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ATI Respiratory/Cardio

Terms in this set (30)

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?

A. A client who is 48hr postoperative following a total hip arthroplasty.

B. A client who is 8hr postoperative following an open surgical appendectomy.

C. A client who is 2hr postoperative following an open reduction external fixation of the right radius.

D. A client who is 4hr postoperative following a laparoscopic cholecystectomy.
A. A client who is 48hr postoperative following a total hip arthroplasty.
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?

A. Lateral position with a pillow at the back and over the chest to support the arm

B. High-Fowler's position with the arms supported on the over-bed table.

C. Semi-Fowler's position with pillows supporting both arms.

D. Supine position with the head of the bed elevated to 15 degrees.
B. High-Fowler's position with the arms supported on the over-bed table.
A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?

A. Hyperkalemia

B. Dyspnea

C. Tachycardia

D. Candidiasis
C. Tachycardia
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen?

A. Nasal cannula

B. Nonrebreather mask

C. Simple face mask

D. Partial rebreather maks
B. Nonrebreather mask
A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?

A. Fluctuation of drainage in the tubing with inspiration

B. Continuous bubbling in the water seal chamber

C. Drainage of 75mL in the first hour after surgery

D. Several small dark-red blood clots in the tubing
B. Continuous bubbling in the water seal chamber
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments?

A. Presence of gag reflex

B. Pain level rating using a 0-10 scale

C. Hydration status

D. Appearance of the IV insertion site
A. Presence of gag reflex
A nurse working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax?

A. Collapsed neck veins on the affected side

B. Collapsed neck veins on the unaffected side

C. Tracheal deviation to the affected side

D. Tracheal deviation to the unaffected side
D. Tracheal deviation to the unaffected side
A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis?

A. pH 7.50, PO2 95mmHg, PaCO2 25mm Hg, HCO3 22 mEq/L

B. pH 7.50, PO2 87mmHg, PaCO2 35mm Hg, HCO3 30 mEq/L

C. pH 7.30, PO2 90mmHg, PaCO2 35mm Hg, HCO3 20 mEq/L

D. pH 7.30, PO2 80mmHg, PaCO2 55mm Hg, HCO3 22 mEq/L
D. pH 7.30, PO2 80mmHg, PaCO2 55mm Hg, HCO3 22 mEq/L
A nurse receives prescriptions from the provider for preforming nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription?

A. A client who has epistaxis

B. A client who has amyotrophic lateral sclerosis

C. A client who has pneumonia

D. A client who has emphysema
A. A client who has epistaxis
A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider?

A. Bleeding at the surgical site

B. Decreased oxygen saturation

C. Urinary retention

D. Increased pain level
B. Decreased oxygen saturation
A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

A. Schedule respiratory treatments following meals.

B. Have the client sit up in a chair for 2hr periods three times per day.

C. Provide a diet that is high in calories and protein.

D. Combine activities to allow for longer rest periods between activities.
C. Provide a diet that is high in calories and protein.
A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?

A. Comolyn sodium

B. Prednisone

C. Fluticasone/salmeterol

D. Albuterol
D. Albuterol
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?

A. Extra drainage system

B. Suture removal set

C. Container of sterile water

D. Nonadherent pads
C. Container of sterile water
A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect?

A. Decreased fremitus

B SaO2 95% on room air

C. Temperature 38.8C (101.8F)

D. Bradypnea
C. Temperature 38.8C (101.8F)
A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse impliement?

A. Airborne

B. Neutropenic

C. Contact

D. Droplet
A. Airborne
A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?

A. Pallor

B. Insertion site pain

C. Persistent cough

D. Temperature 37.3C (99.1F)
C. Persistent cough
A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect?

A. Blood-tinged sputum

B. Decreased tactile fremitus

C. Resonance with percussion

D. Peripheral edema
A. Blood-tinged sputum
A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider?

A. Increased anterior-posterior chest diameter

B. Productive cough with green sputum

C. Clubbing of the fingers

D. Pursed-lip breathing with exertion
B. Productive cough with green sputum
A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take?

A. Use clean technique when suctioning the client's endotracheal tube.

B. Use a rotating motion when removing the suction catheter.

C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube.

D. Suction the clients endotracheal tube every 2 hr.
B. Use a rotating motion when removing the suction catheter.
A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?

A. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma."

B. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage."

C. "I should remove the old twill ties after the new ties are in place."

D. "I should apply suction while inserting the catheter into my tracheostomy tube."
C. "I should remove the old twill ties after the new ties are in place."
A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?

A. Blood pressure

B. Capillary refill

C. Arterial blood gases

D. Heart rate
C. Arterial blood gases
A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?

A. Excess secretions

B. Kinks in the tubing

C. Artificial airway cuff leak

D. Biting on the endotracheal tube
C. Artificial airway cuff leak
A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect?

A. Arterial pH 7.5

B. PaCO2 25mm Hg

C. SaO2 92%

D. PaO2 58mm Hg
D. PaO2 58mm Hg
A nurse is assisting the provider who is preforming a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (Select all that apply.)

A. Wear goggles and a mask during the procedure.

B. Cleanse the procedure area with an antiseptic solution.

C. Instruct the client to take deep breaths during the procedure.

D. Position the client laterally on the affected side before the procedure.

E. Apply pressure to the site after the procedure.
A. Wear goggles and a mask during the procedure.

B. Cleanse the procedure area with an antiseptic solution.

E. Apply pressure to the site after the procedure.
A nurse is providing discharge teaching to a client who has a pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include?

A. "Ringing in the ears is an adverse effect of this medication"

B. "Have your skin test repeated in 4 months to show a positive result."

C. "Expect your urine and other secretions to be orange while taking this medication."

D. "Remember to take this medication with a sip of water just before your first bite of each meal."
C. "Expect your urine and other secretions to be orange while taking this medication."
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?

A. Ronchi on inspiration

B. Elevated temperature

C. Barrel-shaped chest

D. Diminished breath sounds
B. Elevated temperature
A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?

A. Apply supplemental oxygen

B. Increase the rate of IV fluids

C. Administer pain medication

D. Initiate cardiac monitoring
A. Apply supplemental oxygen
A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following statements indicates an understanding of the teaching?

A. "I will monitor my heart rate every day while taking this medication."

B. "I will make sure I have this medication with me at all times."

C. "I will need to carefully rinse out my mouth after I take this medication."

D. "I will take this medication every night even if I don't have symptoms."
D. "I will take this medication every night even if I don't have symptoms."
A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority?

A. Provide a quiet environment.

B. Encourage use of incentive spirometry every 1 to 2 hr.

C. Obtain a blood sample for electrolyte study.

D. Administer heparin via continuous IV infusion.
D. Administer heparin via continuous IV infusion.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider?

A. Decreased bowel sounds

B. Oxygen saturation 92%

C. CO2 24mEq/L

D. Intercostal retractions
D. Intercostal retractions
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