a nurse is assessing the respiratory pattern of an older adult client who is receiving end of life care which of the following assessment findings sho
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Correct answer: A

Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.

2. A patient is receiving discharge instructions after experiencing a stroke. Which instruction is most important for preventing another stroke?

Correct answer: A

Rationale: The correct answer is to take prescribed antihypertensive medications regularly. Hypertension is a major risk factor for stroke, and controlling blood pressure through medication is crucial in preventing recurrent strokes. While physical therapy, diet, and follow-up appointments are also important aspects of post-stroke care, managing hypertension with medication takes precedence due to its direct impact on stroke prevention.

3. 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.

4. A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?

Correct answer: C

Rationale: The correct instruction for a client taking warfarin, an anticoagulant, is to report any signs of bruising or bleeding to the healthcare provider promptly. This is crucial as these symptoms may indicate over-anticoagulation, which can lead to serious complications. Monitoring for signs of bleeding is essential to adjust the medication dosage or take appropriate measures to ensure the client's safety.

5. A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D because clients are typically instructed to avoid solid foods for 12-24 hours before a colonoscopy, not a full 24 hours. This statement indicates a need for further teaching to ensure the client follows the correct dietary instructions for the procedure.

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