NUR 210 EXAM 1 ATI QUESTIONS AND ANSWERS 32
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results
are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is
experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - Correct answer ✔✔✔ B. Respiratory alkalosis
(Causes: hyperventilation, fever and respiratory infections)
A nurse is preparing to care for a client following chest tube placement. Which of the following
items should be available in the clients room? (select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - Correct answer ✔✔✔ A. Oxygen
B. Sterile water
C. enclosed hemostat clamps
E. Occlusive dressing
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the chest tube was accidentally removed. Which of the following actions should
the nurse take first?
A. Obtain a chest x-ray
,B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess respiratory status - Correct answer ✔✔✔ B. Apply sterile gauze to the insertion site
(ABC, allows air to escape and decreases risk of tension pneumothorax)
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the
following are expected findings? (select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - Correct answer ✔✔✔ B. Gentle constant bubbling in
the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the following should
the nurse instruct the client to do?
A. Lie on his left side
B. Use the incentive spirometer
C. Cough at regular intervals
D. Perform the Valsalva maneuver - Correct answer ✔✔✔ D. Perform the Valsalva maneuver
(tell client to take a deep breath, exhale and bear down)
A nurse is planning care for a client following the insertion of a chest tube and drainage system.
Which of the following should be included in the plan of care? (select all that apply)
A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
C. Strip the drainage tubing every 4 hours
,D. Clamp the tube once a day
E. Obtain a chest x-ray - Correct answer ✔✔✔ A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
E. Obtain a chest x-ray
A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical
ventilation and is on pressure support ventilation (PSV) mode. Which of the following
statements by the newly licensed nurse indicates and understanding of PSV?
A. "It keeps the alveoli open and prevents atelectasis"
B. "It allows preset pressure delivered during spontaneous ventilation"
C. "It guarantees minimal minute ventilator"
D. "It delivers a preset ventilatory rate and tidal volume to the client" - Correct answer ✔✔✔ B.
"It allows preset pressure delivered during spontaneous ventilation"
(decreases work of breathing)
A nurse is caring for a client who is experiencing respiratory distress. Which of the following
early manifestations of hypoxemia should the nurse recognize? (select all that apply)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - Correct answer ✔✔✔ B. Pale skin
E. Elevated blood pressure
A nurse is orienting a newly licensed nurse on preforming routine assessment of a client who is
receiving mechanical ventilation via an endotracheal tube. Which of the following information
should the nurse include in the teaching?
, A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 1 to 2 hours - Correct answer ✔✔✔ D. Assess breath sounds
every 1 to 2 hours
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of
the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the
client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask - Correct answer ✔✔✔ B. Venturi mask
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the
following modes of ventilation that increases the effort of the clients respiratory muscles should
the nurse include in the plan of care? (select all that apply)
A. Assist-control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
E. Independent lung ventilation - Correct answer ✔✔✔ B. Synchronized intermittent mandatory
ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
A nurse is assessing a client following a gunshot wound to the chest. For which of the following
findings should the nurse monitor to detect a pneumothorax? (select all that apply)
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results
are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is
experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - Correct answer ✔✔✔ B. Respiratory alkalosis
(Causes: hyperventilation, fever and respiratory infections)
A nurse is preparing to care for a client following chest tube placement. Which of the following
items should be available in the clients room? (select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - Correct answer ✔✔✔ A. Oxygen
B. Sterile water
C. enclosed hemostat clamps
E. Occlusive dressing
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the chest tube was accidentally removed. Which of the following actions should
the nurse take first?
A. Obtain a chest x-ray
,B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess respiratory status - Correct answer ✔✔✔ B. Apply sterile gauze to the insertion site
(ABC, allows air to escape and decreases risk of tension pneumothorax)
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the
following are expected findings? (select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - Correct answer ✔✔✔ B. Gentle constant bubbling in
the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the following should
the nurse instruct the client to do?
A. Lie on his left side
B. Use the incentive spirometer
C. Cough at regular intervals
D. Perform the Valsalva maneuver - Correct answer ✔✔✔ D. Perform the Valsalva maneuver
(tell client to take a deep breath, exhale and bear down)
A nurse is planning care for a client following the insertion of a chest tube and drainage system.
Which of the following should be included in the plan of care? (select all that apply)
A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
C. Strip the drainage tubing every 4 hours
,D. Clamp the tube once a day
E. Obtain a chest x-ray - Correct answer ✔✔✔ A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
E. Obtain a chest x-ray
A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical
ventilation and is on pressure support ventilation (PSV) mode. Which of the following
statements by the newly licensed nurse indicates and understanding of PSV?
A. "It keeps the alveoli open and prevents atelectasis"
B. "It allows preset pressure delivered during spontaneous ventilation"
C. "It guarantees minimal minute ventilator"
D. "It delivers a preset ventilatory rate and tidal volume to the client" - Correct answer ✔✔✔ B.
"It allows preset pressure delivered during spontaneous ventilation"
(decreases work of breathing)
A nurse is caring for a client who is experiencing respiratory distress. Which of the following
early manifestations of hypoxemia should the nurse recognize? (select all that apply)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - Correct answer ✔✔✔ B. Pale skin
E. Elevated blood pressure
A nurse is orienting a newly licensed nurse on preforming routine assessment of a client who is
receiving mechanical ventilation via an endotracheal tube. Which of the following information
should the nurse include in the teaching?
, A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 1 to 2 hours - Correct answer ✔✔✔ D. Assess breath sounds
every 1 to 2 hours
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of
the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the
client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask - Correct answer ✔✔✔ B. Venturi mask
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the
following modes of ventilation that increases the effort of the clients respiratory muscles should
the nurse include in the plan of care? (select all that apply)
A. Assist-control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
E. Independent lung ventilation - Correct answer ✔✔✔ B. Synchronized intermittent mandatory
ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
A nurse is assessing a client following a gunshot wound to the chest. For which of the following
findings should the nurse monitor to detect a pneumothorax? (select all that apply)
