ATI MED/SURG: RESPIRATORY EXAM WITH CORRECT ANSWERS

1. A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilators circuitry C. Decreased lung compliance D. The client coughing or attempting to talk - B. A leak within the ventilators circuitry Rationale: low pressure alarms are often the result of a malfunction or displacement of connections somewhere between ET/ Trach and the vent 2. A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. Nasal Edema B. Mouth breathing C. Periorbital Ecchymosis D. Frequent Swallowing - D. Frequent swallowing rationale: frequent swallowing indicated posterior drainage, could be possible hemorrhage 3. A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma - A. Aspiration of water Rationale: The client should use a shower shield over the stoma when showering or bathing 4. A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. The breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Use the intercostal muscles D. Strengthens the diaphragm - B. Promotes carbon dioxide elimination 5. Beck's triad. What is is used for? - hypotension, JVD, muffled heart sounds Cardiac tamponade 6. The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect? A. Edema of the upper airway B. Plugged Tracheostomy tube C. Infection D. Postoperative bleeding - A. Edema of the upper airway 7. Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? A. Impaired verbal communication B. Risk for chronic low self esteem C. Risk for infection D. Deficient knowledge - A. Impaired verbal communication 8. A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: A. Sleep with the head of the bed elevated B. You may drink 1 glass of alcohol daily C. Do not perform saline irrigations to the nares D. Caffeinated beverages are allowed - A. Sleep with the head of the bed elevated 9. The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of A. 1 to 3 months B. 20 to 30 days C. 3 to 6 months D. 2 to 12 days - D. 2 to 12 days 10. The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? A. Epistaxis, twice last week B. Laryngitis, following a cold C. Hoarseness for 2 weeks D. Aphonia following a football game - C. Hoarseness for 2 weeks