a nurse is performing a focused assessment on a client who has a history of copd and is experiencing dyspnea what finding should the nurse expect
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?

Correct answer: C

Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.

2. A client with diabetes mellitus is being taught about foot care by a nurse. What statement indicates understanding?

Correct answer: B

Rationale: The correct answer is B. Wearing cotton socks is essential for clients with diabetes as it helps protect the feet and reduces the risk of skin breakdown. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage. Choice C is incorrect as clients with diabetes should cut their toenails straight across to prevent ingrown toenails. Choice D is incorrect as applying lotion between the toes can create a moist environment that may increase the risk of fungal infections.

3. A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.

4. A charge nurse is making assignments for the upcoming shift. Which client should the charge nurse assign to a licensed practical nurse (LPN)?

Correct answer: C

Rationale: The correct answer is C because a client with dehydration and inflammatory bowel disease is stable enough for care by an LPN. This condition does not require complex interventions that would necessitate a higher level of nursing care. Choice A is incorrect as administering IV antibiotics for pneumonia requires a higher level of nursing expertise. Choice B is incorrect because monitoring for dehydration may involve assessing vital signs and making critical decisions. Choice D is incorrect as providing care for surgical wound care involves wound assessment, dressing changes, and monitoring for signs of infection, which typically require a registered nurse.

5. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

Correct answer: B

Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.

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