ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 27 Questions
Question 1 of 5
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care?
Correct Answer: A
Rationale: Dyspnea with activity intolerance, such as stopping multiple times while climbing stairs, indicates functional limitation (class III). Assistance with activities of daily living supports the client's needs without restricting activity unnecessarily. Oxygen therapy or bedrest may not be indicated unless hypoxia or severe limitation is present.
Question 2 of 5
While obtaining a client's health history, the client states, 'I am allergic to avocados.' Which responses by the nurse are best? (Select all that apply.)
Correct Answer: A,D,E
Rationale: Assessing the specific allergic response, documenting the allergy, and inquiring about past treatments are critical for safe care. Removing avocados is practical but secondary, and asking about the last time eaten is less relevant.
Question 3 of 5
A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
Correct Answer: B
Rationale: An equal AP and lateral chest diameter suggests a barrel chest, often associated with chronic airflow limitation conditions like COPD or severe asthma. Asking about chronic breathing problems directly addresses the potential underlying cause. Other options are less relevant to this specific finding.
Question 4 of 5
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
Correct Answer: B
Rationale: Continuous cyanosis despite oxygen therapy suggests methemoglobinemia, a serious adverse effect of benzocaine spray. Notifying the Rapid Response Team is critical for immediate advanced care. Other actions do not address the urgent oxygenation issue.
Question 5 of 5
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
Correct Answer: B
Rationale: Absent breath sounds may indicate a pneumothorax, a life-threatening complication post-lung biopsy requiring immediate action. Increased temperature, productive cough, and incisional discomfort are not immediately life-threatening.