a nurse is caring for a client who had an evacuation of a subdural hematoma which of the following actions should the nurse take first
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.

2. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

3. A client with chronic obstructive pulmonary disease is being taught by a nurse. Which nutritional information should the nurse include in the teaching? (SATA)

Correct answer: D

Rationale: In chronic obstructive pulmonary disease, it's important to consider the impact of nutrition on respiratory function. Eating high-fiber foods can lead to increased gas production, causing abdominal bloating and potentially worsening shortness of breath. Therefore, it is advisable for clients with COPD to avoid high-fiber foods to prevent these issues. Resting before meals can help manage dyspnea, and having smaller, more frequent meals can prevent bloating. Increasing calorie and protein intake is essential to prevent malnourishment in COPD patients. Additionally, limiting carbohydrate intake is crucial as it can increase carbon dioxide production, leading to a higher risk of acidosis in these individuals.

4. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

5. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

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