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ATI Respiratory Learning System Med-Surg
A nurse is caring for an elderly patient who suffers from COPD with pneumonia. The nurse should monitor the patient for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis
D. Metabolic acidosis✔✔2. Respiratory acidosis
Respiratory acidosis is a common complication of COPD. This complication occurs because patients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
Respiratory alkalosis✔✔hyperventilation
Occurs when pt exhales too much carbon dioxide
Metabolic alkalosis✔✔high pH, high HCO
Pt has excessive amount of bicarbonate
Clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis.
Excessive vomiting also places a client at risk for development of metabolic alkalosis.
A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome
D. Tinnitus✔✔Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
Hand and foot syndrome = adverse effect of capecitabine, an antineoplastic
- medication used to treat breast and colorectal cancer.
Pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis.
Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemi
A nurse is preparing to assist a provider to withdraw arterial blood from a patient's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take?
A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen.
B. Apply ice to site after obtaining the specimen
C. Perform an Allen's test prior to obtaining the specimen
D. Release pressure applied to puncture site 1 min after needle is withdrawn✔✔3. Perform an Allen's test prior to obtaining the specimen.
The nurse should ensure that circulation to the hand 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.
The nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. High pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site.
The nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. If the sample is not placed on ice, the pH and PO values can be inaccurate. It is not necessary to place ice on the withdrawal site.
A nurse on a med-surg unit is caring for a patient who is postoperative following a hip replacement surgery. The patient reports feeling apprehensive and restless. Which of the follow findings should the nurse recognize as an indication of a PE: a. sudden onset of dyspnea b. Tracheal deviation c. Bradycardia
d. Difficulty swallowing✔✔1. Sudden onset of dyspnea
Clinical manifestations of pulmonary embolism have a rapid onset. PE S&S:
- Dyspnea
- Tachycardia Dyspnea occurs due to reduced blood flow to the lungs.
Tracheal deviation is an indication of pneumothorax.
Difficulty swallowing is an indication of many conditions, including oral cance
Nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. Apply warm compresses to the face B. Take aspirin 650 mg by mouth for mild pain C. Close your mouth when sneezing
D. Lie on your back with your head elevated 30 degree when resting✔✔D. Lie on your back with your head elevated 30 degree when resting
The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.
The client should open her mouth when sneezing to reduce straining on the incisional site.
The client should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation.
The client should apply cold compresses to his face to decrease swelling
A nurse is planning care for a patient who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan: A. Eat high calorie foods first B. increase intake of water at meal times C. Perform active ROM before meals
D. Keep saltine crackers nearby for snacking✔✔1. Eat high-calorie foods first
The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.
Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at mealtimes to reduce the feeling of early satiety.
Rest before meals to decrease dyspnea during meals
The client should keep foods on hand for snacking, but should avoid dry and salty foods, which can place the client at risk for aspiration and make the client's mouth dry.
Albuterol✔✔albuterol Administration Consideration Use cautiously in clients with hypertension and cerebral vascular disorders. Adverse Reaction Include tachycardia, tremor, hypertension, bronchospasm, headache and dizziness. Available Forms aerosol inhaler, tablets, injection. Class bronchodilator Contraindications May included drug hypersensitivity and breast-feeding. Indications Bronchospasm and the prevention of asthma triggered by exercise. IV_Facts
Anorexia and weight loss are clinical manifestations of tuberculosis.
Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.
A nurse is planning care for a patient following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care: A. Clamp the chest tube if there is continuous bubbling in the water seal chamber. B. Keep the chest tube drainage system at the level of the right atrium. C. Tape all connections between the chest tube and drainage system. D. Empty the collection chamber and record the amount of drainage every 8
hr.✔✔C. Tape all of the connections between the chest tube and the drainage system.
The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting.
The nurse should not empty the collection chamber or change the system unless it is almost full.
The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity.
The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally, the nurse should avoid clamping the chest tube unless it becomes necessary to replace the drainage unit or locate an air leak.
A nurse on a medical unit is caring for a patient who apirated gastric contents prior to admission. The nurse administers 100% oxygen by nonbreather mask after the patient reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS):
A. Tympanic temperature 38 C (100.4F) B. PaO2 50mm Hg C. Rhonchi
D. Hypopnea✔✔2. PaO2 50 mm Hg
The patient who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.
ARDS s/sx
- Hyperpnea
- Clear breath sounds because edema occurs in interstitial spaces
- Low PaO2 level even with administration of oxygen
A nurse is providing teaching to a patient about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end maximum inhalation: A. Total lung capacity B. Vital lung capacity C. Functional Residual capacity
D. Residual volume✔✔1. Total lung capacity
Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.
