what are the key components of a respiratory assessment

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What are the key components of a respiratory assessment?

A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Observation, Auscultation, Percussion
C. Auscultation, Palpation, Observation, Percussion
D. Observation, Palpation, Percussion, Auscultation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for symmetry and signs of distress, palpating for tenderness or abnormal masses, performing percussion to assess underlying tissues, and auscultating lung sounds. Choice B is incorrect as observation is a broad term that can encompass both inspection and palpation. Choice C is incorrect as auscultation is usually performed after inspection and palpation. Choice D is incorrect as observation should be more specific, and auscultation is a key component that is typically done last in a respiratory assessment.

2. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

A. Instruct the client to remain in bed until the fatigue resolves
B. Encourage the client to gradually resume self-care tasks with frequent rest periods
C. Assign assistive personnel to perform all self-care tasks for the client
D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.

3. What are the signs and symptoms of hyperkalemia and how should it be managed?

A. Muscle weakness and cardiac arrhythmias; administer calcium gluconate
B. Confusion and bradycardia; administer insulin and glucose
C. Fatigue and irregular heart rate; administer diuretics
D. Nausea and vomiting; administer sodium bicarbonate

Correct answer: A

Rationale: The signs and symptoms of hyperkalemia include muscle weakness and cardiac arrhythmias, making choice A correct. Hyperkalemia can lead to dangerous cardiac effects, and calcium gluconate is used to stabilize the heart by antagonizing the effects of potassium. Choices B, C, and D describe symptoms and interventions that are not typically associated with hyperkalemia. Confusion and bradycardia are not common in hyperkalemia, and insulin and glucose are used in hyperkalemia only under specific circumstances. Fatigue and irregular heart rate are vague symptoms, and diuretics are not the primary treatment for hyperkalemia. Nausea and vomiting are nonspecific symptoms and sodium bicarbonate is not indicated for the management of hyperkalemia.

4. A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

A. Assess mobility
B. Monitor vital signs
C. Provide pain relief
D. Reinforce discharge teaching

Correct answer: A

Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.

5. What are the principles of aseptic technique in wound care?

A. Use sterile gloves and a clean dressing
B. Apply a clean dressing using sterile scissors
C. Wash hands thoroughly before applying the dressing
D. Use a clean glove and avoid contact with the wound

Correct answer: A

Rationale: The correct answer is A: 'Use sterile gloves and a clean dressing.' Aseptic technique in wound care requires the use of sterile gloves to prevent infection. Choice B is incorrect as the method of application does not primarily focus on maintaining asepsis. Choice C, while important for infection control, is not specific to aseptic technique in wound care. Choice D is incorrect because using a single clean glove does not ensure the level of sterility needed for aseptic wound care.