ATI PN COMPREHENSIVE PROCTORED Exam 2021 | PN COMPREHENSIVE PROCTORED Exam_Graded A

ATI PN COMPREHENSIVE PROCTORED Exam 2021 | PN COMPREHENSIVE PROCTORED Exam_Graded A This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold sta ...

ATI PN COMPREHENSIVE PROCTORED Exam 2021 | PN COMPREHENSIVE PROCTORED Exam_Graded A This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE. The nurse assesses a client with asthma and finds wheezing throughout the lung fields and decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhalation. What is the nurse's best action? a. Perform peak expiratory flow readings. b. Assess for a midline trachea. c. Administer oxygen and a rescue inhaler. d. Call a code. C Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding. A client has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Oxygen saturation greater than 95% d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Pain at insertion site g. Disconnection at Y site B, D, E, G Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention. A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a.Production of pink sputum b.Tracheal deviation c.Sudden onset of shortness of breath d.Pain at insertion site e.Drainage of 75 mL/hr ANS: B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur b, d, e Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity