a nurse cares for a client with end stage heart failure who is awaiting a transplant the client appears depressed states i know a transplant is my la
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. 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?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

2. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

3. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Correct answer: C

Rationale: When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.

4. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?

Correct answer: C

Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.

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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