a nurse cares for a client with chronic obstructive pulmonary disease copd who is receiving oxygen therapy which finding requires immediate interventi
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?

Correct answer: B

Rationale: A respiratory rate of 10 breaths per minute in a client with COPD receiving oxygen therapy may indicate respiratory depression, necessitating immediate intervention. An oxygen saturation of 91%, client reports of shortness of breath, and use of accessory muscles are expected in COPD clients.

2. A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct answer: C

Rationale: In a three-chamber chest drainage system, the absence of bubbling in the suction control chamber indicates that no suction is being applied to the chest tube. The nurse should first verify that the suction regulator is on and check the tubing for any leaks that may be causing the lack of suction. Adding more water to the chamber or milking the chest tube are inappropriate actions and could potentially harm the client. Monitoring the client without taking action could lead to complications if the chest tube is not functioning properly.

3. When caring for a client with acute pancreatitis, what intervention is most appropriate?

Correct answer: B

Rationale: Administering pain medication as needed is the most appropriate intervention for a client with acute pancreatitis. Pain management is crucial as pancreatitis can cause severe and debilitating pain. Providing pain relief is essential to improve the client's comfort and well-being.

4. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

5. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

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