1.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle
crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing
them in the selected order of performance. Use all the steps....
Detailed Answer Key
Complex Oyxgenation ATI Practice
1. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle
crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing
them in the selected order of performance. Use all the steps.)
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
B. Establish IV access.
A. Perform a Glasgow Coma Scale assessment.
E. Remove clothing for a thorough assessment.
2. A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous
rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse
effects?
A. Constipation
Rationale: Rifampin does not cause constipation. More common gastrointestinal effects are diarrhea and
nausea.
B. Black colored stools
Rationale: It is most commonly iron supplements that cause stools to turn black, not rifampin.
C. Staining of teeth
Rationale: Teeth may be stained from taking liquid iron preparations, not from taking rifampin.
D. Body secretions turning a red-orange color
Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine,
stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
3. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible.
The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority
for the nurse to take?
A. Prevent aspiration.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority goal is to prevent the client from aspirating. Because the client's jaws
are wired together, aspiration of emesis is a possibility. Therefore, the client should be given
medication for nausea, and wire cutters should be kept at the bedside in case of vomiting.
B. Ensure adequate nutrition.
Rationale:
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, Detailed Answer Key
Complex Oyxgenation ATI Practice
The client should be NPO initially after surgery until the gag reflex has returned. Once the client
is able to eat, the client may advance to a calorie-appropriate, high-protein liquid diet. However,
this is not the priority at this time.
C. Promote oral hygiene
Rationale: The client will have an incision inside the mouth. While it is important that the client receive
frequent mouth cleaning, this is not the priority at this time.
D. Relieve the client's pain.
Rationale: While the client may be in pain and will need to be medicated, this is not the priority at this time.
4. A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse
should inform the client that this medication is contraindicated in clients who have a history of which of the following
conditions?
A. Asthma
Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause
bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle
relaxation.
B. Glaucoma
Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not
contraindicated in a client who has glaucoma.
C. Depression
Rationale: Beta-blockers are contraindicated in clients who have AV heart block, but are not
contraindicated in clients who have depression.
D. Migraines
Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.
5. A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical
ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for
which of the following purposes?
A. Decrease chest wall compliance
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis by relaxing skeletal
muscles, which improves chest wall compliance.
B. Suppress respiratory effort
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the
client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over
the work of breathing for the client. This therapy is especially helpful for a client who has ARDS
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Complex Oyxgenation ATI Practice
and poor lung compliance.
C. Induce sedation
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and have no sedative
effect at all. A sedative or analgesic should be prescribed as an adjunct to the pancuronium.
D. Decrease respiratory secretions
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis. An adverse effect of
this medication is increased production of respiratory secretions.
6. A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The
nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this
finding is most likely an indication of which of the following conditions?
A. An upper respiratory infection
Rationale: Although the spleen plays a role in immunity against bacterial infections, the nurse would be
more concerned about the risk of an upper respiratory infection in a client who has undergone
splenectomy, or removal of the spleen.
B. Pulmonary edema
Rationale: Pulmonary edema may develop in a client who is on bedrest following trauma, but this is not the
most likely cause of decreased breath sounds in this client.
C. Atelectasis
Rationale: Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or
bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective
coughing, and underlying lung disease are risk factors for the development of atelectasis.
D. Delayed gastric emptying
Rationale: Although delayed gastric emptying may result in ineffective coughing, this is not the most likely
cause of decreased breath sounds in this client.
7. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes
slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
A. Check the tubing connections for leaks.
Rationale: This action is used to determine why a water seal chamber has continuous bubbling, not slow,
steady bubbling.
B. Check the suction control outlet on the wall.
Rationale: This action is used to determine why a suction control chamber that is hooked to wall suction
has little or no bubbling.
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, Detailed Answer Key
Complex Oyxgenation ATI Practice
C. Clamp the chest tube.
Rationale: The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage
system. This is not an appropriate action for the nurse to take at this time.
D. Continue to monitor the client's respiratory status.
Rationale: Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the
nurse should continue to monitor the client's respiratory status.
8. A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a
fracture. Which of the following laboratory findings should the nurse expect?
A. Decreased serum calcium level
Rationale: A decreased serum calcium level is an expected finding for FES, although the reason for this
finding is unknown.
B. Decreased level of serum lipids
Rationale: An increase serum lipid level is an expected finding for FES, although the reason for this finding
is unknown.
C. Decreased erythrocyte sedimentation rate (ESR)
Rationale: An increased ESR is an expected finding for FES, although the reason for this finding is
unknown.
D. Increased platelet count
Rationale: A decreased platelet count is an expected finding for FES, although the reason for this finding is
unknown.
9. A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of
hyperventilation and apnea. The nurse should document that the client has which of the following respiratory
alterations?
A. Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid, regular respirations and are commonly seen in clients
who are experiencing metabolic acidosis.
B. Apneustic respirations
Rationale: Apneustic respirations are characterized by a prolonged inspiratory phase alternating with
expiratory pauses.
C. Cheyne-Stokes respirations
Rationale: Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of
hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR
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