a nurse is caring for a client who is postoperative and whose respirations are shallow and 9min which of the following acid based imbalances should th
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?

Correct answer: A

Rationale: The client's shallow respirations at 9/min indicate hypoventilation, leading to an accumulation of carbon dioxide in the blood, causing respiratory acidosis. In this scenario, the client is at risk for developing respiratory acidosis due to inadequate ventilation and subsequent CO2 retention.

2. During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

Correct answer: B

Rationale: In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.

3. A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?

Correct answer: C

Rationale: Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling & smoking increases the risk for fire.

4. How can a nurse manager best improve hand-off communication among the staff? (SATA)

Correct answer: D

Rationale: The SHARE model is a valuable tool for standardizing hand-off reports and other critical communication. By utilizing this model, the nurse manager can ensure consistency and clarity in hand-off communication among the staff. While attending hand-off rounds to coach and mentor, conducting audits using a new template, and creating a template of topics to include in the report can all be beneficial actions, the most effective approach to achieve the goal of improving hand-off communication is by implementing a standardized tool like the SHARE model.

5. A client is wearing a Venturi mask to receive oxygen, and the dinner tray has arrived. What action by the nurse is best?

Correct answer: B

Rationale: In this scenario, the nurse should determine if the client can safely switch to a nasal cannula during meals. It is crucial to ensure that the provider has approved this change. Oxygen is considered a medication and should be delivered continuously. Turning off the oxygen or lifting the mask while eating can lead to a decrease in the FiO2 delivered, potentially compromising the client's oxygenation status. Therefore, the best course of action is to ascertain if transitioning to a nasal cannula is appropriate for the client during the meal.

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