a nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema the clients assessment findings include anxiousness dys
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Nursing Elites

ATI RN

Medical Surgical ATI Proctored Exam

1. A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?

Correct answer: A

Rationale: In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation and reduce the workload on the heart. Providing supplemental oxygen at 5 L/min via facemask helps increase oxygen levels and alleviate respiratory distress. This intervention can help improve oxygen saturation, alleviate dyspnea, and support the client's respiratory function. Placing the client in a high-Fowler's position with legs dependent can also help with respiratory effort, but ensuring adequate oxygenation takes precedence. Sublingual nitroglycerin and IV morphine sulfate are commonly used interventions for cardiac-related conditions, but in this case, addressing oxygenation is the priority to prevent further deterioration.

2. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

3. 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.

4. A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?

Correct answer: C

Rationale: After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.

5. A client takes atorvastatin (Lipitor), with laboratory results showing a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

Correct answer: A

Rationale: There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. The client has elevated renal laboratory results, indicating kidney involvement. The nurse should ask if the client consumes grapefruit or grapefruit juice. While dehydration can elevate BUN, the increase in creatinine is more specific for kidney injury.

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