ATI: #2 Targeted Medical-Surgical 2013: Respiratory

Question 1

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the priority for the nurse to use to evaluate the effectiveness of the mechanical ventilation?
A. BP
B. Capillary refill
C. Arterial blood gases
D. Heart rate

Answer 1

C. Arterial blood gases

Question 2

A nurse is caring for a client who has acute respiratory failure. Which of the following lab findings should the nurse expect?
A. Arterial pH 7.50
B. PaCO2  25mmHg
C. SaO2  92%
D. PaO2  58mmHg

Answer 2

D. PaO2 58mmHg

Question 3

A nurse is caring for a client in acute distress. respiratory. Which of the following devices should the nurse use to provide the highest level of oxygen via a low-flow system?
A. Nasal cannula
B. Nonrebreather mask
C. Simple face mask
D. Partial rebreather mask

Answer 3

B. Nonrebreather mask

Question 4

A nurse is caring for a client who has active TB. Which of the following isolation precautions should the nurse implement?
A. Airborne
B. Neutropenic
C. Contact
D. Droplet

Answer 4

A. Airborne

Question 5

A nurse is discharging a client who has pulmonary TB and is said to start therapy with rifampin. The nurse should plan to include which of the following in the client’s teaching?
A. Ringing in the ears is expected.
B. Purified protein derivative (PPD) skin test results will improve in 4 months.
C. Urine and other secretions will be orange.
D. Take the medication with meals.

Answer 5

C. Urine and other secretions will be orange.

Question 6

A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority?
A. Provide a quiet environment
B. Encourage use of incentive spirometry every 1-2hr
C. Initiate continuous cardiac monitoring
D. Administer heparin via continuous IV infusion

Answer 6

D. Administer heparin via continuous IV infusion

Question 7

A nurse is assessing a client with emphysema. The nurse should report which of the following assessment findings?
A. Digital clubbing
B. Elevated temperature
C. Barrel-shaped chest
D. Diminished breath sounds

Answer 7

A. Digital clubbing

Clubbed fingers and circumoral cyanosis are late signs of serious hypoxemia.

Question 8

A nurse working in the ED is caring for client with chest trauma. Which indicates tension pneumothorax?
A. Collapsed neck veins on the affected side
B. Collapsed neck veins on the unaffected side
C. Tracheal deviation to the affected side
D. Tracheal deviation to the unaffected side

Answer 8

D. Tracheal deviation to the unaffected side

Question 9

Postop client develops acute onset of chest pain that worsens upon inspiration. The client is tachypneic and anxious. What do you do first?
A. Apply supplemental oxygen
B. Increase the rate of IV fluids
C. Administer pain meds
D. Initiate heparin therapy

Answer 9

A. Apply supplemental oxygen

Question 10

A nurse is teaching a client about montelukast. Which statement indicates his understanding?
A. I will take this medication with each meal
B. I will take this medication during an asthma attack
C. I will take this medication up to 3times/day when I begin to wheeze
D. I will take this medication every evening, even when I do not have symptoms

Answer 10

D. I will take this medication every evening, even when I do not have symptoms

Question 11

A nurse is caring for a client with COPD. Which should be included in the care plan?
A. Schedule respiratory treatments following meals
B. Have the client sit in a chair for 2-hr periods 3times/day
C. Provide a diet that is high in calories and protein
D. Combine activities to allow for longer rest periods between activities

Answer 11

C. Provide a diet that is high in calories and protein

Question 12

A client is receiving mechanical ventilation. The low pressure alarm sounds, which was caused by ?
A. Excess secretions
B. Kinks in the tubing
C. Artificial airway cuff leak
D. Biting on the endotracheal tube

Answer 12

C. Artificial airway cuff leak

Question 13

A nurse is providing discharge instructions for a client with a tracheostomy. Which statement indicates a need for further instruction?
A. I need to inspect the stoma for signs of infection or skin irritation
B. I will clean the cannula with half-strength peroxide and rinse with saline
C. I can remove the old twill ties one the new ties are in place
D. I should apply suction with inserting the catheter into my tracheostomy

Answer 13

D. I should apply suction with inserting the catheter into my tracheostomy

Question 14

The nurse should clarify the provider’s prescription to perform nasopharyngeal suctioning for which of the following clients?
A. A client who has a closed-head injury and is lethargic
B. A client who has a fractured femur and reports severe pain
C. A client who has a ruptured appendix & a temperature of 102.2F
D. A client who has emphysema & respirations of 36/min

