a nurse assesses a client after a thoracentesis which assessment finding warrants immediate action
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

2. A student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select one that does not apply)

Correct answer: A

Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease, as they can be changed or controlled through interventions. Age, on the other hand, is a nonmodifiable risk factor, meaning it cannot be altered. Understanding the difference between modifiable and nonmodifiable risk factors is essential in preventive healthcare strategies.

3. A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?

Correct answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

4. A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?

Correct answer: A

Rationale: In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation and reduce the workload on the heart. Providing supplemental oxygen at 5 L/min via facemask helps increase oxygen levels and alleviate respiratory distress. This intervention can help improve oxygen saturation, alleviate dyspnea, and support the client's respiratory function. Placing the client in a high-Fowler's position with legs dependent can also help with respiratory effort, but ensuring adequate oxygenation takes precedence. Sublingual nitroglycerin and IV morphine sulfate are commonly used interventions for cardiac-related conditions, but in this case, addressing oxygenation is the priority to prevent further deterioration.

5. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct answer: A

Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.

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