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

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 client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

Correct answer: B

Rationale: Clients with an alteration in the CYP2C19 gene do not metabolize warfarin (Coumadin) well, leading to higher blood levels and more side effects. As this client is a poor candidate for warfarin therapy, the prescriber will most likely recommend the implantation of an inferior vena cava (IVC) filter. This device helps prevent blood clots from reaching the lungs, reducing the risk of pulmonary embolism.

3. A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D because clients are typically instructed to avoid solid foods for 12-24 hours before a colonoscopy, not a full 24 hours. This statement indicates a need for further teaching to ensure the client follows the correct dietary instructions for the procedure.

4. When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?

Correct answer: D

Rationale: The most effective intervention to prevent the spread of infection when caring for a client with pneumonia is performing hand hygiene before and after client contact. This practice helps reduce the transmission of pathogens from one person to another, promoting infection control and maintaining a safe environment for both the client and healthcare provider.

5. A client is vomiting. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.

Similar Questions

A client with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
How does the pain of a myocardial infarction (MI) differ from stable angina?
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (SATA)

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