Answer 14

A. A client who has a closed-head injury and is lethargic

Question 15

A client has acute respiratory distress syndrome. Which of the following indicates a decline in his condition?
A. Increase in respiratory rate
B. Increase in oxygen saturation
C. Decrease in carbon dioxide retention
D. Decrease in intercostal retractions

Answer 15

A. Increase in respiratory rate

Question 16

Which of the following meds should the nurse plan to administer during an acute asthma attack?
A. Cromolyn sodium
B. Prednisone
C. Fluticasone & Salmeterol
D. Albuterol

Answer 16

D. Albuterol

Question 17

A nurse is caring for a client who is 1hr postop thoracentesis. Which of the following is the priority assessment finding?
A. Pallor
B. Insertion site pain
C. Tracheal deviation to the unaffected side
D. Temperature of 99.1F

Answer 17

C. Tracheal deviation to the unaffected side

Question 18

A nurse is caring for 4 clients. Which on is at greatest risk for pulmonary embolism?
A. A client who is 12hr postop total hip arthroplasty
B. A client who is 8hr postop open surgical appendectomy
C. A client who is 2hr postop open reduction external fixation of the right radius
D. A client who is 4hr postop following laproscopic cholecystectomy

Answer 18

A. A client who is 12hr postop total hip arthroplasty

Question 19

A nurse is caring for a client who is 4hr postop following a total laryngectomy for cancer. Which of the following assessments is the priority?
A. Bleeding at the surgical site
B. Oxygen saturation
C. Urinary retention
D. Level of consciousness

Answer 19

B. Oxygen saturation

Question 20

A nurse is caring for a client in respiratory distress who requires endotracheal suctioning. Which action should the nurse take?
A. Use clean technique to suction the endotracheal tube
B. Use a rotating motion to remove the suction catheter
C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube
D. Suction the client’s endotracheal tube every 2hr

Answer 20

B. Use a rotating motion to remove the suction catheter

Question 21

A nurse is caring for a client following the insertion of a chest tube. The nurse should plan to have which of the following items in the client's room?
A. Extra drainage system
B. Suture removal set
C. Container of sterile water
D. Nonadherent pads

Answer 21

C. Container of sterile water

Question 22

A nurse is assessing a client who has a chest tube in place following thoracic surgery. Which of the following indicates a need for intervention?
A. Fluctuation of the drainage in the tubing with inspiration
B. Continuous bubbling in the water seal chamber
C. Drainage of 75mL in the first hour after surgery
D. Several small, dark-red blood clots in the tubing

Answer 22

B. Continuous bubbling in the water seal chamber

Question 23

A nurse is caring for a postop client who is hypoventilating secondary to general anesthesia effects and incisional pain. Which of the following ABG values support the nurse’s suspicion of respiratory acidosis?
A. pH 7.5 — PaO2 95 — PaCO2 25 — HCO3 22
B. pH 7.5 — PaO2 87 — PaCO2 35 — HCO3 30
C. pH 7.3 — PaO2 90 — PaCO2 35 — HCO3 20
D. pH 7.3 — PaO2 80 — PaCO2 55 — HCO3 22

Answer 23

D. pH 7.3 — PaO2 80 — PaCO2 55 — HCO3 22

ROME

Respiratory= Opposite:

• pH is high, PCO2 is down (Alkalosis).
• pH is low, PCO2 is up (Acidosis).

Metabolic= Equal:

• pH is high, HCO3 is high (Alkalosis).
• pH is low, HCO3 is low (Acidosis).

Question 24

Client is taking albuterol. The nurse should monitor for which adverse effect?
A. Hyperkalemia
B. Dyspnea
C. Tachycardia
D. Candidiasis

Answer 24

D. Candidiasis

Question 25

Client has lung cancer. Which of the following assessment findings should the nurse report?
A. Blood-tinged sputum
B. Decreased tactile fremitus
C. Resonance with precussion
D. Peripheral edema

Answer 25

D. Peripheral edema
Complications of lung cancer: Superior vena cava syndrome, which results from pressure placed on the vena cava by a tumor. It is a medical emergency. Monitor for these early signs: facial, neck & peripheral edema; nosebleeds; dyspnea. Monitor for these late signs: mental status changes: cyanosis; hemorrhage; hypotension. Notify the provider immediately.

Question 26

A nurse is positioning a client with emphysema to promote effective breathing. The nurse should place the client in which of the following positions?
A. Lateral position with a pillow over the chest to support the arm
B. High-Fowler’s position with arms supported on the overbed table
C. Semi-Fowler’s with pillows supporting both arms
D. Supine with HOB at 15 degrees

Answer 26

B. High-Fowler’s position with arms supported on the overbed table