ATI MED SURG RESPIRATORY PROCTORED TEST BANK - EXAMINATION COMPLETE
QUESTIONS AND DETAILED SOLUTIONS LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: 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?
A. - Respiratory acidosis
B. - Metabolic acidosis
C. - Respiratory alkalosis
D. - Metabolic alkalosis
Answer:
C. - Respiratory alkalosis
Rationale: Because of rapid breathing, the client is exhaling excessive
amounts of carbon dioxide. This loss of carbon dioxide decreases the
hydrogen ion level of the blood, which causes the pH to increase and
results in respiratory alkalosis. Incorrect Answers: A. - Respiratory
acidosis reflects an increase in carbon dioxide resulting from inadequate
excretion and an increase in the hydrogen ion level (i.e. decreased pH)
of the blood. Common causes of this acid-base imbalance are airway
obstruction and respiratory depression.</p> B. - Metabolic acidosis
results from a metabolic disturbance such as diabetic ketoacidosis or
excessive ingestion of alcohol or salicylates, not a respiratory problem.
D. - Metabolic alkalosis results from a metabolic disturbance such as
prolonged vomiting or excessive nasogastric suctioning, not a
respiratory problem.
Question 2: A nurse is caring for a client who has chronic
obstructive pulmonary disease (COPD) and is experiencing
shortness of breath. Which of the following actions should the
nurse perform first?
, A. - Monitor the client's arterial blood gas results
B. - Instruct the client to perform controlled coughing
C. - Teach the client how to use pursed-lip breathing
D. - Place the client in an upright position
Answer:
D. - Place the client in an upright position
Rationale: Using the airway, breathing, and circulation (ABC) approach
to client care, the nurse should place the client in an upright position to
facilitate chest expansion and proper diaphragmatic contraction.
Positioning the client upright will also assist with mobilizing secretions
that might be impeding airflow. Incorrect Answers: A. - The nurse should
monitor the client's arterial blood gas results to determine oxygenation
levels; however, there is another action the nurse should take first. B. -
The nurse should instruct the client to perform controlled coughing when
not experiencing shortness of breath; however, there is another action
the nurse should take first. C. - The nurse should teach the client how to
use pursed-lip breathing when not experiencing shortness of breath;
however, there is another action the nurse should take first.
Question 3: A nurse on a medical-surgical unit is assessing a client
who recently transferred from the ICU following endotracheal
extubation. Which of the following findings should the nurse
identify as a possible manifestation of tracheal stenosis and report
to the provider?
A. - Increased coughing
B. - Diaphragmatic breathing
C. - Hemoptysis
D. - Kussmaul respirations
Answer:
,A. - Increased coughing
Rationale: The nurse should identify increased coughing as a
manifestation of tracheal stenosis. Other manifestations include an
inability to cough up secretions and difficulty talking or breathing.
Incorrect Answers: B. - Diaphragmatic breathing is the act of inhaling
deeply by flexing the diaphragm. It is not a manifestation of tracheal
stenosis. C. - Coughing up blood, otherwise known as hemoptysis, is an
abnormal finding following endotracheal extubation that should be
reported to the provider. However, it is not a manifestation of tracheal
stenosis. D. - Kussmaul respirations are a deep and labored breathing
pattern that is most often seen in clients who have metabolic acidosis. It
is not a manifestation of tracheal stenosis.
Question 4: A nurse in a provider's office is assessing a client who
states he was recently exposed to tuberculosis. Which of the
following findings is a clinical manifestation of pulmonary
tuberculosis?
A. - Pericardial friction rub
B. - Weight gain
C. - Night sweats
D. - Cyanosis of the fingertips
Answer:
C. - Night sweats
Rationale: Night sweats and fevers are clinical manifestations of
tuberculosis. Incorrect Answers: A. - A pericardial friction rub is a clinical
manifestation of rheumatic carditis. B. - Anorexia and weight loss are
clinical manifestations of tuberculosis. D. - Cyanosis of the fingertips is a
clinical manifestation of Raynaud's disease.
Question 5: 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. - "I can keep my dentures in during the procedure."
B. - "I am allowed only clear liquids prior to the procedure."
C. - "A tissue sample might be obtained during the procedure."
D. - "A signed consent form is not required for this procedure."
Answer:
C. - "A tissue sample might be obtained during the procedure."
Rationale: The nurse should inform the client that a tissue sample might
be obtained during the procedure for biopsy testing. Incorrect Answers:
A. - The client needs to remove dentures, glasses, or contacts so they
can be stored safely until after the procedure is completed. B. - The
client should ingest nothing by mouth for 6 hours prior to the procedure
to reduce the risk of aspiration. D. - A signed consent form is required
prior to a bronchoscopy because it requires sedation, and risk is
involved. By signing the consent form, the client is demonstrating an
understanding of the procedure and the risks.
Question 6: A nurse on a medical-surgical unit is caring for 4
clients. Which of the following clients should the nurse monitor for
crepitus?
A. - A client who has a chest tube following a pneumothorax
B. - A client who has an acute exacerbation of Crohn's disease
C. - A client who is postoperative following a laparoscopic
appendectomy
D. - A client who is recovering from thyroid storm
Answer:
A. - A client who has a chest tube following a pneumothorax
Rationale: Crepitus, a crackling sound resulting from air trapped under
QUESTIONS AND DETAILED SOLUTIONS LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: 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?
