a nurse is caring for a group of clients which of the following clients are not at risk for pulmonary embolism
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam Quizlet

1. A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?

Correct answer: B

Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.

2. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

3. A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?

Correct answer: C

Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.

4. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?

Correct answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

5. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

Correct answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.

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