a nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season the nurse sh
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Nursing Elites

ATI RN

Medical Surgical ATI Proctored Exam

1. A client reports a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?

Correct answer: A

Rationale: When a client reports headache and vertigo after turning on the furnace for the first time, it suggests carbon monoxide poisoning. Carbon monoxide is an odorless, colorless gas that can be released by malfunctioning heating systems. Symptoms of carbon monoxide poisoning include headache, dizziness, weakness, nausea, and confusion. It is crucial for the nurse to suspect this condition promptly to ensure the client's safety and well-being.

2. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

3. During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?

Correct answer: B

Rationale: The presence of expired food in the refrigerator is concerning as it raises safety issues for the client and indicates potential financial constraints preventing them from buying fresh food. The nurse should consider referring the client to services like Meals on Wheels or other home-based food programs to address this issue and ensure the client's nutritional needs are met.

4. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

5. A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Correct answer: A

Rationale: Continuous bubbling in the water-seal chamber indicates air is leaking into the pleural space, which is a complication. The water-seal chamber should have intermittent bubbling during normal functioning. Occasional bubbling in the water-seal chamber is normal and shows the system is working as intended. Constant bubbling in the suction-control chamber suggests an issue with the suction control. Fluctuations in the fluid level in the water-seal chamber are an expected finding.

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