a nurse is caring for a client who has a pulmonary embolism which of the following interventions should the nurse include in the plan of care
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A client with a pulmonary embolism is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: Administering anticoagulants as prescribed is a crucial intervention for clients with pulmonary embolism to prevent further clot formation. Encouraging the client to ambulate frequently may dislodge the clot and lead to worsening symptoms. Placing the client in a prone position can compromise respiratory function. Initiating seizure precautions is not directly related to the management of pulmonary embolism.

2. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?

Correct answer: B

Rationale: The correct answer is B: Tachycardia. Tachycardia can indicate a hemolytic transfusion reaction, a severe and life-threatening complication of blood transfusion. The nurse should report tachycardia immediately to prevent further complications. Low back pain, flushed skin, and headache are also important to monitor during a blood transfusion, but they are not as indicative of a severe transfusion reaction as tachycardia.

3. A client at 14 weeks gestation reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?

Correct answer: A

Rationale: The correct response is to use open-ended questions that allow the client to explore and express their feelings. Choice A encourages the client to describe their feelings, fostering open communication and providing an opportunity for the client to express themselves freely. Choices B and C do not directly address the client's feelings and may not promote open communication. Choice D focuses on the timing of the feelings rather than exploring the feelings themselves, making it a less therapeutic response.

4. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing intervention for a patient with an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing acute asthma symptoms. Administering corticosteroids (Choice B) is also important in the treatment plan, but it is not the priority intervention during an acute attack. Providing supplemental oxygen (Choice C) may be necessary but is not the priority initial intervention. Starting IV fluids (Choice D) is not typically indicated as a priority intervention for an acute asthma attack.

5. A nurse is caring for a client who has osteoarthritis. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: In osteoarthritis, joint pain that improves with rest is a common characteristic due to the relief obtained by reducing weight-bearing on the affected joint. Joint stiffness that improves with movement is more indicative of rheumatoid arthritis, not osteoarthritis. Red, warm joints are typically seen in inflammatory arthritis conditions like rheumatoid arthritis, while systemic inflammation is not a primary feature of osteoarthritis.

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