a nurse in the emergency department is caring for a client who is having an acute asthma attack which of the following assessments indicates that the

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ATI Fundamentals

1. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

2. After routine patient contact, how long should hand washing last at least?

A. 30 seconds
B. 1 minute
C. 2 minutes
D. 3 minutes

Correct answer: A

Rationale: Proper hand washing for 30 seconds is recommended after routine patient contact as it effectively removes pathogens. This duration ensures thorough cleaning without excessive time consumption, promoting infection control and prevention.

3. Which of the following vascular system changes result from aging?

A. Increased peripheral resistance of the blood vessels
B. Decreased blood flow
C. Increased workload of the left ventricle
D. All of the above

Correct answer: D

Rationale: As individuals age, various changes occur in the vascular system. These changes include increased peripheral resistance of the blood vessels, decreased blood flow, and an increased workload of the left ventricle. Therefore, all the listed changes result from aging, making option D, 'All of the above,' the correct answer.

4. A healthcare professional in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the healthcare professional take first?

A. Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. Administer 100% humidified oxygen.

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, airway compromise is a critical concern. Administering 100% humidified oxygen is the priority to ensure adequate oxygenation. This intervention takes precedence over obtaining baseline ECG, obtaining blood specimens, or inserting an IV catheter, as airway management and oxygenation are fundamental in the initial assessment and management of a client with potential airway compromise.

5. What is the appropriate needle gauge for intradermal injection?

A. 20G
B. 22G
C. 25G
D. 26G

Correct answer: D

Rationale: Intradermal injections require a very fine needle to be used to deliver the medication into the dermis layer of the skin. A 26G needle is typically used for intradermal injections as it is thin enough to penetrate the skin's surface and deposit the medication accurately.