Gas exchange and oxygenation ATI
A nurse is collecting data from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply) 1) A diet high in saturated fats 2) A history of an overactive bladder 3) A history of smoking for 25 years 4) A sedentary lifestyle 5) A waist circumference of 84 cm (33 inches)
1) A diet high in saturated fats 3) A history of smoking for 25 years 4) A sedentary lifestyle
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect? 1) Crackles in the lungs 2) Edema of the lower extremities 3) A rapid, irregular heart rate. 4) A systolic murmur
1) Crackles in the lungs
A nurse is assisting with the care of a client with a chest tube. Which of the following actions should the nurse take? 1) Monitor the client for subcutaneous emphysema 2) Expect continuous bubbling in the water seal chamber 3) Keep the drainage system above the level of the client's chest. 4) Clamp the chest tubing when the client is ambulating.
1) Monitor the client for subcutaneous emphysema
A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use? 1) Nasal cannula 2) Nonrebreather mask 3) Partial rebreather mask 4) Simple face mask
1) Nasal cannula
A nurse is collecting data from a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following? 1) Normal breathing 2) Kussmaul breathing 3) Cheyne-Stokes breathing 4) Apnea
1) Normal breathing
A nurse is reinforcing teaching with a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? (Select all that apply) 1) Post a "No Smoking" sign inside their home 2) Attach oxygen containers to a fixed object 3) Store spare oxygen containers in a closet. 4) Notify the fire department that oxygen is used inside the home. 5) Ensure that oxygen tubing is no longer than 60 feet in length.
1) Post a "No Smoking" sign inside their home 2) Attach oxygen containers to a fixed object 4) Notify the fire department that oxygen is used inside the home.
A nurse is reinforcing teaching with a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include? 1) "Use the CPAP mask during the daytime." 2) "Cover your nose with the CPAP mask." 3) "Medications to assist with breathing can be administered through the CPAP machine." 4) "You will need supplemental oxygen to use the CPAP machine."
2) "Cover your nose with the CPAP mask."
A nurse is reinforcing teaching with a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include? 1) "Exhale into the incentive spirometer." 2) "Use the incentive spirometer every hour while awake." 3) "Hold your breath for 10 seconds while using the incentive spirometer." 4) "Use the incentive spirometer two times each session."
2) "Use the incentive spirometer every hour while awake."
A nurse is assisting with planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first? 1) A client who is taking a new cholesterol-lowering medication. 2) A client who reports dyspnea when walking to the bathroom 3) A client who has a new diagnosis of aortic valve stenosis and needs a referral to a cardiologist 4) A client who has asthma and is being discharged home
2) A client who reports dyspnea when walking to the bathroom
A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations? 1) Trachea 2) Alveoli 3) Diaphragm 4) Bronchial tubes
2) Alveoli
A nurse is collecting data from a client who has COPD. The nurse should identify that which of the following is an expected finding? 1) Jugular vein distension 2) Clubbing of the fingers 3) Heart murmur 4) Paradoxical breathing
2) Clubbing of the fingers
A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take? 1) Perform chest percussion therapy six times a day. 2) Listen for a hollow sound when performing chest percussion therapy. 3) Use flat hands to perform chest percussion therapy. 4) Apply chest percussion therapy over the client's ribs.
2) Listen for a hollow sound when performing chest percussion therapy.
A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following? 1) Tachycardia 2) Murmur 3) Gallop 4) Stroke volume
2) Murmur
A nurse is collecting data from a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity? 1) Hypertension 2) Ringing in the ears 3) Fever 4) Dilated pupils
2) Ringing in the ears
A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia? 1) Diabetic ketoacidosis 2) Smoke inhalation 3) Administration of a stimulant medication 4) Right-sided heart failure
2) Smoke inhalation
A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect? 1) Regurgitation 2) Stenosis 3) Muscle atrophy 4) Hypotension
2) Stenosis
A nurse is reinforcing teaching with a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity? 1) The volume of air inspired and expired with a regular breath 2) The maximum volume of air that is expired after a maximum inspiration. 3) The amount of additional air that can be inspired after a regular inspiration. 4) The amount of air in the lung after maximal inspiration
2) The maximum volume of air that is expired after a maximum inspiration.
A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statement by the newly licensed nurse indicated an understanding of the atrial fibrillation? 1) "Atrial fibrillation is caused by electrical signals that come from the ventricles." 2) "Atrial fibrillation causes a lower-than-expected heart rate." 3) "Atrial fibrillation is caused by electrical signals outside of the SA node." 4) "Atrial fibrillation is causes diaphoresis in most clients."
3) "Atrial fibrillation is caused by electrical signals outside of the SA node."
A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take? 1) Use clean technique to perform the procedure 2) Apply suction when inserting the catheter 3) Administer 100% oxygen before the procedure 4) Suction the tracheostomy for 20 seconds each time
3) Administer 100% oxygen before the procedure
A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first? 1) Auscultate the lungs 2) Document the respiratory rate 3) Obtain the oxygen saturation 4) Check the capillary refill
3) Obtain the oxygen saturation
A nurse is assisting with planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output? 1) Respiratory rate 2) Blood pressure 3) Stroke volume 4) Vital capacity
3) Stroke volume
A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use? 1) Nasal Cannula 2) Nonrebreather mask 3) Partial rebreather mask 4) Simple face mask
4) Simple face mask.
A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis. 1) Lymphatic fluid 2) Oxygenated blood 3) Synovial fluid 4) Surfactant
4) Surfactant
A nurse is explaining the sequence of electrical conduction in the heart to a newly licensed nurse. What should the nurse include as the correct sequence of the transmission of electrical impulses?
SA node AV node Bundle of His Right and Left bundle branches Purkinje fibers
A nurse is reinforcing teaching with a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps?
Take a deep breath Hold your breath for several seconds Exhale slowly Brace the incision with a pillow and try to cough deeply