Exam (elaborations)
NURS 406MED SURGE Respiratory ATI Completed A
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NURS 406 NURS406 MED SURGE Respiratory ATI
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1- A charge nurse receives notification of the admission of a client who is coughing frequently andwhose sputum is pink, frothy, and copious. The client has history of night sweats, anorexia, and
weight loss. Which of the following actions should the nurse take? (SATA)
-Assign the client to a private room with negative-pressure airflow
-Wear an N95 respirator when entering the client’s room.
2- A nurse is assisting a provider with a comprehensive physical examination of a client. When the
provider uses transillumination, the nurse should explain to the client that this technique help
evaluate which of the following structures?
-Maxillary sinuses
3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How
should the nurse assist the client with smoking cessation?
-Discuss ways the client can reduce the number of cigarettes smoked per day.
4- A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and
is malnourished. Which of the following recommendations to promote nutritional intake should
the nurse include in the plan?
-Eat high-calorie food first.
Rational: client who has COPD experience early satiety. Client should eat calorie-dense food first.
5- A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should
identify that which of the following findings is an adverse effect of this medication?
-Tinnitus.
Rational: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
6- A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of
the following findings is a manifestation of a pulmonary embolism?
-Stabbing chest pain
Rational: sudden chest pain that is sharp and stabbing is a manifestation of pulmonary
embolism. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood),
tachypnea, tachycardia, diaphoresis, and feeling of impending doom.
,7- A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and
a high-pitched inspiratory sound (stridor). The nurse should identify theses findings as
manifestations of which of the following complications?
-Respiratory obstruction
8- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the
following laboratory values should the nurse expect?
-ph 7.49,HCO3-32mEq/L, PaCO2 40mmHg
Rational: Metabolic alkalosis: pH and bicarbonate values are greater than the expected
references range, and the PaCO2 is within the expected reference range.
9- A nurse is providing teaching to a client who has a chronic cough and is scheduled for a
bronchoscopy. Which of the following client statements indicates an understanding of the
teaching?
-“A tissue sample might be obtained during the procedure”
10- A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse
take? (SATA)
-Explain that the client will receive sedation and will not remember the procedure.
-Verify that the client understands the purpose and nature of the procedure.
11- A nurse is preparing a client for discharge following a bronchoscopy. Which of the following
assessment is the nurse’s monitoring priority?
-Confirming the gag reflex
Rational: The greater risk to the client’s safety is aspiration resulting from a depressed gag reflex.
12- A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2
chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall.
When a family member asks why the client has 2 chest tubes, which of the following responses
should the nurse make?
-“The lower tube will drain blood, and the higher tube will remove air.”
13- A nurse is providing teaching to a client who will undergo a total laryngectomy. Which of the
following statements indicate that the client understands the impact of the surgery?
, - “I understands that I will have a permanent tracheostomy after the surgery.”
Rational: With a partial laryngectomy, the tracheostomy is temporary. With the total laryngectomy the
tracheostomy will be permanent.
14- A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse
tells the client to be careful while bathing to prevent which of the following complications?
-Aspiration of water.
Rational: This is a client with a tracheostomy, so he will need to use a shower shield over the
stoma when bathing or showering to keep water out of the airway.
15- A nurse is caring for a client who is extremely anxious and is hyperventilating. The client’s ABG
results are pH 7.50, PaCO2 27 mmHg, and HCO3-25 mEq/L. The nurse should identify that the
client has which of the following acid-base imbalances?
-Respiratory alkalosis.
16- A nurse is planning postoperative education for a client who will undergo a radical neck
dissection for cancer of the larynx. The nurse should include which of the following topics?
(SATA)
-NPO status
-Alternative methods of communication
- Changes in body image
-Swallowing exercises.
17- A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin
test. Which of the following pieces of information should the nurse include?
- “You must return to the clinic to have the test read in 2 or 3 days.”
18- A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty/
Which of the following instructions should the nurse include?
“Lie on your back with your head elevated 30º when resting.”
19- A nurse is preparing to assist provider with an arterial blood withdrawal from a client’s
radial artery for ABG measurements. Which of the following actions the nurse plan to
take?
, -Perform an Allen’s test prior to obtaining the specimen.
Rational: the nurse should ensure that the circulation of the hands is adequate from the
ulnar artery in case the radial artery is injured from the blood draw. The most common
site for withdrawal of arterial blood gases is the radial artery.
20- A nurse is providing teaching to a client about pulmonary function testing. Which of the
following tests measures the volume of air the lungs can holds at the end of maximum
inhalation?
-Total lung capacity
21- A nurse is providing preoperative teaching to a client who is to undergo a
pneumonectomy. The client states, “I am afraid coughing will hurt after surgery.” Which
of the following statements by the nurse is appropriate?
-“I will show you how to splint your incision while coughing.”
22- 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 leak within the ventilator’s circuitry.
23- 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?
-Frequent swallowing
Rational: this indicates posterior nasal bleeding and possibly hemorrhage.
24- A nurse is caring for a client immediately following extubation. Which of the following
manifestations indicates that the nurse should call the rapid response team?
-Stridor
Rational: the nurse should identify that stridor (high-pitched crowing sound heard during
inspiration) is caused by laryngeal edema and can indicate impending airway
obstruction.
25- A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube
has become disconnected from the chest drainage system. Which of the following
actions should the nurse take?
-Immerse the end of the chest tube in a bottle of sterile water.
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