a nurse is assessing a client for signs of respiratory distress which of the following findings should the nurse look for
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A healthcare professional is assessing a client for signs of respiratory distress. Which of the following findings should the healthcare professional look for?

Correct answer: A

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of respiratory distress. Shallow breathing is a key indicator of respiratory distress, reflecting an inadequate exchange of oxygen and carbon dioxide. Bradycardia (Choice B) refers to a slow heart rate and is not typically a direct sign of respiratory distress. Increased appetite (Choice C) and warm, dry skin (Choice D) are unrelated to respiratory distress. Therefore, the correct answer is A.

2. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.

3. A client who is 8 hours postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborn’s blood type is B positive. Which of the following statements is appropriate?

Correct answer: B

Rationale: The correct answer is B. Rh-negative mothers who give birth to an Rh-positive baby should receive Rh immune globulin within 72 hours of delivery to prevent the development of antibodies in future pregnancies. Choice A is incorrect because Rh-negative individuals are the ones who require Rh immune globulin. Choice C is incorrect as the administration of Rh immune globulin is time-sensitive and not typically scheduled for a 6-week appointment. Choice D is incorrect because Rh immune globulin is necessary to prevent sensitization regardless of the number of pregnancies.

4. A client has been prescribed amlodipine for hypertension. Which of the following adverse effects should the nurse instruct the client to report?

Correct answer: B

Rationale: The correct answer is B: 'Dizziness.' Amlodipine, a calcium channel blocker used for hypertension, can cause dizziness due to its blood pressure-lowering effects. It is crucial for clients to report dizziness to their healthcare provider as it may indicate hypotension. Dry cough (choice A) is more commonly associated with ACE inhibitors, rash (choice C) may be seen in allergic reactions, and headache (choice D) is a less common side effect of amlodipine.

5. A client who is having suicidal thoughts tells the nurse, “It just doesn’t seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?

Correct answer: B

Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.

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