ATI Adult Medical-Surgical Nursing Nclex Questions
Stephanie Smith
Chapter 26 – Respiratory Failure
1. A nurse in an emergency department is
... [Show More] assessing a client who was in a MVC. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6℃ (101.4℉), and SaO2 92% on room air. Which of the following actions should the nurse take first?
A. Obtain a chest x-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via a high-flow mask.
D. Initiate IV access.
Rationale: C- According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to provide the client oxygen to restore optimal breathing.
2. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
A. “This medication is given to treat infection.”
B. “This medication is given to facilitate ventilation.”
C. “This medication is given to decrease inflammation.”
D. “This medication is given to reduce anxiety.”
Rationale: B- Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption.
3. A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.)
A. A client who experienced a near-drowning incident
B. A client following a coronary artery bypass graft surgery.
C. A client who has a hemoglobin of 15.1 mg/Dl
D. A client who has dysphagia
E. A client who experienced a drug overdose
Rationale: A, B, D, E- A client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. A client who experienced a drug overdose is at risk for developing ARDS due to damage to the central nervous system.
4. A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for the client? (Select all that apply.)
A. Administer antibiotics.
B. Provide supplemental oxygen.
C. Administer antiviral medications.
D. Administer of bronchodilators.
E. Maintain ventilatory support.
Rationale: B, D, E- Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered given to treat severe hypoxemia. Administering of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client’s airway. Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.
5. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.)
A. Fentanyl
B. Furosemide
C. Midazolam
D. Dexamethasone
Rationale: A, C- Fentanyl is a pain medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. Midazolam is a sedative medication used to treat clients with ARDS when a neuromuscular blocking agent such as vecuronium is administered.
Chapter 27 – Cardiovascular Diagnostic and Therapeutic Procedures
1. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching?
A. “Air should be instilled into the monitoring system prior to the procedure.”
B. “The client should be positioned on the left side during the procedure.”
C. “The transducer should be level with the second intercostal space after the line is placed.”
D. “A chest x-ray is needed to verify placement after the procedure?”
Rationale: D- The nurse should ensure that a chest x-ray is obtained to confirm proper placement of the lines following placement.
2. A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following finding should the nurse expect?
A. Poor skin turgor
B. Bilateral crackles in the lungs
C. Jugular vein distension
D. Dry mucous membranes
E. Hepatomegaly [Show Less]