ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct answer: B
Rationale: When a client develops an airway obstruction and remains conscious, the nurse's initial action should be to administer the abdominal thrust maneuver. This technique, also known as the Heimlich maneuver, can help dislodge the obstructing object and clear the airway. Inserting an oral airway, turning the client to the side, or performing a blind finger sweep are not recommended as the first interventions for a conscious individual with an airway obstruction.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct answer: D
Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.
3. A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?
- A. Petechiae on the chest and abdomen
- B. WBC 16,000/mm3
- C. Negative throat culture
- D. Severe hyperemia of pharyngeal mucosa
Correct answer: C
Rationale: Viral pharyngitis is typically caused by a virus, not bacteria, so a negative throat culture is an expected finding. The presence of petechiae on the chest and abdomen (Choice A) is not a common manifestation of viral pharyngitis. Elevated WBC count (Choice B) is more indicative of a bacterial infection rather than a viral one. Severe hyperemia of the pharyngeal mucosa (Choice D) is a possible finding in pharyngitis but is not specific to viral pharyngitis.
4. 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?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow to normal breaths alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
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.
5. A healthcare professional is assessing a client with left-sided heart failure. Which finding is most commonly associated with this condition?
- A. Peripheral edema
- B. Jugular vein distention
- C. Hepatomegaly
- D. Crackles in the lungs
Correct answer: D
Rationale: Crackles in the lungs are commonly associated with left-sided heart failure due to pulmonary congestion. Left-sided heart failure leads to the backup of blood into the lungs, causing fluid leakage into the alveoli, which results in the characteristic crackling sound upon auscultation.
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