a client is receiving o2 at 4 liters per nasal cannula what comfort measure may the nurse delegate to unlicensed assistive personnel uap
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

2. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

3. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Correct answer: B

Rationale:

4. When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?

Correct answer: A

Rationale: The movement of the trachea toward the unaffected side is concerning as it can indicate a tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea should be midline, so any deviation should be reported promptly to the provider for further evaluation and intervention.

5. During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?

Correct answer: C

Rationale: In a client experiencing an acute asthma attack, decreased breath sounds suggest severe airway obstruction or respiratory fatigue, indicating a worsening condition. Loud wheezing, increased respiratory rate, and a productive cough are common manifestations during an asthma attack as the airways constrict, leading to turbulent airflow causing wheezing, increased effort to breathe resulting in a higher respiratory rate, and mucus production causing a productive cough. However, decreased breath sounds signify a critical situation requiring immediate intervention.

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