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. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.

3. A healthcare professional is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the healthcare professional administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct answer: A

Rationale: To calculate the mL of albuterol syrup needed per dose, first, determine how many milligrams are in the prescribed dose: 1.6 mg. Next, set up a proportion to find the equivalent mL for 1.6 mg using the given concentration of 2 mg/5mL. The calculation is: (1.6 mg x 5 mL) / 2 mg = 4 mL. Therefore, the correct answer is 4 mL to administer per dose.

4. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

5. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

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