A nurse is assessing a patient who has a chest tube in place following a thoracic surgery. Which of the following findings indicates a need for intervention:
1. Fluctuation of drainage in the tubing with inspiration.
2. Continuous bubbling in the water seal chamber.
3. Drainage of 75 mL in th...
ATI Respiratory Questions &
Answer(RATED A+)
A nurse is assessing a patient who has a chest tube in place following a thoracic
surgery. Which of the following findings indicates a need for intervention:
1. Fluctuation of drainage in the tubing with inspiration.
2. Continuous bubbling in the water seal chamber.
3. Drainage of 75 mL in the first hour after surgery.
4. Several small, dark-red blood clots in the tubing. -ANSWER 2. Continuous bubbling
in the water seal chamber.
Continuous bubbling in the water seal chamber suggests an air leak.
A nurse is caring for an elderly patient who suffers from COPD with pneumonia. The
nurse should monitor the patient for which of the following acid-base imbalances?
Respiratory acidosis is a common complication of COPD. This complication occurs
because patients who have COPD are unable to exhale carbon dioxide due to a loss of
elastic recoil in the lungs.
A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The nurse
should identify that which of the following findings is an adverse effect of this
medication?
1. Hallucinations
2. Pruritis
3. Hand and foot syndrome
4. Tinnitis -ANSWER 4. Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
A nurse is preparing to assist a provider to withdraw arterial blood from a patient's radial
artery for measurement of ABG. Which of the following actions should the nurse plan to
take?
1. Hyperventilate the patient with 100% oxygen prior to obtaining the specimen.
2. Apply ice to the site after obtaining the specimen.
,3. Perform an Allen's test prior to obtaining the specimen.
4. Release pressure applied to the puncture site 1 minute after the needle is withdrawn.
-ANSWER 3. Perform an Allen's test prior to obtaining the specimen.
The nurse should ensure that circulation to the hand is adequate from the ulnar artery in
case the radial artery is injured from the blood draw. The most common site for
withdrawal of arterial blood gases is the radial artery.
A nurse is providing instructions about pursed-lip breathing for a patient who has COPD
with emphysema. The nurse should explain that this breathing technique accomplishes
which of the following:
A patient who has COPD with emphysema should use pursed-lip breathing when
experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the
patient's pace of breathing, making each breath more effective. Pursed-lip breathing
releases trapped air in the lungs and prolongs exhalation to slow the breathing rate.
This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.
A nurse is preparing a patient for a thoracentesis. In which of the following positions
should the nurse place the patient:
1. Lying flat on the affected site
2. Prone with arms raised over the head
3. Supine with the head of the bed elevated
4. Sitting while leaning forward over the bedside table -ANSWER 4. Sitting while leaning
forward over the bedside table
When preparing a patient for a thoracentesis, the nurse should have the patient sit on
the edge of the bed and lean forward over the bedside table because this position
maximizes the space between the patient's ribs and allows for aspiration of
accumulated fluid and air.
A nurse on a med-surg unit is caring for a patient who is postoperative following a hip
replacement surgery. The patient reports feeling apprehensive and restless. Which of
the follow findings should the nurse recognize as an indication of a PE:
1. Sudden onset of dyspnea
2. Tracheal deviation
3. Bradycardia
4. Difficulty swallowing -ANSWER 1. Sudden onset of dyspnea
, Clinical manifestations of a PE have a rapid onset. Dyspnea occurs due to reduced
blood flow to the lungs.
A nurse is planning care for a patient who has COPD and is malnourished. Which of the
following recommendations to promote nutritional intake should the nurse include in the
plan:
1. Eat high-calorie foods first
2. Increase intake of water at meal times
3. Perform active range of motion exercises before meals
4. Keep saltine crackers nearby for snacking -ANSWER 1. Eat high-calorie foods first
The client who has COPD often experiences early satiety. Therefore, the patient should
eat high-calorie foods first.
A nurse is developing a teaching plan for a patient about preventing acute asthma
attacks. Which of the following points should the nurse plan to discuss first:
1. How to eliminate environmental triggers that precipitate attacks
2. The patient's perception of the disease process and what might have triggered
attacks in the past
3. The patient's medication regimen
4. Manifestations of respiratory infections -ANSWER 2. The patient's perception of the
disease process and what might have triggered attacks in the past
The nurse should apply the nursing process priority-setting framework. The nurse can
use the nursing process to plan patient care and prioritize nursing actions. Each step of
the nursing process builds on the previous step, beginning with assessment. Before the
nurse can formulate a plan of action, implement a nursing intervention, or notify a
provider of a change in a patient's status, the nurse must first collect adequate data
from the patient. Assessing the patient will provide the nurse with knowledge to make
an appropriate decision. Therefore, the first step the nurse should take is to assess the
patient's current knowledge.
A nurse in a provider's office is assessing a patient who states he was recently exposed
to TB. Which of the following findings is a clinical manifestation of pulmonary TB:
1. Pericardial friction rub
2. Weight gain
3. Night sweats
4. Cyanosis of the fingertips -ANSWER 3. Night sweats
Night sweats and fevers are clinical manifestations of TB.
A nurse is planning care for a patient following placement of a chest tube 1 hour ago.
Which of the following actions should the nurse include in the plan of care:
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