a nurse is assessing a patient with pneumonia which finding is most concerning
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

2. A nurse is preparing to administer verapamil to a client who is 2 days postmyocardial infarction. The nurse should monitor the client for which of the following outcomes as a therapeutic response to the medication?

Correct answer: B

Rationale: The correct answer is B: Decreased anginal pain. Verapamil is a calcium channel blocker used to relieve angina by reducing myocardial oxygen demand. Monitoring for decreased anginal pain is essential as it indicates a therapeutic response to the medication. Choices A, C, and D are incorrect as verapamil's primary goal in this context is not to decrease blood pressure, heart rate, or anxiety.

3. When working with a client who does not speak the same language, which of the following actions should the nurse take?

Correct answer: C

Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.

4. A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?

Correct answer: B

Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.

5. A client has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance. What should the nurse instruct the client?

Correct answer: C

Rationale: The correct answer is to instruct the client to gargle with water after each use of the beclomethasone inhaler. Beclomethasone can cause oral thrush, and gargling with water helps prevent this complication. Choice A is incorrect because the client should not skip doses even if breathing improves, as the medications are prescribed for maintenance. Choice B is incorrect as there is no specific instruction to use the albuterol inhaler first in this scenario. Choice D is incorrect because inhalers should not be stored in the refrigerator unless specified by the manufacturer.

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