a nurse is caring for a client with heart failure who has gained 2 kg 44 lbs in the past 24 hours what action should the nurse take first
Logo

Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

2. A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?

Correct answer: B

Rationale: In a client with a high respiratory rate, low PaO2, and low SaO2, the priority intervention is to improve oxygenation. Administering oxygen via a face mask will help increase the oxygen supply to the client's lungs and tissues, addressing the hypoxemia. While mechanical ventilation may be necessary in severe cases, administering oxygen is the initial and most appropriate intervention to address the client's respiratory distress. Sedatives should not be given without ensuring adequate oxygenation. Assessing for pulmonary embolism is important but not the priority at this moment when the client is experiencing respiratory distress and hypoxemia.

3. When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?

Correct answer: D

Rationale: The most effective intervention to prevent the spread of infection when caring for a client with pneumonia is performing hand hygiene before and after client contact. This practice helps reduce the transmission of pathogens from one person to another, promoting infection control and maintaining a safe environment for both the client and healthcare provider.

4. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct answer: A

Rationale: In a closed chest drainage system, slow, steady bubbling in the suction control chamber is an expected finding, indicating proper functioning of the system. There is no immediate need for intervention as this indicates the system is working as intended. The nurse should continue to monitor the client's respiratory status for any signs of distress or changes. Checking tubing connections for leaks or clamping the chest tube are unnecessary actions based on the information provided. Checking the suction control outlet on the wall is also not indicated in this scenario.

5. 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.

Similar Questions

During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
Prior to performing percussion, vibration, and postural drainage on an adolescent client with pneumonia, which of the following nursing actions should the nurse complete first?
A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

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