ATI PRACTICE ASSESSMENT- RESPIRATORY/30 QUESTIONS
AND ANSWERS
A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax? - -Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
-A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. The nurse should plan to include what in the client's discharging teaching plan? - -Urine and other secretions will be orange.
-A nurse is caring for a client who has bacterial pneumonia. The nurse should expect what assessment finding? - -Temp 101.8 degrees F
Rat.: an elevated temp is an expected finding for a client who has bacterial pneumonia
-A nurse is assessing a client who has a chest tube in place following thoracic surgery. What finding indicates a need for intervention? - -Continuous bubbling in the water seal chamber. Rat.: continuous bubbling is the water seal chamber suggests an air leak.
-A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm sounds. What should the nurse recognize as a cause of the alarm? - -Artificial airway cuff leak. Rat.: an artificial airway leak interferes with oxygenation and causes the low pressure alarm to sound.
-A nurse is caring for a client who has acute respiratory distress syndrome. What assessment finding indicates a decline in the client's condition? - -Increase in respiratory rate. Rat.: an increase in resp. rate indicates increased work of breathing and the need for improvement in oxygen delivery
-A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority? - -Administer heparin via continuous IV infusion. Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore, this is the priority intervetion.
-A nurse is planning care for a client who has COPD. What intervention should the nurse include in the plan of care? - -Provide a diet that is high in calories and protein. Rat.: the nurse should provide the client who has COPD with a diet that is high is calories and protein and low in carbohydrates.
-A nurse is caring for a client who has COPD. What findings should the nurse report to the provider? - -
Productive cough with green sputum Rat.: A nurse should report this as it indicates an infection
-A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse expect? - -PaO2 58mmHg
AND ANSWERS
A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax? - -Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
-A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. The nurse should plan to include what in the client's discharging teaching plan? - -Urine and other secretions will be orange.
-A nurse is caring for a client who has bacterial pneumonia. The nurse should expect what assessment finding? - -Temp 101.8 degrees F
Rat.: an elevated temp is an expected finding for a client who has bacterial pneumonia
-A nurse is assessing a client who has a chest tube in place following thoracic surgery. What finding indicates a need for intervention? - -Continuous bubbling in the water seal chamber. Rat.: continuous bubbling is the water seal chamber suggests an air leak.
-A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm sounds. What should the nurse recognize as a cause of the alarm? - -Artificial airway cuff leak. Rat.: an artificial airway leak interferes with oxygenation and causes the low pressure alarm to sound.
-A nurse is caring for a client who has acute respiratory distress syndrome. What assessment finding indicates a decline in the client's condition? - -Increase in respiratory rate. Rat.: an increase in resp. rate indicates increased work of breathing and the need for improvement in oxygen delivery
-A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority? - -Administer heparin via continuous IV infusion. Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore, this is the priority intervetion.
-A nurse is planning care for a client who has COPD. What intervention should the nurse include in the plan of care? - -Provide a diet that is high in calories and protein. Rat.: the nurse should provide the client who has COPD with a diet that is high is calories and protein and low in carbohydrates.
-A nurse is caring for a client who has COPD. What findings should the nurse report to the provider? - -
Productive cough with green sputum Rat.: A nurse should report this as it indicates an infection
-A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse expect? - -PaO2 58mmHg
