NUR 210 EXAM ONE ATI QUESTIONS WITH CORRECT ANSWERS GRADED TO PASS

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 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 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 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 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 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 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 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 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 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 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 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. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain - CORRECT A. Tachypnea B. Deviation of the trachea E. Pleuritic pain A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A. Assess the clients pain B. Obtain a large-bore IV C. Administer lorazepam D. Prepare for chest tube insertion - CORRECT B. Obtain a large-bore IV (ABC) A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? A. "Notify your provider if you experience weakness" B. "You should be able to return to work in 1 week" C. "You need to wear a mask when in crowded areas" D. "Notify your provider if you experience a productive cough" - CORRECT D. Notify your provider if you experience a productive cough (respiratory infection) A nurse in the emergency department is assessing a client who has suspected flail chest. Which of the following findings should the nurse expect? (select all that apply) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement - CORRECT B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement A nurse in the emergency department is assessing a client who was in a motor vehicle crash.Findings include absent breath soun ds in the left lower lope with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6C and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Prepare for chest tube insertion C. Administer oxygen via a high-flow mask D. Initiate IV access - CORRECT C. Administer oxygen via a high-flow mask A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "this medication is given to treat infection" B. "this medication is given to facilitate ventilation" C. "this medication is given to decrease inflammation" D. "This medication is given to reduce anxiety" - CORRECT B. "this medication is given to facilitate ventilation" (neuromuscular blocking agent) A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (select all that apply) A. a client who experienced a near drowning incident B. a client following coronary artery bypass graft surgery C. a client who has a hemoglobin of 15.1 mg/dL D. a client who has dysphagia E. A client who experienced a drug overdose - CORRECT A. a client who experienced a near drowning incident B. a client following a CABG surgery D. a client who has dysphagia E. a client who experienced a drug overdose A nurse is planning care for a client who has severe acute respiratory distress syndrome. Which of the following actions should be included in the plan of care for this client? (select all that apply) A. Administer antibiotics B. Provide supplemental oxygen C. administer antiviral medications D. Administer bronchodilators E. maintain ventilatory support - CORRECT B. Provide supplemental oxygen D. Administer bronchodilators E. Maintain ventilatory support A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (select all that apply) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone - CORRECT A. Fentanyl (pain medicine) C. Midazolam (sedative medication) A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72, heart rate 116 with regular rhythm, and respiratory rate 42 and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68, PaO2 96, PaCO2 38, HCO3 28 B. pH 7.48, PaO2 100, PaCO2 28, HCO3 23 C. pH 6.98, PaO2 100, PaCO2 30, HCO3 18 D. pH 7.58, PaO2 96, PaCO2 38, HCO3 29 - CORRECT C. pH 6.98, PaO2 100, PaCO2 30, HCO3 29 Metabolic acidosis A nurse is caring for a client who was in a motor vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.06, PaO2 96, PaCO2 52, HCO3 24 B. pH 7.42, PaO2 100, PaCO2 38, HCO3 23 C. pH 6.98, PaO2 100, PaCO2 30, HCO3 18 D. pH 7.58, PaO2 96, PaCO2 38, HCO3 29 - CORRECT A. pH 7.06, PaO2 96, PaCO2 52, HCO3 24 Respiratory acidosis A nurse is obtaining arterial blood gases for a client who has vomited for 24 hours. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hours? A. respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis - CORRECT D. metabolic alkalosis A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. metabolic acidosis can occur due to diabetic ketoacidosis B. metabolic acidosis can occur in a client who has myasthenia gravis C. metabolic acidosis can occur in a client who has asthma D. metabolic acidosis can occur due to cancer - CORRECT A. metabolic acidosis can occur due to diabetic ketoacidosis A nurse is assessing a client who has pancreatitis. The clients arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (select all that apply) A. tachycardia B. hypertension C. bounding pulses D. hyperreflexia E. dysrhythmia F. tachypnea - CORRECT E. dysrhythmia F. tachypnea A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing 3 specimens. Which of the following statements by the client indicates understanding of the teaching? A. i will continue to take my warfarin while i complete these tests B. I'm glad i don't have to follow any special diet at this time C. this test determines if i have parasites in my bowel D. this is an easy way to screen for colon cancer - CORRECT D. this is an easy way to screen for colon cancer A nurse is caring for a client following paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A. client report of upper chest pain B. decreased urine output C. pallor D. temperature elevation - CORRECT D. fever indicates bowel perforation A nurse is planning care for a client who has a new prescription for total parenteral nutrition. Which of the following interventions should be included in the plan of care? (select all that apply) A. obtain a capillary blood glucose 4 times daily B. administer prescribed medications through a secondary port on the TPN IV tubing C. monitor vital signs 3x during a 12 hour shift D. change the TPN IV tubing every 24 hours E. ensure a daily aPTT is obtained - CORRECT A. obtain a capillary blood glucose 4x daily, risk for hyperglycemia C. monitor vitals every 4 hours to assess fluid volume and for infection D. change IV tubing of TPN every 24 hours A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observes clear, pale yellow fluid leaking from the operative sites.Which of the following is an appropriate nursing intervention? A. place a clean towel near the drainage site B. apply a dry, sterile dressing C. apply direct pressure to the site D. place the client in a supine position - CORRECT B. apply a dry, sterile dressing A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which orf the following medications? A. Propranolol B. Metoclopraamide C. Ranitidine D. Vasopressin - CORRECT D. vasopressin A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to report? A. history of cholelithiasis B. elevated serum amylase level C. decrease in bowel sounds upon auscultation D. hand spasms present when BP is checked - CORRECT D. hand spasms (hypocalcemia) A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? A. instruct the client to chew the medication before swallowing B. offer a glass of water following administration C. administer the medications 30 minutes before meals D. sprinkle the contents on peanut butter - CORRECT B. offer a glass of water following administration A nurse is completing an admission assessment of a client who has pancreatitis Which of the following findings should the nurse expect? A. pain in the right upper quadrant radiating to right shoulder B. report of pain being worse when sitting upright C. pain relieved with defecation D. epigastric pain radiating to the left shoulder - CORRECT D. epigastric pain radiating to the left shoulder A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign. A. tap lightly at the costovertebral margin on the clients back B. palpate the right lower quadrant C. inspect the skin around the umbilicus D. auscultate the area below the scapula - CORRECT C. inspect the skin around the umbilicus