ATI Fundamentals

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While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?

  • A. Obtain baseline vital signs and oxygen saturation.
  • B. Obtain a sputum culture.
  • C. Obtain a complete history from the client.
  • D. Provide a pneumococcal vaccine.
Correct Answer: A

Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.

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A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

  • A. Oxygen equipment
  • B. Incentive spirometer
  • C. Pulse oximeter
  • D. Sterile dressing
Correct Answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

During the removal of a chest tube, what should the nurse instruct the client to do?

  • A. Lie on their left side.
  • B. Use the incentive spirometer.
  • C. Cough at regular intervals.
  • D. Perform the Valsalva maneuver.
Correct Answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

A healthcare professional is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the professional recognize?

  • A. Confusion
  • B. Pale skin
  • C. Bradycardia
  • D. Hypotension
Correct Answer: B

Rationale: Pale skin is an early manifestation of hypoxemia due to decreased oxygenation of the blood. The skin may appear pale as the body redirects blood flow to vital organs in response to low oxygen levels. Confusion, bradycardia, and hypotension may occur as hypoxemia worsens, but pale skin is one of the initial signs that healthcare professionals should recognize when assessing a client experiencing respiratory distress.

A client is being educated by a healthcare provider on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?

  • A. ''This medication can decrease my immune response.''
  • B. ''I take this medication to prevent asthma attacks.''
  • C. ''I need to take this medication with food.''
  • D. ''This medication has a slow onset to treat my symptoms.''
Correct Answer: B

Rationale: The correct answer is, 'I take this medication to prevent asthma attacks.' Bronchodilators are commonly used to relieve bronchospasm in conditions such as asthma. This medication helps to dilate the airways, making it easier to breathe and preventing asthma attacks. The other options are incorrect: option A is inaccurate as bronchodilators do not decrease immune responses, option C is incorrect as bronchodilators are typically taken on an empty stomach for better absorption, and option D is false as bronchodilators have a rapid onset to provide quick relief of symptoms.

During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

  • A. Continuous bubbling in the water seal chamber
  • B. Gentle constant bubbling in the suction control chamber
  • C. Drainage system positioned upright at chest level
  • D. Exposed sutures without dressing
Correct Answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

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