a nurse is orienting a new client family to the inpatient unit what info does the nurse give to help the client promote his or her own safety
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

2. 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?

Correct answer: A

Rationale: Before initiating percussion, vibration, and postural drainage, the nurse should first auscultate the lung fields to assess the baseline lung sounds and identify areas of congestion or abnormality. This initial assessment helps the nurse to tailor the percussion and drainage techniques effectively. Assessing pulse and respirations, sputum characteristics, and providing instructions to the client for exhalation are important steps in the procedure but should follow the initial auscultation to ensure a comprehensive and individualized care approach.

3. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

4. A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?

Correct answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

5. While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Correct answer: B

Rationale: Flail chest is characterized by paradoxical chest movement, where the chest moves inward during inspiration and bulges out during expiration. This occurs due to multiple rib fractures causing a segment of the chest wall to move independently from the rest of the thorax. Atelectasis refers to collapsed lung tissue, hemothorax is blood in the pleural space, and pneumothorax is air in the pleural space. In this scenario, the client's presentation aligns with the characteristic findings of flail chest.

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