a nurse assesses a client with pneumonia which clinical manifestation should the nurse expect to find
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?

Correct answer: C

Rationale: Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.

2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?

Correct answer: D

Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.

3. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?

Correct answer: A

Rationale: The correct technique for suctioning a tracheostomy involves applying suction while withdrawing the catheter to avoid damaging the tracheal mucosa. Therefore, the student applying suction while inserting the catheter indicates a need for further teaching. Preoxygenating the client, suctioning up to three times if necessary, and limiting suctioning to 10 to 15 seconds each time are all appropriate actions in tracheostomy suctioning.

4. When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?

Correct answer: B

Rationale: When a client develops an airway obstruction and remains conscious, the nurse's initial action should be to administer the abdominal thrust maneuver. This technique, also known as the Heimlich maneuver, can help dislodge the obstructing object and clear the airway. Inserting an oral airway, turning the client to the side, or performing a blind finger sweep are not recommended as the first interventions for a conscious individual with an airway obstruction.

5. 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.

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