A. - Respiratory acidosis
B. - Metabolic acidosis
C. - Respiratory alkalosis
D. - Metabolic alkalosis
Answer:
C. - Respiratory alkalosis
Rationale: Because of rapid breathing, the client is exhaling excessive
amounts of carbon dioxide. This loss of carbon dioxide decreases the
hydrogen ion level of the blood, which causes the pH to increase and
results in respiratory alkalosis. Incorrect Answers: A. - Respiratory
acidosis reflects an increase in carbon dioxide resulting from inadequate
excretion and an increase in the hydrogen ion level (i.e. decreased pH)
of the blood. Common causes of this acid-base imbalance are airway
obstruction and respiratory depression.</p> B. - Metabolic acidosis
results from a metabolic disturbance such as diabetic ketoacidosis or
excessive ingestion of alcohol or salicylates, not a respiratory problem.
D. - Metabolic alkalosis results from a metabolic disturbance such as
prolonged vomiting or excessive nasogastric suctioning, not a
respiratory problem.
Question 2: A nurse is caring for a client who has chronic
obstructive pulmonary disease (COPD) and is experiencing
shortness of breath. Which of the following actions should the
nurse perform first?
, A. - Monitor the client's arterial blood gas results
B. - Instruct the client to perform controlled coughing
C. - Teach the client how to use pursed-lip breathing
D. - Place the client in an upright position
Answer:
D. - Place the client in an upright position
Rationale: Using the airway, breathing, and circulation (ABC) approach
to client care, the nurse should place the client in an upright position to
facilitate chest expansion and proper diaphragmatic contraction.
Positioning the client upright will also assist with mobilizing secretions
that might be impeding airflow. Incorrect Answers: A. - The nurse should
monitor the client's arterial blood gas results to determine oxygenation
levels; however, there is another action the nurse should take first. B. -
The nurse should instruct the client to perform controlled coughing when
not experiencing shortness of breath; however, there is another action
the nurse should take first. C. - The nurse should teach the client how to
use pursed-lip breathing when not experiencing shortness of breath;
however, there is another action the nurse should take first.
Question 3: A nurse on a medical-surgical unit is assessing a client
who recently transferred from the ICU following endotracheal
extubation. Which of the following findings should the nurse
identify as a possible manifestation of tracheal stenosis and report
to the provider?
A. - Increased coughing
B. - Diaphragmatic breathing
C. - Hemoptysis
D. - Kussmaul respirations
Answer:
,A. - Increased coughing
Rationale: The nurse should identify increased coughing as a
manifestation of tracheal stenosis. Other manifestations include an
inability to cough up secretions and difficulty talking or breathing.
Incorrect Answers: B. - Diaphragmatic breathing is the act of inhaling
deeply by flexing the diaphragm. It is not a manifestation of tracheal
stenosis. C. - Coughing up blood, otherwise known as hemoptysis, is an
abnormal finding following endotracheal extubation that should be
reported to the provider. However, it is not a manifestation of tracheal
stenosis. D. - Kussmaul respirations are a deep and labored breathing
pattern that is most often seen in clients who have metabolic acidosis. It
is not a manifestation of tracheal stenosis.
Question 4: A nurse in a provider's office is assessing a client who
states he was recently exposed to tuberculosis. Which of the
following findings is a clinical manifestation of pulmonary
tuberculosis?
A. - Pericardial friction rub
B. - Weight gain
C. - Night sweats
D. - Cyanosis of the fingertips
Answer:
C. - Night sweats
Rationale: Night sweats and fevers are clinical manifestations of
tuberculosis. Incorrect Answers: A. - A pericardial friction rub is a clinical
manifestation of rheumatic carditis. B. - Anorexia and weight loss are
clinical manifestations of tuberculosis. D. - Cyanosis of the fingertips is a
clinical manifestation of Raynaud's disease.
Question 5: 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. - "I can keep my dentures in during the procedure."
B. - "I am allowed only clear liquids prior to the procedure."
C. - "A tissue sample might be obtained during the procedure."
D. - "A signed consent form is not required for this procedure."
Answer:
C. - "A tissue sample might be obtained during the procedure."
Rationale: The nurse should inform the client that a tissue sample might
be obtained during the procedure for biopsy testing. Incorrect Answers:
A. - The client needs to remove dentures, glasses, or contacts so they
can be stored safely until after the procedure is completed. B. - The
client should ingest nothing by mouth for 6 hours prior to the procedure
to reduce the risk of aspiration. D. - A signed consent form is required
prior to a bronchoscopy because it requires sedation, and risk is
involved. By signing the consent form, the client is demonstrating an
understanding of the procedure and the risks.
Question 6: A nurse on a medical-surgical unit is caring for 4
clients. Which of the following clients should the nurse monitor for
crepitus?
A. - A client who has a chest tube following a pneumothorax
B. - A client who has an acute exacerbation of Crohn's disease
C. - A client who is postoperative following a laparoscopic
appendectomy
D. - A client who is recovering from thyroid storm
Answer:
A. - A client who has a chest tube following a pneumothorax
Rationale: Crepitus, a crackling sound resulting from air trapped under
