a nurse is preparing a client for transfer to the icu for placement of a pulmonary artery catheter the nurse should explain to the client that this ca
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Nursing Elites

ATI RN

Medical Surgical ATI Proctored Exam

1. When preparing a client for transfer to the ICU for placement of a pulmonary artery catheter, the nurse should explain that this catheter is used to monitor which of the following conditions?

Correct answer: D

Rationale: A pulmonary artery catheter is primarily used to monitor hemodynamic status. It provides essential information on cardiac output, preload, afterload, and overall cardiovascular function. This data helps healthcare providers manage the client's fluid status, cardiac function, and guide treatment interventions in critically ill patients. Monitoring intracranial pressure, spinal cord perfusion, or renal function would require different monitoring devices and techniques, not a pulmonary artery catheter.

2. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

3. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.

4. A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?

Correct answer: B

Rationale: Proper administration of insulin is crucial for clients with type 1 diabetes as they are dependent on insulin for blood glucose control.

5. A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?

Correct answer: B

Rationale: Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.

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