disease (COPD expresses difficulty in bringing up bronchial secretions. Which action should the nurse take to help the client with tenacious bronchial secretions?
- A. Maintaining a semi-Fowler's position as much as possible
- B. Administering oxygen via nasal cannula at 2 L per min
- C. Helping the client select a low-salt diet
- D. Encouraging the client to drink eight glasses of water daily
Correct answer: D
Rationale: Encouraging the client to drink eight glasses of water daily is the most appropriate action to help with tenacious bronchial secretions in COPD. Increased fluid intake can help in thinning the mucus, making it easier for the client to cough up and clear secretions. This addresses the client's difficulty in bringing up bronchial secretions. Maintaining a semi-Fowler's position can aid in breathing but does not directly address the issue of clearing secretions. Administering oxygen may be necessary for COPD, but it does not specifically target the tenacious secretions. Selecting a low-salt diet can be helpful in managing COPD in general, but it does not directly address the client's current concern of clearing bronchial secretions.
2. During a home visit, a nurse sees a client with COPD receiving oxygen at 2 L/min through a nasal cannula. The client reports difficulty breathing. What is the priority nursing action at this time?
- A. Increase the oxygen flow to 3 L/min.
- B. Evaluate the client's respiratory status.
- C. Call emergency services for the client.
- D. Instruct the client to cough and clear secretions.
Correct answer: B
Rationale: The priority nursing action in this situation is to evaluate the client's respiratory status. When a client with COPD on oxygen therapy experiences difficulty breathing, the nurse should first assess the client's respiratory status to determine the severity of the situation. Increasing the oxygen flow without proper assessment can be harmful if not clinically indicated. While calling emergency services may eventually be necessary, it should not be the immediate action without assessing the client first. Instructing the client to cough and clear secretions is not appropriate as the nurse needs to evaluate the respiratory status before proceeding with interventions.
3. In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions?
- A. Apply a heating pad on a low setting to help relieve leg pain.
- B. Adjust the thermostat so that the environment is warm.
- C. Wear antiembolic stockings during the day.
- D. Rest with the legs above heart level.
Correct answer: D
Rationale: Resting with the legs above heart level is important for clients with peripheral arterial disease (PAD) to promote better circulation and reduce leg pain. Applying a heating pad on a low setting can actually worsen symptoms by causing burns or increasing blood flow to the area, which is not recommended for PAD. While keeping the environment warm is generally beneficial, it is not a specific instruction for managing PAD. Antiembolic stockings are typically used for preventing blood clots in hospitalized patients and may not be directly related to managing PAD at home.
4. A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is
- A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
- B. a protein whose levels reflect the risk for coronary artery disease.
- C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
- D. a protein that helps transport oxygen throughout the body.
Correct answer: C
Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.
5. A client prescribed home oxygen therapy is receiving discharge teaching from a nurse. Which statement by the client indicates a need for further teaching?
- A. I will be able to tell the amount of oxygen being delivered by looking at the flowmeter.
- B. I should contact my doctor if I notice a decrease in my ability to concentrate.
- C. I will ensure that visitors smoke outside.
- D. I should see a frosty buildup on the tank when I refill my portable oxygen.
Correct answer: A
Rationale: The correct answer is A. The client's statement indicates a need for further teaching because the flowmeter indicates the flow rate of oxygen, not the total amount of oxygen being delivered. Choices B, C, and D demonstrate understanding of safety measures and indications for seeking medical attention in relation to home oxygen therapy, making them appropriate statements.
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