a nurse is performing a focused assessment on a client who has a history of copd and is experiencing dyspnea what finding should the nurse expect
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?

Correct answer: C

Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.

2. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?

Correct answer: A

Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.

3. While documenting client care, which entry should the nurse identify as an example of implementing client care?

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

4. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

Correct answer: B

Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.

5. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?

Correct answer: B

Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.

Similar Questions

A nurse is providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?
A healthcare professional is reviewing the laboratory values of a client who is experiencing fluid volume deficit (FVD). What finding should the professional expect?
When teaching a client about the correct use of a cane, what should the nurse include?
A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?
A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

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