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 home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

Correct answer: B

Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.

3. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

Correct answer: A

Rationale: The most important action a client can take to protect against errors is to bring a list of all medications and their purposes. This helps ensure that the healthcare team has accurate information about the client's medications, reducing the risk of medication errors, which are the most common type of healthcare mistake. Knowing the medications and their purposes can also aid in preventing drug interactions and adverse effects during the surgical procedure.

4. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

5. A client is wearing a Venturi mask to receive oxygen, and the dinner tray has arrived. What action by the nurse is best?

Correct answer: B

Rationale: In this scenario, the nurse should determine if the client can safely switch to a nasal cannula during meals. It is crucial to ensure that the provider has approved this change. Oxygen is considered a medication and should be delivered continuously. Turning off the oxygen or lifting the mask while eating can lead to a decrease in the FiO2 delivered, potentially compromising the client's oxygenation status. Therefore, the best course of action is to ascertain if transitioning to a nasal cannula is appropriate for the client during the meal.

Similar Questions

A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)
A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

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