ATI Med Surg Respiratory Detailed Answer Key

Detailed Answer Key Medsurge Respiratory g g g g




Latest 2025
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1.A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following
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room assignments should the nurse make for the client?
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A. A room with air exhaust directly to the outdoor environment
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Rationale:A room with air exhaust directly to the outside environment eliminates contamination of other
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client-care areas. This type of ventilation system is referred to as an airborne infection
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isolation room. g g




B. A room with another nonsurgical client
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Rationale:A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A
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client who has tuberculosis should have a private room.
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C. A room in the ICU
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Rationale:A client who has active tuberculosis and no other comorbidities is not critically ill.
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D. A room that is within view of the nurses' station
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Rationale:The client's room should be well ventilated and private, but it is not necessary for it to be close
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to the nurses' station. g g g g




2.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle
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crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing
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them in the selected order of performance. Use all the steps.) C. Open the airway using a jaw-thrust maneuver.
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D. Determine effectiveness of ventilator efforts.
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B. Establish IV access.
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A. Perform a Glasgow Coma Scale assessment.
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E. Remove clothing for a thorough assessment.
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3.A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to
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assess in this client? (Select all that apply.)
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A. Dyspnea
B. Bradycardia

, C. Barrel chest g




D. Clubbing of the fingers g g g



E. Deep respirations
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Rationale:

Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which
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they become weakened and collapse. Dyspnea is seen in clients with emphysema as the
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lungs try to increase the amount of oxygen available to the tissues.</br></br>Bradycardia is
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incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for
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less oxygen to the tissues. </br></br>Barrel chest is correct. Clients with emphysema lose
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lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs;
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the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel
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chest typical of emphysema clients.</br></br>Clubbing of the fingers is correct. Clubbing
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results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails
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become extremely curved from front to back.</br></br>Deep respirations is incorrect. Clients
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with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations
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become increasingly shallow.
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4.A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible.
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gThe client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the
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gpriority for the nurse to take?
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A. Prevent aspiration. g




Rationale:When using the airway, breathing, circulation approach to client care, the nurse should
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determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired
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together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and
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wire cutters should be kept at the bedside in case of vomiting. B. Ensure adequate nutrition.
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Rationale:The client should be NPO initially after surgery until the gag reflex has returned. Once the
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client is able to eat, the client may advance to a calorie-appropriate, high-protein liquid diet.
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However, this is not the priority at this time.
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C. Promote oral hygiene
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Rationale:The client will have an incision inside the mouth. While it is important that the client receive
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frequent mouth cleaning, this is not the priority at this time. D. Relieve the client's pain.
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Rationale:While the client may be in pain and will need to be medicated, this is not the priority at this time.
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5.A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
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gmanifestations should the nurse monitor? g g g g




A. Confusion
Rationale:Myasthenia gravis does not affect cognition, level of consciousness, or orientation. g g g g g g g g g g

, B. Weakness
Rationale:Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory g g g g g g g g g g

distress or predispose the client to respiratory infections.
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C. Increased intracranial pressure g g



Rationale:

Myasthenia gravis does not affect pressure within the brain.
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D. Increased urinary output g g



Rationale:Myasthenia gravis does not cause increased urine output. g g g g g g g




6.A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The
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nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia.
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Rationale:Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It occurs as the
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tumor grows in size and impedes the esophagus.
g g g g g g g g g B. hoarseness. g



Rationale:Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to
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tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of
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cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may
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sound harsh and lower in pitch than normal. C. dyspnea.
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Rationale:Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the
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tumor grows in size and impedes the airway opening. D. weight loss.
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Rationale:Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
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7.A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of
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the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks
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as the priority for assessment and intervention?
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A. Airway obstruction g



Rationale:When using the airway, breathing, circulation approach to client care, the nurse determines
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that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve
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damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can
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result in severe g g g

respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this
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client's care. g g




B. Infection
Rationale:Prevention of infection is essential throughout hospitalization and treatment; however, another
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risk is the priority. g g g g

, C. Fluid imbalance g



Rationale:Adequate fluid replacement is essential throughout the acute phase of burn treatment; however,
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another risk is the priority. g g g g g



D. Paralytic ileus g



Rationale:Paralytic ileus can develop during the acute phase of burn care and might require nasogastric
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decompression; however, another risk is the priority.
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8.A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse,
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"I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which
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of the following actions should the nurse take to help this client with tenacious bronchial secretions?
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A. Maintaining a semi-Fowler's position as often as possible
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Rationale:Although a semi-Fowler's position can help the client breathe more easily, it will not alter the
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consistency of secretions. g g g




B. Administering oxygen via nasal cannula at 2 L/min g g g g g g g



Rationale:Administration of oxygen helps correct hypoxemia, but it will not alter the consistency of g g g g g g g g g g g g g

secretions. g




C. Helping the client select a low-salt diet
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Rationale:Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of
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secretions. g




D. Encouraging the client to drink 2 to 3 L of water daily g g g g g g g g g g g



Rationale:COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema.
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Maintaining hydration through the consumption of adequate fluids will help liquefy thick g g g g g g g g g g g

secretions and facilitate their expectoration.
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9.A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes
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slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A.
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Check the tubing connections for leaks.
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Rationale:This action is used to determine why a water seal chamber has continuous bubbling, not slow,
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steady bubbling. g g




B. Check the suction control outlet on the wall.
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Rationale:This action is used to determine why a suction control chamber that is hooked to wall suction
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g has little or no bubbling. C. Clamp the chest tube.
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Rationale:The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage
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system. This is not an appropriate action for the nurse to take at this time.
g g g g g g g g g g g g g g g g D. Continue to monitor the client's
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respiratory status.
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