a nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer the nurse should anticipate that the clie
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Nursing Elites

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ATI Detailed Answer Key Medical Surgical

1. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?

Correct answer: B

Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.

2. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?

Correct answer: A

Rationale: In this scenario, the client may have subcutaneous emphysema, where air leaks into the tissues surrounding the tracheostomy. The priority action for the nurse is to assess the client's oxygen saturation and other indicators of oxygenation to ensure adequate oxygen supply. If the client is stable, the nurse can then proceed to palpate the skin of the upper chest to check for subcutaneous emphysema. If the client is unstable, the nurse should promptly notify the Rapid Response Team. Using a bag-valve-mask device may be necessary for oxygenating the client, but assessing oxygen saturation comes first to guide further interventions.

4. A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?

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.

5. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

Similar Questions

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The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select ONE that does not apply)
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