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ATI Practice Assessment- Respiratory Exam- 30 Q’s and A’s
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ATI Practice Assessment- Respiratory Exam- 30 Q’s and A’s
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ATI Practice Assessment- RespiratoryExam- 30 Q’s and A’s
A nurse working in the emergency department is caring for a client following
a chest trauma. What findings indicates a tension pneumothorax? - -
Tracheal deviation to the unaffected side.
Rat.: a tension pneumothorax results from free air filling the chest cavity,
causing the lung to collapse and forcing the trachea to deviate to the
unaffected side.
-A nurse is discharging a client who has pulmonary tuberculosis and is to
start therapy with refampin. The nurse should plan to include what in the
client's discharging teaching plan? - -Urine and other secretions will be
orange.
-A nurse is caring for a client who has bacterial pneumonia. The nurse
should expect what assessment finding? - -Temp 101.8 degrees F
Rat.: an elevated temp is an expected finding for a client who has bacterial
pneumonia
-A nurse is assessing a client who has a chest tube in place following
thoracic surgery. What finding indicates a need for intervention? - -
Continuous bubbling in the water seal chamber.
Rat.: continuous bubbling is the water seal chamber suggests an air leak.
-A nurse is caring for a client receiving mechanical ventilation. The low
pressure alarm sounds. What should the nurse recognize as a cause of the
alarm? - -Artificial airway cuff leak.
Rat.: an artificial airway leak interferes with oxygenation and causes the low
pressure alarm to sound.
-A nurse is caring for a client who has acute respiratory distress syndrome.
What assessment finding indicates a decline in the client's condition? - -
Increase in respiratory rate.
Rat.: an increase in resp. rate indicates increased work of breathing and the
need for improvement in oxygen delivery
-A nurse is caring for a client who has pulmonary embolism. Which of the
following interventions is the priority? - -Administer heparin via continuous
IV infusion.
Rat.: using the airway, breathing, circulation approach to client care, the
nurse should place priority on stabilizing circulation to the lungs by admin.
heparin to prevent further clot formation. Therefore, this is the priority
intervetion.
, -A nurse is planning care for a client who has COPD. What intervention
should the nurse include in the plan of care? - -Provide a diet that is high in
calories and protein.
Rat.: the nurse should provide the client who has COPD with a diet that is
high is calories and protein and low in carbohydrates.
-A nurse is caring for a client who has COPD. What findings should the nurse
report to the provider? - -Productive cough with green sputum
Rat.: A nurse should report this as it indicates an infection
-A nurse is caring for a client who has acute respiratory failure. What lab
findings should the nurse expect? - -PaO2 58mmHg
Rat.: nurse should expect to find a low partial pressures of oxygen for a
patient who has acute resp. failure
-A nurse is caring for a client who is postop and is hypoventilating secondary
to general anesthesia effects and incisional pain. What ABG values support
the nurses suspicion of respiratory acidosis? - -pH 7.30, PO2 80mmHg,
PaCO2 55mmHg, HCO3 22mEq/L
Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which
indicates resp. acidosis.
-A nurse is assisting with a thoracentesis. What actions is appropriate for the
nurse to take when assisting with this procedure? - -Wear goggles and mask
during the procedure: should wear this to reduce the risk of exposure to
pleural fluid.
Cleanse the area with an antiseptic solution: this decreases the risk of
infection, which is increased due to the invasive procedure.
Apply pressure to the site after the needle is withdrawn: this decreases the
risk of bleeding at the needle insertion site.
-A nurse is caring for a client who is in respiratory distress and requires
endotracheal suctioning. What actions should the nurse take? - -Use a
rotating motion to remove the suction catheter.
Rat.: the nurse should do this during withdrawal to reduce the risk of tissue
trauma.
-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? -
-Container of sterile water.
Rat.: the nurse should plan to place the open end of the tubing if it becomes
disconnected into the sterile water to prevent a pneumothroax. The tubing
and sterile water are then placed below the clients chest.
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