a nurse is providing care after auscultating clients breath sounds which finding is correctly matched to the nurses primary intervention
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. 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.

2. A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?

Correct answer: A

Rationale: Depression can occur in clients with heart failure, especially in older adults. When a client expresses thoughts of being a burden and death, it is crucial for the nurse to address these concerns. Offering to talk more about the client's feelings provides an opportunity for open communication and a deeper understanding of the client's emotions. Open-ended questions like the one in choice A encourage the client to express themselves freely, leading to better assessment and client-centered care. Choices B and C fail to address the client's emotional distress directly, and choice D diverts the focus without addressing the client's immediate concerns.

3. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

Correct answer: D

Rationale: Fluticasone is a corticosteroid often used to manage asthma. One of the common adverse effects associated with inhaled corticosteroids like fluticasone is oral candidiasis, also known as thrush. This fungal infection can develop in the mouth and throat due to the steroid's local immunosuppressive effects. Patients should be advised to rinse their mouths after using inhaled corticosteroids to reduce the risk of oral candidiasis. Monitoring for symptoms such as white patches, sore throat, or difficulty swallowing is essential to detect and manage this adverse effect promptly.

4. A student asks the faculty to explain best practices when communicating with a person from the LGBTQ community. What answer by the faculty is most accurate?

Correct answer: B

Rationale: It is essential not to make assumptions about the health needs of individuals from the LGBTQ community. Each person is unique, and assuming their needs based on their sexual orientation or gender identity can lead to incorrect care and communication. By being open-minded and avoiding assumptions, healthcare providers can create a safe and supportive environment for LGBTQ individuals to discuss their health needs openly and honestly.

5. Which action best demonstrates respect for autonomy when working with a client?

Correct answer: A

Rationale: Respect for autonomy involves allowing individuals to make decisions about their care. By asking if the client has questions before signing a consent form, the nurse is respecting the client's right to make informed choices and decisions regarding their healthcare. This action supports the principle of self-determination and autonomy in healthcare decision-making.

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