a client has a tracheostomy that is 3 days old upon assessment the nurse notes the clients face is puffy the eyelids are swollen what action by the n
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. 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.

2. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.

3. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

4. A nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?

Correct answer: B

Rationale: The diet recommended for this client would be low in saturated fats & red meat, high in vegetables & whole grains (fiber), low in salt, & low in trans-fat. The best choice is the chicken with broccoli & tomatoes. The French fries have too much fat & the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat & no vegetables.

5. A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

Correct answer: A

Rationale: When auscultating the lungs of a client with pleurisy, the healthcare professional should expect to hear loud, scratchy sounds. These sounds are characteristic of pleurisy, which is an inflammation of the pleura, causing a rough, grating sound during breathing.

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