ATI RN Targeted Medical Surgical: Respiratory Online Practice 2024

ATI RN Targeted Medical Surgical: Respiratory Online Practice 2024 a nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? A.) Excess secretions B.) Kinks in the tubing C.) Artificial airway cuff leak D.) Biting on the endotracheal tube ️artificial airway cuff leak rationale: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound. a nurse is providing discharge teaching to a client who has a temporary tracheostomy. which of the following statements by the client indicates an understanding of the teaching? A.) "Ringing in the ears is an adverse effect of this medication." B.) "Have your skin test repeated in 4 months to show a positive result." C.) "Expect your urine and other secretions to be orange while taking this medication." D.) "Remember to take this medication with a sip of water just before your first bite of each meal." ️"I should remove the old twill ties after the new ties are in place." rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation. a nurse is caring for 4 clients. which of the following clients is at greatest risk for a pulmonary embolism? A.) A client who is 48 hr postoperative following a total hip arthroplasty B.) A client who is 8 hr postoperative following an open surgical appendectomy C.) A client who is 2 hr postoperative following an open reduction external fixation of the right radius D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy ️A client who is 48 hr postoperative following a total hip arthroplasty rationale: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications. a nurse is caring for a newly admitted client who has emphysema. the nurse should place the client in which of the following positions to promote effective breathing? A.) Lateral position with a pillow at the back and over the chest to support the arm B.) High-Fowler's position with the arms supported on the overbed table C.) Semi-Fowler's position with pillows supporting both arms D.) Supine position with the head of the bed elevated to 15° ️High-Fowler's position with the arms supported on the overbed table rationale: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table. a nurse is caring for a client who has asthma and is receiving albuterol. for which of the following adverse effects should the nurse monitor the client? A.) Hyperkalemia B.) Dyspnea C.) Tachycardia D.) Candidiasis ️Tachycardia rationale: The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis. a nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. the nurse should identify that which of the following assessments if the priority? A.) presence of gag reflex B.) pain level rating using 0 to 10 scale C.) hydration status D.) appearance of the IV insertion site ️presence of gag reflex rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex. a nurse is assessing a client who has lung cancer. which of the following manifestations should the nurse expect? A.) Blood-tinged sputum B.) Decreased tactile fremitus C.) Resonance with percussion D.) Peripheral edema ️blood-tinged sputum rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor. a nurse working in an ED is caring for a client following an acute chest trauma. which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A.) Collapsed neck veins on the affected side B.) Collapsed neck veins on the unaffected side C.) Tracheal deviation to the affected side D.) Tracheal deviation to the unaffected side ️Tracheal deviation to the unaffected side rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. 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 developing a plan of care for a client who has active TB. which of the following isolation precautions should the nurse include in the plan? A.) Airborne B.) Neutropenic C.) Contact D.) Droplet ️Airborne rationale: The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask. a nurse in an ED is caring for a client who's experiencing acute respiratory failure. which of the following