what are the key components of a focused respiratory assessment

ATI LPN

ATI PN Comprehensive Predictor 2020 Answers

1. What are the key components of a focused respiratory assessment?

A. Inspection, Palpation, Percussion, Auscultation
B. Observation, Percussion, Auscultation, Palpation
C. Auscultation, Palpation, Observation, Percussion
D. Palpation, Inspection, Auscultation, Percussion

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for any abnormalities, palpating to assess tenderness and chest expansion, percussion to evaluate underlying structures, and auscultation to listen to lung sounds. Choice B is incorrect because observation is generally part of inspection, not a separate component. Choice C is incorrect as auscultation should come before percussion in a respiratory assessment. Choice D is incorrect because inspection should precede palpation in a structured assessment.

2. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?

A. Use of tobacco might lead to alcohol and drug abuse.
B. Smoking in adolescence increases the risk of developing lung cancer later in life.
C. Use of tobacco decreases the level of athletic ability.
D. Smoking in adolescence increases the risk of lifelong addiction.

Correct answer: C

Rationale: The most likely consequence to discourage adolescents from smoking is the immediate effect of decreased athletic ability. This consequence is more tangible and relevant to high school students compared to long-term health risks like lung cancer or addiction. While choices A, B, and D are all negative outcomes of smoking, choice C is more likely to have a direct impact on adolescents due to its immediate and visible effects on their physical performance.

3. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

A. Soak feet in hot water daily
B. Use a heating pad on the feet daily
C. Cut toenails straight across
D. Massage feet with lotion daily

Correct answer: C

Rationale: The correct answer is C: 'Cut toenails straight across.' This instruction is crucial for clients with diabetes to prevent ingrown toenails and potential foot complications. Soaking feet in hot water daily (Choice A) can lead to skin damage and is not recommended for diabetic individuals. Using a heating pad on the feet daily (Choice B) can cause burns or injuries due to reduced sensation in the feet that often accompanies diabetes. Massaging feet with lotion daily (Choice D) is generally safe but may not address the specific preventive measure of cutting toenails correctly.

4. A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

A. Instruct the client to perform ankle pumps
B. Administer anticoagulant therapy as prescribed
C. Maintain the client in a prone position
D. Encourage the client to ambulate as tolerated

Correct answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

5. What should a healthcare provider monitor in a client with constipation?

A. Monitor the client's bowel sounds every 4 hours
B. Increase the client's activity to stimulate bowel movement
C. Encourage the client to use a stool softener
D. Encourage the client to rest in bed until constipation resolves

Correct answer: C

Rationale: Encouraging the client to use a stool softener is the appropriate intervention for constipation. Stool softeners help to soften the stool, making it easier to pass and relieving constipation without straining the client. Monitoring bowel sounds (Choice A) may be relevant for other gastrointestinal issues but is not specifically indicated for constipation. Increasing activity (Choice B) can be helpful in some cases, but it is not the first-line intervention for constipation. Encouraging bed rest (Choice D) can worsen constipation by reducing mobility and promoting inactivity.