ATI Practice Assessment- Respiratory

A nurse is providing discharge instructions for a client following a tracheostomy. What statement by the client indicates a need for further instruction?

"I should apply suction while inserting the catheter into my tracheostomy" Rat.: the client should apply suction only when withdrawing the catheter to prevent tissue trauma.

A nurse is caring for four clients. What client is at greatest risk for pulmonary embolism?

A client who is 12hr postop following a total hip arthroplasty Rat.: it is this client due to decreased mobility of the affected extremity.

A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm sounds. What should the nurse recognize as a cause of the alarm?

Artificial airway cuff leak. Rat.: an artificial airway leak interferes with oxygenation and causes the low pressure alarm to sound.

A nurse is assessing a client who has emphysema. The nurse should report what assessment findings?

Elevated temp. Rat.: clients who have emphysema are at risk for the development of pneumonia and other resp. infections. A nurse should report this as it indicates a possible resp. infection.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. What assessments by the nurse is priority?

Gag reflex. Rat.: the greatest risk to the client is aspiration due to a decreased gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

A nurse is positioning a client who has emphysema to promote effective breathing. The nurse should place the client in what position?

High fowlers position with arms supported on the overbed table. Rat.: The nurse should place the client in a position that allows for greater expansion of the chest.

A nurse is caring for a client who has acute respiratory distress syndrome. What assessment finding indicates a decline in the client's condition?

Increase in respiratory rate. Rat.: an increase in resp. rate indicates increased work of breathing and the need for improvement in oxygen delivery

A nurse is caring for a client who is 4hr postop following a total laryngectomy for laryngeal cancer. What assessment is priority?

Oxygen saturation Rat.: Using ABC's approach the nurse should identify the client's oxygen sat is the priority. This client is at risk for hypoxia due to airway obstruction and decreased oxygen sat is an indication of an obstructed airway.

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax?

Tracheal deviation to the unaffected side. Rat.: 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 assisting with a thoracentesis. What actions is appropriate for the nurse to take when assisting with this procedure?

Wear goggles and mask during the procedure: should wear this to reduce the risk of exposure to pleural fluid. Cleanse the area with an antiseptic solution: this decreases the risk of infection, which is increased due to the invasive procedure. Apply pressure to the site after the needle is withdrawn: this decreases the risk of bleeding at the needle insertion site.

A nurse is providing instruction to a client on how to use montelukast to treat chronic asthma. What statement indicates the client understands the teaching?

"I will take this med every evening, even when I do not have symptoms." Rat.: Montelukast is used for prophylaxis of asthma exacerbation and is taken on daily basis in the evening.

A nurse receives prescription from the provider to perform nasopharyngeal suctioning for each of the following clients. The nurse should clarify the providers prescription for what client?

A client who has a closed-head injury and is lethargic. Rat.: a recent head injury is a contraindication for nasopharyngeal suctioning becasue suctioning can increase intracranial pressure.

A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority?

Administer heparin via continuous IV infusion. Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore, this is the priority intervetion.

A nurse is caring for a client who has active tuberculosis. What isolation precautions should the nurse implement?

Airborne Rat.: the nurse should initiate airborne precautions for the client who has TB because TB is a resp. infection that is spread through the air.

A nurse is planning care for a client who has asthma. The medications should the nurse plan to admin during an acute asthma attack?

Albuterol Rat.: this is a short acting beta adrenergic agonist, as it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse is caring for a client who is postop and develops an acute onset of severe chest pain that worsens upon inspiration. The client is anxious and tachypneic. What actions should the nurse take first?

Apply supplemental oxygen. Rat.: when using ABC's approach the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A nurse is caring for client in acute resp. failure who is receiving mechanical ventilation. The assessment is priority for the nurse to use to evaluate the effectiveness of the mechanical ventilation?

Arterial blood gases Rat.: when using ABC's approach, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen sat and acid-base balance.

A nurse is caring for a client who has lung cancer. What assessment findings should the nurse expect?

Blood-tenged sputum Rat: the nurse should expect blood tinged sputum secondary to bleeding from the tumor.

A nurse is caring for a client following the insertion of a chest tube. The nurse should plan to have which of the following items in the client's room?

Container of sterile water. Rat.: the nurse should plan to place the open end of the tubing if it becomes disconnected into the sterile water to prevent a pneumothroax. The tubing and sterile water are then placed below the clients chest.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. What finding indicates a need for intervention?

Continuous bubbling in the water seal chamber. Rat.: continuous bubbling is the water seal chamber suggests an air leak.

A nurse is caring for a client who has COPD. What findings should the nurse report to the provider?

Productive cough with green sputum Rat.: A nurse should report this as it indicates an infection

A nurse is caring for a client who is taking albuterol. For what AE's should the nurse monitor the client?

Tachycardia Rat.: the nurse should monitor for this, a common AE, esp. if the client uses albuterol excessively.

A nurse is caring for a client who is in respiratory distress. What device should the nurse use to provide the highest level of oxygen via a low-flow system?

Nonrebreather mask Rat.: this mask is made up of a reservoir bag from which the client obtains the oxygen, a one way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FlO2 which provides the highest level of oxygen.

A nurse is caring for a client who has acute respiratory failure. What lab findings should the nurse expect?

PaO2 58mmHg Rat.: nurse should expect to find a low partial pressures of oxygen for a patient who has acute resp. failure

A nurse is planning care for a client who has COPD. What intervention should the nurse include in the plan of care?

Provide a diet that is high in calories and protein. Rat.: the nurse should provide the client who has COPD with a diet that is high is calories and protein and low in carbohydrates.

A nurse is caring for a client who has bacterial pneumonia. The nurse should expect what assessment finding?

Temp 101.8 degrees F Rat.: an elevated temp is an expected finding for a client who has bacterial pneumonia

A nurse is caring for a client who is 1hr postop following a thoracentesis. What is the priority assessment finding?

Tracheal deviation to the unaffected side. Rat: when using the ABC's approach the nurse should identify tracheal deviation as the priority assessment because this indicates a tension pneumothorax, which is a medical emergency.

A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. The nurse should plan to include what in the client's discharging teaching plan?

Urine and other secretions will be orange.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. What actions should the nurse take?

Use a rotating motion to remove the suction catheter. Rat.: the nurse should do this during withdrawal to reduce the risk of tissue trauma.

A nurse is caring for a client who is postop and is hypoventilating secondary to general anesthesia effects and incisional pain. What ABG values support the nurses suspicion of respiratory acidosis?

pH 7.30, PO2 80mmHg, PaCO2 55mmHg, HCO3 22mEq/L Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which indicates resp. acidosis.