a nurse assesses a client who is experiencing an acute asthma attack which assessment finding requires immediate intervention
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: A silent chest in a client experiencing an acute asthma attack indicates severe airway obstruction and impending respiratory failure. It is a critical finding that requires immediate intervention as it signifies a lack of airflow and ventilation. Loud wheezing, increased respiratory rate, and use of accessory muscles are common signs of an asthma attack and indicate the body's attempt to compensate. However, a silent chest suggests a dangerous lack of airflow that necessitates urgent medical attention to prevent respiratory arrest.

2. During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?

Correct answer: B

Rationale: The presence of expired food in the refrigerator is concerning as it raises safety issues for the client and indicates potential financial constraints preventing them from buying fresh food. The nurse should consider referring the client to services like Meals on Wheels or other home-based food programs to address this issue and ensure the client's nutritional needs are met.

3. 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.

4. A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?

Correct answer: C

Rationale: Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling & smoking increases the risk for fire.

5. While assessing a client with pulmonary tuberculosis, which of the following findings should the nurse expect?

Correct answer: A

Rationale: When assessing a client with pulmonary tuberculosis, the nurse should expect lethargy as a common finding. Tuberculosis can cause fatigue and weakness due to the body's efforts to fight the infection. High-grade fever is another common symptom of tuberculosis, not weight gain or dry cough. Weight loss is more typical in tuberculosis due to decreased appetite and systemic effects of the infection. A persistent productive cough with sputum is more characteristic of tuberculosis rather than a dry cough.

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