Exam (elaborations)
ATI RN TARGETED MEDICAL SURGICAL: RESPIRATORY ONLINE PRACTICE 2019
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ATI RN TARGETED MEDICAL SURGICAL: RESPIRATORY ONLINE PRACTICE 2019
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ATI RN TARGETED MEDICAL SURGICAL:RESPIRATORY ONLINE PRACTICE 2019
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 - answers -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." - answers -"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 -
answers -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 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 - answers -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 - answers -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 - answers -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.
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