a nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot the client has a blood pressure of 10
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Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

2. During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?

Correct answer: B

Rationale: SBAR is a structured form of communication used in healthcare settings. It stands for Situation, Background, Assessment, and Recommendation. In this scenario, informing the on-call physician about the client's allergies to morphine & codeine falls under the 'Background' component of the SBAR format, making choice B the correct answer.

3. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

4. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

Correct answer: C

Rationale: A potassium level of 6.5 mEq/L is critically high and can lead to life-threatening cardiac dysrhythmias, requiring immediate intervention. Hyperkalemia is a common complication in clients with ESRD due to the kidneys' inability to excrete potassium effectively. High potassium levels can result in serious cardiac consequences such as arrhythmias, cardiac arrest, and death. Prompt action is necessary to prevent these severe complications.

5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

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