a nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation which of the following actions is the nurses highes
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

Correct answer: D

Rationale: During an acute asthma exacerbation, the priority intervention is to administer a nebulized beta-adrenergic medication, such as albuterol, to help open the airways and improve breathing. This action helps address the underlying cause of the exacerbation. Oxygen therapy may be needed but is not the priority over administering the bronchodilator. Providing rest and positioning the client in high-Fowler's are important but come after administering the medication to address the immediate breathing difficulties.

2. When caring for a client with acute renal failure, which laboratory value is most important to monitor?

Correct answer: B

Rationale: In acute renal failure, monitoring serum potassium is crucial because impaired kidney function can lead to hyperkalemia, which can result in life-threatening cardiac dysrhythmias. Elevated potassium levels need close monitoring and prompt interventions to prevent serious complications.

3. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.

4. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?

Correct answer: B

Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.

5. A client is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select ONE that does not apply)

Correct answer: D

Rationale: When educating a client on smoking cessation, the nurse should include several strategies. Finding an activity to keep hands busy helps distract from smoking urges. Making a list of reasons to quit smoking reinforces motivation. Identifying a consequence for backsliding can serve as a deterrent. Drinking water is beneficial for overall health but is not directly related to smoking cessation. It's crucial to support the client, encourage healthy habits, and address challenges without punitive measures.

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