MED SURGE Respiratory ATI
1- A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink,
... [Show More] frothy, and copious. The client has history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (SATA)
-Assign the client to a private room with negative-pressure airflow
-Wear an N95 respirator when entering the client’s room.
2- A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique help evaluate which of the following structures?
-Maxillary sinuses
3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation?
-Discuss ways the client can reduce the number of cigarettes smoked per day.
4- A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?
-Eat high-calorie food first.
Rational: client who has COPD experience early satiety. Client should eat calorie-dense food first.
5- A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?
-Tinnitus.
Rational: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
6- A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?
-Stabbing chest pain
Rational: sudden chest pain that is sharp and stabbing is a manifestation of pulmonary embolism. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and feeling of impending doom.
7- A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound (stridor). The nurse should identify theses findings as manifestations of which of the following complications?
-Respiratory obstruction
8- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect?
-ph 7.49,HCO3-32mEq/L, PaCO2 40mmHg
Rational: Metabolic alkalosis: pH and bicarbonate values are greater than the expected references range, and the PaCO2 is within the expected reference range.
9- A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
-“A tissue sample might be obtained during the procedure”
10- A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (SATA)
-Explain that the client will receive sedation and will not remember the procedure.
-Verify that the client understands the purpose and nature of the procedure.
11- A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessment is the nurse’s monitoring priority?
-Confirming the gag reflex
Rational: The greater risk to the client’s safety is aspiration resulting from a depressed gag reflex. 12- A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2
chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make?
-“The lower tube will drain blood, and the higher tube will remove air.”
13- A nurse is providing teaching to a client who will undergo a total laryngectomy. Which of the following statements indicate that the client understands the impact of the surgery?
- “I understands that I will have a permanent tracheostomy after the surgery.”
Rational: With a partial laryngectomy, the tracheostomy is temporary. With the total laryngectomy the tracheostomy will be permanent.
14- A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse tells the client to be careful while bathing to prevent which of the following complications?
-Aspiration of water.
Rational: This is a client with a tracheostomy, so he will need to use a shower shield over the stoma when bathing or showering to keep water out of the airway.
15- A nurse is caring for a client who is extremely anxious and is hyperventilating. The client’s ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3-25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?
-Respiratory alkalosis.
16- A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (SATA)
-NPO status
-Alternative methods of communication
- Changes in body image
-Swallowing exercises.
17- A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include?
- “You must return to the clinic to have the test read in 2 or 3 days.” [Show Less]