Vital lung capacity✔✔Measures amt of air the client can exhale after maximum inhalation
Residual volume✔✔Measures amt of air in lungs after forced expiration
Functional Residual Capacity✔✔Measures amt of air in lungs after normal expiration
A nurse in the emergency department is assessing a patient for a closed pneumothorax and significant bruising of the left chest following a MVA. The client reports severe left chest pain on inspiration. The nurse should assess the patient for which of the following manifestations of a pneumothorax:
A. absence of breath sounds B. Expiratory wheezing
B. To mobilize secretions in airway C. To dilate the bronchioles
D. To stimulate the cough reflex✔✔2. To mobilize secretions in the airways
The purpose of chest physiotherapy is to loosen the patient's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity.
A positive test means the client has been exposed to tubercle bacillus (TB), but it does not mean that the client has an active case of tuberculosis. The client should have a chest x-ray to rule out active tuberculosis.
The nurse will inject 0.1 mL of purified protein derivative intradermally to the dorsal aspect of the client's forearm.
A nurse in an urgent care clinical is collecting data from a patient who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax: A. Dry cough B. Rhinitis C. Sore throat
D. Swollen lymph nodes✔✔1. Dry cough
A dry cough is a clinical manifestation found in the prodromal stage of having inhalation anthrax.
During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.
Anthrax✔✔An infection caused by the bacteria Bacillus anthracis. Although it's most commonly found in grazing animals (such as sheep, pigs, cattle, horses, and goats), anthrax can sometimes infect humans. In the environment, anthrax can form spores (a version of the germ in a hard shell) that can live in the soil for years. There are three main types of anthrax: cutaneous (skin) anthrax, which can occur if someone handles contaminated animals or animal products (especially animal hides) while they have a cut, abrasion, or rash on the skin; intestinal anthrax, which
can occur if someone eats contaminated meat; and pulmonary (inhaled) anthrax, which is extremely rare but can occur if someone breathes anthrax spores, usually found in the dust kicked up by animals. Symptoms vary depending on the type of anthrax. Pulmonary anthrax usually begins with flu-like symptoms but, if untreated, can rapidly turn into severe pneumonia (an inflammation of the lungs).
A nurse is providing preoperative teaching to a patient who is to undergo a pneumoectomy. The patient states "I am afraid it will hurt to cough after surgery." Which of the following statements by the nurse is appropriate: A. "after the surgeon removes the lung, you will not need to cough." B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. "Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain."
D. I will show you how to splint your incision while you cough.✔✔D.. I will show you how to splint your incision while you cough.
The client who had a pneumonectomy should cough to clear secretions from the remaining lung. The nurse should show the client how to splint her incision to reduce pain when coughing.
A patient is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the patient's chest. After notifying the provider, the nurse should document the finding as which of the following: A. Friction rub B. Crackles C. Crepitus
D. Tactile Fremitus✔✔3. Crepitus
Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the patient's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.
nurse should assess the need for suctioning every 2 hr and then suction as necessary.
The nurse should assess the client's airway after coughing and only suction the client's secretions if the client is not able to cough and expectorate secretions.
A nurse working in the ED is caring for a patient following a chest trauma. Which
of the following findings indicates a tension pneumothorax:✔✔4. Tracheal deviation to the unaffected side
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 is caring for a patient who is scheduled for a thoracentesis. Prior to the
procedure, which of the following actions should the nurse take:✔✔1. Position the client in an upright position, leaning over the bedside table.
A nurse is reviewing ABG laboratory results of a patient who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base
imbalances:✔✔2. Respiratory alkalosis
A nurse is assessing a patient following a bronchoscopy. Which of the following
findings should the nurse report to the provider:✔✔4. Bronchospasms
A nurse is caring for a patient who is scheduled for a throacentesis. Which of the folowing supplies should the nurse ensure are in the patient's room? (Select all that
apply)✔✔1. Oxygen equipment
- Pule oximeter
- Sterile dressing
A nurse is caring for a patient following a throacentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all
that apply)✔✔1. Dyspnea
A nurse is preparing to care for a patient following chest tube placement. Which of the following items should be available in the patient's room? (Select all that
apply)✔✔1. Oxygen
- Sterile water
- Occlusive dressing
A nurse is caring for a patient who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the
following actions should the nurse take first?✔✔2. Apply sterile gauze to the insertion site
A nurse is assessing a patient who has a chest tube and drainage system in place.
Which of the following are expected findings? (Select all that apply)✔✔2. Gentle constant bubbling in the suction control chamber
- Rise and fall in the level of water in the water seal chamber with inspiration and expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the
following should the nurse instruct the patient to do?✔✔4. Perform the Valsalva maneuver
A nurse is planning care for a patient following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care?
