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 with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Using the peak flow meter every morning is crucial for monitoring asthma control and making timely treatment adjustments. While using the meter when feeling short of breath or before using an inhaler can also be beneficial, the daily morning routine helps in consistent management of asthma symptoms.

3. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

Correct answer: A

Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.

4. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Correct answer: D

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

5. A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?

Correct answer: B

Rationale: Tidal volume is the amount of air delivered with each breath during mechanical ventilation. A common formula used to calculate tidal volume is 6-8 mL/kg of ideal body weight. For a client with an ideal weight of 60 kg, the expected tidal volume would be 60 kg x 6-8 mL/kg = 360-480 mL. Therefore, the most appropriate choice is 480 mL (Option B), which falls within the expected range based on the client's weight.

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