a nurse assesses a client with asthma and notes bilateral wheezing decreased pulse oxygen saturation and suprasternal retraction on inhalation which a
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

2. A nursing student asks what essential hypertension is. What response by the registered nurse is best?

Correct answer: C

Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.

3. A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Correct answer: B

Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.

4. A client in a clinic presents with an acute asthma exacerbation. Which of the following medications should reduce the symptoms?

Correct answer: D

Rationale: During an acute asthma exacerbation, the preferred medication for symptom relief is a short-acting beta-agonist like albuterol, typically delivered via a jet nebulizer for quick onset and efficacy. Cromolyn, montelukast, and budesonide are not as effective for immediate symptom relief in acute exacerbations and are more commonly used for prevention or long-term management of asthma symptoms.

5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

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