(Select all that apply)✔✔1. Encourage the patient to cough every 2 hours
- Check for continuous bubbling in the suction chamber
- Obtain a chest x-ray
A chest x-ray is obtained following the procedure to verify chest tube placement.
A nurse is discharging a patient who has pulmonary TB and is to start therapy with rifampin. The nurse should plan to include which of the following in the patient's
teaching plan:✔✔3. Urine and other secretions will be orange.
Rifampin will turn urine and other secretions orange.
A nurse is assisting with a thoracentesis. Which of the following actions is appropriate for the nurse to take when assisting with this procedure: (Select all that
apply)✔✔1. Wear goggles and mask during the procedure
- Cleanse the area with an antiseptic solution
- Apply pressure to the site after the needle is withdrawn
A nurse is caring for a patient who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse
take:✔✔2. Use a rotating motion to remove the suction catheter
A nurse is caring for a patient following the insertion of a chest tube. The nurse
should plan to have which of the following items in the patient's room:✔✔3. Container of sterile water
A nurse is assessing a patient who has emphysema. The nurse should report which
of the following assessment findings:✔✔2. Elevated temperature
Patients who have emphysema are at risk for development of pneumonia and other respiratory infections. A nurse should report an elevated temperature to the provider.
A nurse in the emergency department is caring for a patient who is having an acute asthma attack. Which of the following assessments indicates that the respiratory
status is declining? (Select all that apply)✔✔2. Wheezing
- Retraction of sternal muscles
- PVCs
A nurse is caring for a patient 2 hours after admission. The patient has an SaO2 of 91% exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to
administer?✔✔4. Beta 2 agonist
A nurse is providing discharge teaching to a patient who has a new prescription for prednisone for asthma. Which of the following patient statements indicates an
understanding of the teaching:✔✔3. "I will take my medication with meals."
A nurse is assessing a patient who has a history of asthma. Which of the following
factors should the nurse identify as a risk for asthma?✔✔2. Environmental allergies
A nurse is reinforcing teaching with a patient on the purpose of taking a bronchodilator. Which of the following patient statements indicates an
understanding of the teaching?✔✔2. "I take this medication to prevent asthma attacks."
A nurse is providing discharge teaching to a patient who has COPD and a new prescription for albuterol. Which of the following statements by the patient
indicates an understanding of the teaching?✔✔3. "I can have an increase in my heart rate while taking this medication.
A nurse is preparing to administer a dose of a new prescription of prednisone to a patient who has COPD. The nurse should monitor for which of the following
adverse effects of this medication? (Select all that apply)✔✔3. Fluid retention
- Black, tarry stools
A nurse is discharging a patient who has COPD. Upon discharge, the patient is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the
nurse?✔✔1. "There are portable oxygen delivery systems that you can take with you."
A nurse is instructing a patient on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the
teaching."✔✔4. "I will take in a deep breath and hold it before exhaling."
A nurse is planning to instruct a patient on how to perform pursed-lip breathing.
Which of the following should the nurse include in the plan of care?✔✔3. Take a deep breath in through your nose.
A home health nurse is teaching a patient who has active TB. The provider has prescribed the following medication regiment: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily.
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 101.2 F, and blood pressure 100/54 mm Hg. Which of the following nursing actions is the
priority?✔✔3. Administer oxygen therapy.
A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate
concern for the nurse?✔✔2. "I take antacids several time a day."
A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the
therapy?✔✔1. Hip arthroplasty 2 weeks ago
A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select
all that apply)✔✔1. Tachypnea
- Deviation of the trachea
- Pleuritic pain
A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which
of the following actions should the nurse perform first?✔✔2. Obtain a large-bore IV needle for decompression.
A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when
teaching the client?✔✔4. "Notify your provider if you experience a productive cough."
A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that
apply)✔✔2. Cyanosis
- Hypotension
- Dyspnea
- Paradoxic chest movement
A nurse in the emergency department is assessing a client who was in a MVA. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 101.4 F, and SaO2 92% on room air. Which of the following actions should the
nurse take first?✔✔3. Administer oxygen via a high-flow mask.
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the
newly licensed nurse indicates understanding of the teaching?✔✔2. "This medication is given to facilitate ventilation."
Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption.
A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing respiratory distress syndrome? (Select all that
apply)✔✔1. A client who experienced a near-drowning incident.
- A client following coronary artery bypass graft surgery.
- A client who has dyphagia.
- A client who experienced a drug overdose.
A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of
care for this client? (Select all that apply)✔✔2. Provide supplemental oxygen
- Administer of bronchodilators
- Maintain ventilatory support
A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate
administering with this medication? (Select all that apply)✔✔1. Fentanyl
- Midazolam
