ATI questions OXYGENATION

2. A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?

A. Obtain baseline vital signs and oxygen saturation.

1. A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.)

A. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.)

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing

5. A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)

A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?

A. Position the client in an upright position, leaning over the bedside table.

5. A nurse is planning to instruct a client on how to perform pursed‑lip breathing. Which of the following should the nurse include in the plan of care?

C. Take a deep breath in through your nose.

4. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

D. "I will take in a deep breath and hold it before exhaling."

3. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

D. Assess breath sounds every 1 to 2 hr.

2. A nurse is caring for a client 2 hr after admission. The client 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?

D. Beta2 agonist

3. A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions.

1. B. Administer oxygen therapy. 2. C. Perform a sputum culture. 3. A. Administer antibiotics. 4. D. Administer an antipyretic medication to promote client comfort.

3. A nurse is discharging a client who has COPD. Upon discharge, the client 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?

A. "There are portable oxygen delivery systems that you can take with you."

1. A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.)

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.)

A. Dyspnea C. Fever D. Hypotension

5. A nurse is planning care for a client 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.)

A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. E. Obtain a chest x‑ray.

2. A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.)

A. Hypokalemia C. Fluid retention E. Black, tarry stools

5. A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?

B. "I need to avoid drinking fluids if I develop symptoms."

5. A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?

B. "I take this medication to prevent asthma attacks."

1. A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.)

B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area."

1. A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV?

B. "It allows preset pressure delivered during spontaneous ventilation."

2. A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching?

B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."

2. A nurse is caring for a client 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?

B. Apply sterile gauze to the insertion site.

4. A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?

B. Environmental allergies

3. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.)

B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

2. A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)

B. Pale skin E. Elevated blood pressure

5. A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply.)

B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation

4. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?

B. Venturi mask

1. A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.)

B. Wheezing C. Retraction of sternal muscles E. Premature

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Bronchospasms

1. A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching?

C. "I can have an increase in my heart rate while taking this medication."

3. A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching?

C. "I will take my medication with meals."

3. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol?

C. "Watch for any changes in vision."

4. A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

C. "You might notice tingling of your hands."

4. A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?

D. Palpation of the orbital areas

4. A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?

D. Perform the Valsalva maneuver.