a nurse is assessing a client who had a myocardial infarction upon auscultating heart sounds the nurse hears the following sound what action by the nu
Logo

Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

2. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?

Correct answer: A

Rationale: In COPD, the client often develops a barrel chest, characterized by an increased anterior-posterior diameter of the chest. This change is due to air trapping and hyperinflation of the lungs. Decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typically associated with COPD. Weight loss is more common due to increased work of breathing and decreased energy expenditure in individuals with COPD.

3. A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Correct answer: B

Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.

4. A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?

Correct answer: B

Rationale: When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.

5. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

Correct answer: A

Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.

Similar Questions

A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
A client in a clinic presents with an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?

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