ATI RESPIRATORY LEARNING SYSTEM MED-SURG
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: - Answers -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?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis - Answers -2. Respiratory acidosis
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.
Respiratory alkalosis - Answers -hyperventilation
Occurs when pt exhales too much carbon dioxide
Metabolic alkalosis - Answers -high pH, high HCO3
Pt has excessive amount of bicarbonate
Clients who use bicarbonate of soda as an antacid are at risk for the development of
metabolic alkalosis.
Excessive vomiting also places a client at risk for development of metabolic alkalosis.
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?
A. Hallucinations
B. Pruritus
C. Hand and foot syndrome
D. Tinnitus - Answers -Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
Hand and foot syndrome = adverse effect of capecitabine, an antineoplastic
- medication used to treat breast and colorectal cancer.
,Pruritus is an adverse effect of methotrexate, which is used to treat cancer and
rheumatoid arthritis.
Hallucinations are an adverse effect of asparaginase, which is an antineoplastic
medication used to treat acute lymphocytic leukemi
A nurse is preparing a patient for a thoracentesis. In which of the following positions
should the nurse place the patient:
A. lying flat on affected side
B. Prone with arms raised over head
C. Supine with HOB elevated
D. Sitting while leaning forward over the bedside table - Answers -4. Sitting while
leaning forward over the bedside table
-- 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:
a. sudden onset of dyspnea
b. Tracheal deviation
c. Bradycardia
d. Difficulty swallowing - Answers -1. Sudden onset of dyspnea
Clinical manifestations of pulmonary embolism have a rapid onset.
PE S&S:
- Dyspnea
- Tachycardia
Dyspnea occurs due to reduced blood flow to the lungs.
Tracheal deviation is an indication of pneumothorax.
Difficulty swallowing is an indication of many conditions, including oral cance
Nurse is providing discharge teaching to a client who is postoperative following a
rhinoplasty. Which of the following instructions should the nurse include?
A. Apply warm compresses to the face
B. Take aspirin 650 mg by mouth for mild pain
C. Close your mouth when sneezing
D. Lie on your back with your head elevated 30 degree when resting - Answers -D. Lie
on your back with your head elevated 30 degree when resting
The nurse should instruct the client to rest in the semi-Fowler's position to prevent
aspiration of nasal secretions.
, The client should open her mouth when sneezing to reduce straining on the incisional
site.
The client should avoid taking aspirin, because it increases the risk of bleeding by
decreasing platelet aggregation.
The client should apply cold compresses to his face to decrease swelling
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:
A. Eat high calorie foods first
B. increase intake of water at meal times
C. Perform active ROM before meals
D. Keep saltine crackers nearby for snacking - Answers -1. Eat high-calorie foods first
The client who has COPD often experiences early satiety. Therefore, the client should
eat calorie-dense foods first.
Although it is important for a client who has COPD to maintain adequate fluid intake to
prevent dehydration and inhibit the production of tenacious secretions, the client should
limit intake of water at mealtimes to reduce the feeling of early satiety.
Rest before meals to decrease dyspnea during meals
The client should keep foods on hand for snacking, but should avoid dry and salty
foods, which can place the client at risk for aspiration and make the client's mouth dry.
Albuterol - Answers -albuterol
Administration Consideration
Use cautiously in clients with hypertension and cerebral vascular disorders.
Adverse Reaction
Include tachycardia, tremor, hypertension, bronchospasm, headache and dizziness.
Available Forms
aerosol inhaler, tablets, injection.
Class
bronchodilator
Contraindications
May included drug hypersensitivity and breast-feeding.
Indications
Bronchospasm and the prevention of asthma triggered by exercise.
IV_Facts
Dilute before injection. Do not mix with other drugs.
Nursing Consideration
Assess respiratory status often. Watch for adverse reactions.
Therapeutic Actions
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: - Answers -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?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis - Answers -2. Respiratory acidosis
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.
Respiratory alkalosis - Answers -hyperventilation
Occurs when pt exhales too much carbon dioxide
Metabolic alkalosis - Answers -high pH, high HCO3
Pt has excessive amount of bicarbonate
Clients who use bicarbonate of soda as an antacid are at risk for the development of
metabolic alkalosis.
Excessive vomiting also places a client at risk for development of metabolic alkalosis.
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?
A. Hallucinations
B. Pruritus
C. Hand and foot syndrome
D. Tinnitus - Answers -Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
Hand and foot syndrome = adverse effect of capecitabine, an antineoplastic
- medication used to treat breast and colorectal cancer.
,Pruritus is an adverse effect of methotrexate, which is used to treat cancer and
rheumatoid arthritis.
Hallucinations are an adverse effect of asparaginase, which is an antineoplastic
medication used to treat acute lymphocytic leukemi
A nurse is preparing a patient for a thoracentesis. In which of the following positions
should the nurse place the patient:
A. lying flat on affected side
B. Prone with arms raised over head
C. Supine with HOB elevated
D. Sitting while leaning forward over the bedside table - Answers -4. Sitting while
leaning forward over the bedside table
-- 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:
a. sudden onset of dyspnea
b. Tracheal deviation
c. Bradycardia
d. Difficulty swallowing - Answers -1. Sudden onset of dyspnea
Clinical manifestations of pulmonary embolism have a rapid onset.
PE S&S:
- Dyspnea
- Tachycardia
Dyspnea occurs due to reduced blood flow to the lungs.
Tracheal deviation is an indication of pneumothorax.
Difficulty swallowing is an indication of many conditions, including oral cance
Nurse is providing discharge teaching to a client who is postoperative following a
rhinoplasty. Which of the following instructions should the nurse include?
A. Apply warm compresses to the face
B. Take aspirin 650 mg by mouth for mild pain
C. Close your mouth when sneezing
D. Lie on your back with your head elevated 30 degree when resting - Answers -D. Lie
on your back with your head elevated 30 degree when resting
The nurse should instruct the client to rest in the semi-Fowler's position to prevent
aspiration of nasal secretions.
, The client should open her mouth when sneezing to reduce straining on the incisional
site.
The client should avoid taking aspirin, because it increases the risk of bleeding by
decreasing platelet aggregation.
The client should apply cold compresses to his face to decrease swelling
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:
A. Eat high calorie foods first
B. increase intake of water at meal times
C. Perform active ROM before meals
D. Keep saltine crackers nearby for snacking - Answers -1. Eat high-calorie foods first
The client who has COPD often experiences early satiety. Therefore, the client should
eat calorie-dense foods first.
Although it is important for a client who has COPD to maintain adequate fluid intake to
prevent dehydration and inhibit the production of tenacious secretions, the client should
limit intake of water at mealtimes to reduce the feeling of early satiety.
Rest before meals to decrease dyspnea during meals
The client should keep foods on hand for snacking, but should avoid dry and salty
foods, which can place the client at risk for aspiration and make the client's mouth dry.
Albuterol - Answers -albuterol
Administration Consideration
Use cautiously in clients with hypertension and cerebral vascular disorders.
Adverse Reaction
Include tachycardia, tremor, hypertension, bronchospasm, headache and dizziness.
Available Forms
aerosol inhaler, tablets, injection.
Class
bronchodilator
Contraindications
May included drug hypersensitivity and breast-feeding.
Indications
Bronchospasm and the prevention of asthma triggered by exercise.
IV_Facts
Dilute before injection. Do not mix with other drugs.
Nursing Consideration
Assess respiratory status often. Watch for adverse reactions.
Therapeutic Actions
