a nurse in the emergency department is caring for a client who has full thickness burns of the thorax and upper torso after securing the clients airwa
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023

1. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

Correct answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

2. A client with heart failure is receiving furosemide. Which of the following assessment findings indicates that the medication is effective?

Correct answer: B

Rationale: The absence of adventitious breath sounds indicates that furosemide is effective in managing heart failure. Adventitious breath sounds such as crackles indicate fluid accumulation in the lungs, a common complication of heart failure. Therefore, the absence of these abnormal sounds suggests that furosemide is effectively reducing fluid overload. Elevated blood pressure (choice A) is not a desired outcome in heart failure management. Weight gain (choice C) and decreased urine output (choice D) are signs of fluid retention and ineffective diuresis, indicating that furosemide is not working effectively.

3. What is the first step when administering a blood transfusion?

Correct answer: B

Rationale: The correct answer is to verify the client's blood type before administration. This step is crucial to ensure compatibility and prevent adverse reactions such as hemolytic transfusion reactions. Warming the blood to body temperature (Choice A) is not the first step and is not typically done during blood transfusions. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow infusion. Administering diuretics before the transfusion (Choice D) is unnecessary and not a standard practice when initiating a blood transfusion.

4. When should a healthcare provider suction a client's tracheostomy?

Correct answer: B

Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.

5. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.

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