a nurse is assessing a client who had a myocardial infarction upon auscultating heart sounds the nurse hears the following sound what action by the nu
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

2. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

3. Prior to a cardiac catheterization, what is the most important action for the nurse to take?

Correct answer: D

Rationale: Assessing the client for allergies, particularly to iodine or shellfish, is crucial before a cardiac catheterization because the contrast dye used during the procedure can lead to allergic reactions. Identifying any allergies beforehand allows the healthcare team to take necessary precautions to prevent potential adverse reactions and ensure the client's safety.

4. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

5. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

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