a nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis the client states she is anxious and is unable to get enough air

ATI RN

ATI Fundamentals Proctored Exam Quizlet

1. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

2. What is the most common injury among elderly persons?

A. Atherosclerotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

Correct answer: D

Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.

3. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

A. ''I am allergic to morphine.''
B. ''I take antacids several times a day.''
C. ''I had a blood clot in my leg several years ago.''
D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

4. Which of the following patients is at greater risk for contracting an infection?

A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic surgery
D. A newly diagnosed diabetic patient

Correct answer: A

Rationale: Leukopenia, characterized by low white blood cell count, significantly reduces the body's ability to fight infections. Patients with leukopenia are at a higher risk of contracting infections due to compromised immune defenses.

5. Palpating the midclavicular line is the correct technique for assessing

A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.