a nurse assesses a client who is intubated has an intra aortic balloon pump the client is restless agitated what action should the nurse perform fir
Logo

Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

Correct answer: A

Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.

2. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

3. When caring for a client with Alzheimer's disease, what is the most appropriate communication technique for a nurse to use?

Correct answer: C

Rationale: When communicating with clients with Alzheimer's disease, using simple and direct statements is the most appropriate technique. This approach helps to minimize confusion, enhance understanding, and facilitate effective communication with individuals who may have difficulty processing complex information due to their condition.

4. A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

Correct answer: B

Rationale: Option B, 'I will take my bronchodilators after meals,' indicates a need for further teaching. Bronchodilators should be taken before meals to help open the airways and make breathing easier before eating. This statement suggests a misunderstanding of the timing for optimal bronchodilator effectiveness. Options A, C, and D are all appropriate strategies for facilitating eating for a client with chronic obstructive pulmonary disease.

5. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

Similar Questions

A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
How does the pain of a myocardial infarction (MI) differ from stable angina?
A healthcare professional is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses