ATI Med-Surg Exam 3 2021/2022 Graded A+
1. Select to the appropriate chamber meter (image of the atrium ocean machine)
A. suction control
b. Water
... [Show More] Seal
C. Air Leak
D. collection chamber
2. The nurse is caring for several clients on the respiratory unit. Which client will the nurse assess for the development of a pulmonary embolism?
A. Young adult with a femur fracture
B. Older adult who aspirated a tube feed
C. Middle-aged woman receiving a blood transfusion
D. Older adult with COPD
3. A patient who has been running a low grade fever, has had a chest tube inserted and is admitted to the medical surgical unit. Which medication subscription should the nurse clarify?
A. Ceftriaxone ivpb every 8 hrs
B. Metoprolol 50mg po bid
C. Morphine sulfate 4mg iv every 4 hours as needed for pain
D. Furomeside 40mg po daily
4. What assessment data is the nurse most likely to obtain in a patient who has survived the acute phase of ARDS and has progressed to the fibrotic stage?
A. Resolution of edema and healing of the lung
B. Continue hypoxemia because of diffusion limitation
C. Increased lung compliance caused by breakdown of fibrotic tissue
D. Chronic Pulmonary edema and atelectasis
5. When assessing a patient’s oxygen saturation (SaO2), the nurse notes a decrease from 96% to 82% over the course of the shift. What is the priority intervention?
A. Order “stat” ABGs to confirm the SpO2 with PaO2
B. Start administration of oxygen via nasal cannula at 2 L/min
C. Check the position of the probe on the finger or earlobe
D. Notify the provider of the change in baseline PaO2
Found a similar question answer was hyperoxygentate the client for 30-60second Other answer option is check position of probe on the finger or earlobe
6. Which Arterial Blood Gas value reflects effective treatment of respiratory acidosis in the patient with ARDS?
A. Ph 7.28: Pao2 96: Paco2: 45 HCO3 12
B. Ph 7.32: PaO2 98: PaCO2 25: HCO3 17
C. Ph 7.48: PaO2 85: PaCO2 32: HCO3 12
D. Ph 7.35: PaO2 78: PaCO2 55: HCO3 30 ARDS = PACO2 LOWER THAN 80-100
7. A patient with a pleural effusion had a thoracentesis and analysis of the fluid sent to the laboratory reveals a high (RBC) count. What does the nurse report?
A. Pulmonary edema
B. Infection
C. Trauma
D. Liver failure
8. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening the UAP reports that the client has a coughing spell during the meal. What action by the nurse takes priority?
A. Request thicker liquids for meals
B. Re-evalution by speech and swallow
C. Report the UAP to the manager
D. Assess the client’s lung sounds
9. A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
A. When the insertion site becomes red and warm to the touch
B. When the tube drainage decreases and becomes sanguineous
C. When the client experiences pain at the insertion site
D. When the tube becomes disconnected from the drainage system
10. A nurse cares for a client with a 40-year smoking history who’s experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with the clients history and clinical manifestations?
A. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles
B. Increased number and size of mucus glands producing large amounts of thick mucus
C. Left ventricular hypertrophy creating a decrease in cardiac output
D. Increased pulmonary pressure creating a higher workload on the right side of the heart
11. A nurse answers a call light and finds a client anxious, short of breath, reported right sided chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
A. Take a full set of vital signs
B. Provide reassurance to the client
C. Notify the Rapid Response Team
D. Assess the client’s lung sounds
12. A client is on intravenous heparin to treat a pulmonary embolism. The client’s most recent partial thromboplastin time (PTT) was 25 seconds.What order should the nurse anticipate?
A. Decrease the heparin rate
B. Increase the heparin rate
C. Stop heparin, start warfarin
D. No change to the heparin rate
13. A nurse caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
A. Platelet count: 82,000/L
B. Red blood cell count: 4.8/mm3
C. White blood cell count: 8.7/mm3
D. Hemoglobin: 14.2 g/dL
14. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
A. Change the sensor on the pulse oximeter
B. Assess for other manifestations of hypoxia
C. Obtain a new oximeter from central supply
D. Tell the client to take slow, deep breaths
15. A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
A. Find another provider to intubate
B. Monitor the client’s oxygen saturation
C. Interrupt the procedure to give oxygen
D. Ensure the client has adequate sedation
16. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority?
A. Suction the endotracheal tube
B. Ensure all connections are patent
C. Listen to the client’s lung sounds
D. Determine if the tube is kinked
17. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
A. Sedate the client immediately
B. Restrain the client’s hands
C. Assess the cause of the agitation
D. Reassure the client that he or she is safe
18. A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
A. Ensuring there is a bag-valve-mask in the room
B. Obtaining personal protective equipment
C. Assessing that the ventilator settings are correct
D. Planning to suction the client upon arrival to the room
19. A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?
A. It will prepare the gastrointestinal tract for enteral feedings
B. It will increase the mortality of the gastrointestinal tract
C. It will keep the gastrointestinal tract functioning normally
D. It will prevent ulcers from the stress of mechanical ventilation
20. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
A. Apply oxygen at 100%
B. Ensure a patent airway
C. Assess the respiratory rate
D. Start two large-bore IV lines
21. A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
A. Not aspirating prior to injection
B. Choosing an 22-gauge, 1-inch needle
C. Assessing the client’s platelet count
D. Swabbing the injection site with alcohol
According to quizlet Choosing an 18-gauge, 2-inch needle His answer option is a 22 gauge, 1-inch needle
22. A client in the emergency department has several broken ribs. What care measure will best promote comfort?
A. Providing wamed blankets
B. Humidifying the supplemental oxygen
C. Offering frequent, small drinks of water
D. Allowing the client toe choose the position in bed
23. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
A. Tissue plasminogen activator
B. Avoiding the complications associated
C. Unfractionated heparin
D. Low molecular weight heparin
E. Low molecular weight heparin
F. Unfractioned heparin ANSWER
24. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?
A. Prepare to assist with intubation
B. Facilitate a portable chest x-ray
C. Auscultate the client’s lung sounds
D. Administer oxygen and reassess
25. A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?
A. “It is hypoxemia that continues even after the client is weaned from oxygen”
B. “It is hypoxemia from lung damage due to mechanical ventilation”
C. “It is chronic hypoxemia that accompanies restrictive airway disease”
D. “It is hypoxemia that persists even with 100% oxygen administration”
26. A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information
Shortness of breath for 20 minutes Feels frightened
"Can't catch my breath"
Laboratory Analysis pH: 7.12
PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88%
Physical Assessment Pulse: 120 beats/min
Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles
What action by the nurse is most appropriate?
A. Pr [Show Less]