this is a condition where the lung collapses due to air leaking into the space between the lung and the chest wall this is a condition where the lung collapses due to air leaking into the space between the lung and the chest wall
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. What is the term for a condition where the lung collapses due to air leaking into the space between the lung and the chest wall?

Correct answer: A

Rationale: Pneumothorax is the correct answer for this question. Pneumothorax is the collapse of a lung caused by the presence of air in the pleural space between the lung and chest wall. This condition can lead to chest pain, shortness of breath, and may require emergency treatment such as chest tube insertion to remove the air. Pleural effusion is the accumulation of fluid in the pleural space, not air. Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. Pulmonary fibrosis is a condition characterized by scarring and thickening of lung tissue, not related to air leaking into the pleural space.

2. What is the initial step in managing a suspected pulmonary embolism in a patient?

Correct answer: A

Rationale: Administering oxygen is the initial step in managing a suspected pulmonary embolism. Oxygen therapy is crucial to improve oxygenation levels in the blood when there is a suspected blockage in the pulmonary artery. Administering anticoagulants, although important in the treatment of pulmonary embolism, is not the first step as ensuring adequate oxygen supply takes precedence. Repositioning the patient or administering IV fluids are not the primary interventions for a suspected pulmonary embolism and are not as essential as providing oxygen support.

3. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?

Correct answer: A 34-year-old on NPO status who is receiving intravenous D5W

Rationale: The correct answer is the 34-year-old on NPO status receiving intravenous D5W because D5W is a hypotonic solution that can dilute the blood's sodium levels, leading to hyponatremia. Patients on NPO status rely solely on intravenous fluids for hydration, making them more susceptible to electrolyte imbalances. Choices B, C, and D are less likely to cause hyponatremia. Choice B, the 50-year-old with an infection on a sulfonamide antibiotic, is at risk for allergic reactions or renal issues. Choice C, the 67-year-old taking ibuprofen, is at risk for gastrointestinal bleeding or kidney problems. Choice D, the 73-year-old on digoxin with tachycardia, is more likely to experience digoxin toxicity, affecting the heart's rhythm.

4. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?

Correct answer: C

Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.

5. A healthcare provider is assessing an infant who has hydrocephalus and is 6 hours postoperative following placement of a ventriculoperitoneal shunt. Which of the following findings should the provider report to the healthcare provider?

Correct answer: D

Rationale: The provider should report the leakage of cerebrospinal fluid to the healthcare provider as it may indicate shunt malfunction or infection, requiring immediate attention to prevent complications. Decreased urine output, a temperature of 37.5 degrees C, and a heart rate of 130/min are common postoperative findings and may not be directly related to shunt function. While these findings should still be monitored, they do not require immediate reporting like cerebrospinal fluid leakage.

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