a nurse is providing care after auscultating clients breath sounds which finding is correctly matched to the nurses primary intervention
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

2. A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

Correct answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

3. When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?

Correct answer: C

Rationale: In pneumonia, lung tissue consolidation occurs, leading to dullness on percussion. This is a typical finding in pneumonia. Fremitus and decreased tactile fremitus are more commonly associated with conditions like pleural effusion or pneumothorax. Hyperresonance is typically seen in conditions causing air trapping, such as emphysema.

4. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

Correct answer: A

Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.

5. 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.

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