ATI MED SURG FORM A EXAM SOLUTIONS WITH EXPLANATION

ATI MED SURG FORM A EXAM SOLUTIONS WITH EXPLANATION A nurse is caring for an older client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a) respiratory alkalosis b) respiratory acidosis c) metabolic alkalosis d) metabolic acidosis - ANSWER-b) respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicated that the nurse should suction the client's airway secretions? a) the client is unable to speak b) the client's airway secretions were last suctioned 2 hr ago c) the client coughs and expectorates a large mucous plug d) the nurse auscultates coarse crackles in the lung field - ANSWER-d) the nurse auscultates coarse crackles in the lung field The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions. A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a) pericardia friction rub b) weight gain c) night sweats d) cyanosis of the fingertips - ANSWER-c) night sweats Night sweats and fevers are clinical manifestations of tuberculosis. A nurse in the ED is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? a) absence of breath sounds b) expiratory wheezing c) inspiratory stridor d) rhonchi - ANSWER-a) absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? a) position the client supine with his legs elevated when in bed b) encourage the client to ambulate for 15 minutes every hour while awake for the first 24 hr c) the client to sit with his legs dependent after ambulating d) instruct the client to wear knee-length socks for 2 weeks after surgery - ANSWER-a) position the client supine with his legs elevated when in bed should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart A nurse is reviewing a client's repeat lab results 4 hr after administering fresh frozen plasma. Which of the following lab results should the nurse review? a) prothrombin time b) WBC count c) platelet count d) hematrocrite - ANSWER-a) prothrombin time A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? a) how to eliminate environmental triggers that precipitate attacks b) the client's perception of the disease process and what might have triggered past attacks c) the client's medication regimen d) manifestations of respiratory infections - ANSWER-b) the client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process prioritysetting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge. A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? a) friction rub b) crackles c) crepitus d) tactile fremitus - ANSWER-c) crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.