Ati n480 advanced med surg exam
Total Questions : 34
Showing 10 questions, Sign in for moreA nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia and hypoxia in the older adult client?
An emergency department nurse is expecting to admit a heat stroke client en route after being found unresponsive during the hottest day of the week. Which of the following manifestations will the nurse anticipate for the client to present? (Select all that apply.)
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?
Client reports an injury to their right ribs after falling 6 feet from a ladder. Client reports pain as 8 on a scale of 0 to 10 over the right lower rib cage with ecchymosis. Client is dyspneic and respirations are shallow. Client states, "It's hard for me to breathe."
A nurse is reviewing the client's medical record. Which of the following provider orders should the nurse anticipate for a client who has a pneumothorax?
A nurse is caring for a client who has a pneumothorax.
For each potential provider's order, click to specify if the potential order is anticipated, non-essential, or contraindicated for the client.
Explanation
Thoracentesis is non-essential for a client with pneumothorax because it is primarily used to drain fluid accumulation, not air. Unless there is a suspicion of a hemothorax or fluid build-up, thoracentesis would not address the cause of the client's respiratory distress and would not be the initial intervention.
Prepare for insertion of a chest tube is anticipated because it is the standard treatment for pneumothorax. A chest tube allows continuous evacuation of air from the pleural space, promoting lung re-expansion and stabilizing breathing, which is urgently needed for clients who report severe dyspnea and shallow respirations.
Pulmonary Function Tests (PFTs) are contraindicated because they involve deep inhalation and forceful exhalation maneuvers, which could cause further lung collapse or exacerbate the pneumothorax. These tests are inappropriate during acute respiratory distress and must be deferred until the pneumothorax resolves.
Obtaining intravenous access is anticipated because having a reliable IV line ensures immediate access for emergency medications, fluids, sedation, and possible analgesia, particularly when preparing for procedures such as chest tube insertion or stabilizing hemodynamic status in case of deterioration.
Obtain ABGs is anticipated because arterial blood gases provide critical information about the client's respiratory efficiency, including oxygenation, ventilation, and acid-base balance. These results help guide the need for supplemental oxygen therapy, ventilatory support, or further interventions.
A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGS?
- pH 7.22 (7.35-7.45)
- PaCOâ‚‚ 68 mm Hg (35-45)
- Base excess -2
- PaOâ‚‚ 78 mm Hg (80-100)
- Saturation 80%
- Bicarbonate 26 mEq/L (22-26)
A nurse is caring for a client admitted for liver failure and chronic kidney disease. They present with bradycardia, hypotension, and rapid respirations. The client's arterial blood gas results are noted below. Which of the following acid-base imbalances is the client experiencing?
- pH 7.29 (pH 7.35-7.45)
- PaCOâ‚‚ 44 (PaCO2 35-45)
- PaOâ‚‚ 95 (PaO2 80-100)
- HCO3 16 (HCO3 21-28)
A nurse is completing education with a client over the phone preparing for their scheduled pulmonary functions tests (PFTS). Which of the following statements requires further teaching?
A newly licensed nurse is caring for a mechanically ventilated client in the intensive care unit. The high pressure alarm becomes triggered. Which of the following interventions is appropriate for this alarm?
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