a nurse in the emergency department is assessing a client who was in a motor vehicle crash findings include absent breath sounds in the left lower lob

ATI RN

ATI Fundamentals Proctored Exam Quizlet

1. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

A. Obtain a chest X-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via high-flow mask.
D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

2. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³

Correct answer: D

Rationale: Leukocytosis is defined as an increase in the total white blood cell count. A normal WBC count typically ranges from 4,500 to 10,000/mm³. A WBC count of 25,000/mm³, as indicated in choice D, is significantly higher than the normal range and clearly indicates leukocytosis.

3. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

4. A healthcare provider is assessing a client who has left-sided heart failure. Which of the following should the healthcare provider identify as a manifestation of pulmonary congestion?

A. Frothy, pink sputum
B. Jugular vein distention
C. Weight gain
D. Bradypnea

Correct answer: A

Rationale: Pulmonary congestion is a common manifestation of left-sided heart failure. When the left side of the heart fails, blood backs up into the lungs, leading to pulmonary congestion. This can result in symptoms such as frothy, pink-tinged sputum due to the presence of blood in the respiratory secretions. Jugular vein distention, weight gain, and bradypnea are also associated with heart failure, but frothy, pink sputum specifically indicates pulmonary congestion in this scenario.

5. What is the most common psychogenic disorder among elderly individuals?

A. Depression
B. Sleep disturbances (e.g., bizarre dreams)
C. Inability to concentrate
D. Decreased appetite

Correct answer: A

Rationale: Depression is the most common psychogenic disorder among elderly individuals. It can manifest as persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyed. Elderly individuals may also experience changes in appetite, sleep disturbances, and difficulty concentrating. Detecting and addressing depression in the elderly is crucial for their overall well-being and quality of life.