ATI Medical Surgical Proctored Exam 2023

Correct Answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

Correct Answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

Correct Answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

Correct Answer: A

Rationale: Class III dyspnea indicates significant limitations in activity due to shortness of breath. Clients with this level of dyspnea should be encouraged to participate in activities within their tolerance levels. Providing assistance with activities of daily living helps conserve energy for essential tasks while promoting independence. Oxygen therapy is only necessary if hypoxia is present, and complete bedrest is generally not recommended for clients with dyspnea unless specifically indicated.

Correct Answer: D

Rationale: When educating a client with COPD about nutrition, it is important to consider factors that can impact breathing and digestion. Avoiding drinking fluids just before and during meals can help prevent bloating, which may impede breathing. Resting before meals if experiencing dyspnea can aid in reducing respiratory effort during eating. Having about six small meals a day can help prevent overeating and decrease the feeling of fullness, promoting easier breathing. However, it is crucial to be cautious with high-fiber foods as they can produce gas, leading to abdominal bloating and increased shortness of breath. Clients with COPD should focus on increasing calorie and protein intake to prevent malnourishment. It is advisable not to increase carbohydrate intake as this can elevate carbon dioxide production and exacerbate breathing difficulties.