ATI Gas Exchange Day 2

a nurse is caring for a group of clients. which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (select all that apply)

-A client who has had a cerebrovascular accident -A client who is 4 hr postoperative following a leg amputation with general anesthesia -A client who has had radiation therapy for head and neck cancer

a nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60kg. the nurse should expect the tidal volume to be set at which of the following?

480 ml

a nurse is preparing to suction a client who has a tracheostomy. identify the sequence of actions the nurse should take. (Put the steps in order)

-Adjust the suction. -don steril gloves -check the function of the suction catheter -hyperoxygenate the client -insert the catheter without suction -apply suction while rotating the catheter -assess for secretion clearance

a nurse is preparing to provide trach care for a client who has a no disposable trach tube. which of the following equipment should the nurse plan to use? (select all that apply)

-Clean gloves -Sterile cotton-tipped applicator -Sterile basin

a nurse is caring for a client who has a closed suction drain. which of the following actions should the nurse take? select all that apply

-empty the collection chamber using sterile technique

a nurse is caring for a client who develops a PE. which of the following interventions should the nurse implement first?

Administer oxygen therapy.

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive CPT. Which of the following actions should the nurse plan to take?

Albuterol is a bronchodilator that relaxes and dilates the airway to promote air exchange. The nurse should administer the medication prior to implementing CPT to improve airway clearance. Albuterol facilitates the removal of the secretions as the chest wall is being percussed.

a nurse is caring for a child who has a trach. after suction, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds

a nurse is caring for an older adult client who had a femoral head feature 24hrs ago and is in skin traction. the client reports sob and dyspnea. the nurse should suspect that the client has developed which of the following complications?

Fat embolism

a nurse is reviewing the lab findings for a client who developed fat embolism syndrome (FES) following a fracture. which of the following laboratory findings should the nurse expect?

Decreased serum calcium level

a nurse is caring for a client who has retuned to the unit following a surgical procedure. the client's o2 sat is 85%. which of the following actions should the nurse take first?

Raise the head of the bed.

a nurse is caring for a client who has a newly inserted chest drainage system with a water seal. which of the following actions should the nurse take?

Keep the collection device below the level of the client's chest.

a nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. which of the following interventions should the nurse take to reduce the risk for ventilator associated pneumonia?

Rinse the client's mouth with an antimicrobial solution every 4 hr.

a nurse is assessing a client who has hypoxia. which of the following findings should the nurse expect?

Tachycardia

a home health nurse is teaching a Childs parent about endotrach suctioning. which of the following information should the nurse include in the teaching?

Apply suction for less than 10 seconds.

a nurse is caring for a client who experienced a femur fracture 8 hrs ago and now reports sudden onset dyspnea and severe chest pain. which of the following actions should the nurse take first?

Provide high-flow oxygen.

a nurse is assessing a client who is 2 days post and auscultates bil breath sounds, but absent breath sounds in the bases. the nurse should suspect which of the following postop complications?

Atelectasis

a nurse is assessing a client who has developed atelectasis post. which of the following findings should the nurse expect?

Increasing dyspnea

a nurse is performing chest physiotherapy o a client who has a respiratory infection. to increase the velocity and turbulence of the air the client exhales, which of the following techniques should the nurse use?

Vibration

a nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right sided pneumothorax. the client complains of chest burning. which of the following actions should the nurse take?

reposition the client

A nurse is preparing to administer an IM injection of meperidine to a client. which of the following is the priority assessment the nurse should complete?

resp rate