ATI Adult Medical Surgical

Correct Answer: B

Rationale: The correct answer is B: Diminished cough effort. Clients with myasthenia gravis often experience muscle weakness, including respiratory muscles, which can lead to diminished cough effort. This weakness can result in ineffective airway clearance, putting the client at a high risk. Pain when coughing (choice A) is not directly related to the etiology of ineffective airway clearance in myasthenia gravis. While thick, dry secretions (choice C) and excessive inflammation (choice D) can contribute to airway clearance issues, the primary concern in myasthenia gravis is the muscle weakness affecting cough effort.

Correct Answer: B

Rationale: Salmeterol is classified as a long-acting beta2-agonist, which is used to prevent asthma attacks by providing extended bronchodilation. It is not typically used for immediate relief of acute bronchospasm or for suppressing cough. Additionally, salmeterol does not have the primary purpose of thinning respiratory secretions.

Correct Answer: C

Rationale: In this scenario, the client is experiencing symptoms of shortness of breath, which could indicate fluid overload from the PRBC transfusion. By decreasing the intravenous flow rate of the transfusion, the nurse can slow down the rate of blood being infused, potentially alleviating the symptoms of fluid overload and shortness of breath. This intervention can help prevent further complications and promote the client's comfort and safety.

Correct Answer: C

Rationale: In children, ringing in the ears (tinnitus) can be a sign of aspirin toxicity. Aspirin toxicity can be particularly concerning in children and can lead to serious complications. Therefore, it is crucial for the nurse to prioritize monitoring for signs of aspirin toxicity, such as tinnitus, and promptly notify the healthcare provider if such symptoms occur.

Correct Answer: C

Rationale: The nurse should stop the magnesium sulfate infusion immediately in a client with preeclampsia exhibiting diminished reflexes, respiratory depression, and low urinary output, which indicate magnesium sulfate toxicity. This action is crucial to prevent further complications and adverse effects on the client.