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 is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

Correct answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

3. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Correct answer: B

Rationale:

4. After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?

Correct answer: C

Rationale: After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.

5. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Correct answer: B

Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.

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