a nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area she states that she starte
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. 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.

2. A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?

Correct answer: B

Rationale: Proper administration of insulin is crucial for clients with type 1 diabetes as they are dependent on insulin for blood glucose control.

3. A client interested in smoking cessation is being taught by a nurse. Which statements should the nurse include in the teaching? (Select one that does not apply)

Correct answer: C

Rationale: When teaching a client interested in smoking cessation, the nurse should advise finding an activity that keeps the hands busy, keeping healthy snacks on hand, making a list of reasons for quitting smoking, and not being upset if a relapse occurs. Drinking eight glasses of water each day is a healthy habit but is not directly related to smoking cessation strategies, making it the option that does not apply in this context.

4. During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?

Correct answer: B

Rationale: The presence of expired food in the refrigerator is concerning as it raises safety issues for the client and indicates potential financial constraints preventing them from buying fresh food. The nurse should consider referring the client to services like Meals on Wheels or other home-based food programs to address this issue and ensure the client's nutritional needs are met.

5. A client with tuberculosis is starting medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.

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