a nurse is caring for a client who had coronary artery bypass grafting yesterday what actions does the nurse delegate to the unlicensed assistive pers
Logo

Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)

Correct answer: C

Rationale: The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.

2. A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?

Correct answer: B

Rationale: In a client with a high respiratory rate, low PaO2, and low SaO2, the priority intervention is to improve oxygenation. Administering oxygen via a face mask will help increase the oxygen supply to the client's lungs and tissues, addressing the hypoxemia. While mechanical ventilation may be necessary in severe cases, administering oxygen is the initial and most appropriate intervention to address the client's respiratory distress. Sedatives should not be given without ensuring adequate oxygenation. Assessing for pulmonary embolism is important but not the priority at this moment when the client is experiencing respiratory distress and hypoxemia.

3. A healthcare professional is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the healthcare professional anticipate administering?

Correct answer: C

Rationale: In the scenario of a pulmonary embolism, the priority medication to administer is Heparin. Heparin is an anticoagulant that helps prevent the formation of new blood clots and the growth of existing ones, which is crucial in managing pulmonary embolism. Furosemide is a diuretic used to treat fluid retention, Dexamethasone is a corticosteroid used for inflammation, and Atropine is an anticholinergic medication used for various purposes such as treating bradycardia.

4. A patient is receiving discharge instructions after experiencing a stroke. Which instruction is most important for preventing another stroke?

Correct answer: A

Rationale: The correct answer is to take prescribed antihypertensive medications regularly. Hypertension is a major risk factor for stroke, and controlling blood pressure through medication is crucial in preventing recurrent strokes. While physical therapy, diet, and follow-up appointments are also important aspects of post-stroke care, managing hypertension with medication takes precedence due to its direct impact on stroke prevention.

5. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

Similar Questions

A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?
A healthcare professional is assessing a client with left-sided heart failure. Which finding is most commonly associated with this condition?
A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses