ATI pulmonary questions

22. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at greatest risk for A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus

A. Airway obstruction

25. A nurse is planning care for a client who has quadriplegia. Which of the following nursing actions are most essential for prevention of pulmonary emboli (PE)? (Select all that apply.) A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results E. Massage calves every shift

A. Assess legs for redness B. Apply elastic compression stockings C. Perform passive range of motion exercises D. Monitor INR results

20. A school nurse interprets the peak expiratory flow rate for a child with asthma and finds that the child is in the yellow zone of the client's asthma action plan. This means which of the following? A. The child should use his quick-relief inhaler B. The child's asthma is getting worse C. The child's peak flow is 50% to 79% of his best peak flow D. the child needs to go to the hospital E. the child is able to perform his usual activities

A. The child should use his quick-relief inhaler B. The child's asthma is getting worse C. The child's peak flow is 50% to 79% of his best peak flow

24. A nurse is caring for a client who has a femur fracture and, 8 hr after the injury, reports a sudden onset of dyspnea and severe chest pain. Which action should the nurse take first? A. administer oxygen B. prepare for an ICU transfer C. increase the IV fluid infusion rate D. administer pain medication

A. administer oxygen

19. A nurse is caring for a client who has just returned from the surgical suite following a thoracotomy. Which of the following postoperative interventions should the nurse give highest priority to? A. administer oxygen by mask or NC at 6L/min B. monitor urinary output via FC q2h C. assess chest tube drainage hourly D. maintain IV of D5 1/2NS at 125mL/hr

A. administer oxygen by mask or NC at 6L/min

18. A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care? A. airway protection B. decreasing ICP C. stabilizing cardiac arrhythmias D. preventing musculoskeletal disability

A. airway protection

6. A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A. auscultate lung fields B. assess pulse and respirations C. assess characteristics of her sputum D. instruct to slowly exhale with pursed lips

A. auscultate lung fields

12. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client has had intermaxillary fixation to repair and stabilize the fracture. The nurse should recognize that the most important goal in the immediate postoperative period is to do which of the following? A. prevent aspiration B. ensure adequate nutrition C. promote oral hygiene D. relieve the client's pain

A. prevent aspiration

4. A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. give morphine IV B. administer oxygen therapy C. start an iv infusion of LR D. initiate cardiac monitoring

B. administer oxygen therapy

14. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture. Which of the following is the nurse's priority? A. pain control B. airway management C. oral hygiene D. nutritional support

B. airway management

8. A nurse is dining at a restaurant when a woman begins to scream that her husband is choking. Which of the following should the nurse do first? A. instruct the wife to call 911 B. ask the victim if he can speak C. use the jaw-thrust maneuver D. administer an abdominal thrust

B. ask the victim if he can speak

5. A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention? A. insert an IV line B. count the RR C. administer oxygen D. prepare equipment for intubation

B. count the RR

16. A nurse is caring for a client with burns to face, ears, and eyelids. Which of the following is the priority finding to report to the provider? A. urinary output 25mL/hr B. difficulty swallowing C. heart rate 122 bpm D. lip edema

B. difficulty swallowing

17. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? A. increase the oxygen flow to 3L/min B. evaluate the client's respiratory status C. call EMS for the client D. have the client cough and expectorate secretions

B. evaluate the client's respiratory status

15. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia B. hoarseness C. dyspnea D. weight loss

B. hoarseness

21. A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is the priority nursing action when the client is brought into the emergency room? A. cover the burned area with sterile gauze B. inspect mouth for signs of inhalation injuries C. administer IV pain medications D. draw blood for a CBC count

B. inspect mouth for signs of inhalation injuries

23. A nurse is caring for a client who is immediately postoperative following thoracic surgery. The nurse administers a narcotic analgesic to the client frequently for pain. Which of the following should the nurse recognize as the primary reason for this action? A. it decreases the client's level of anxiety B. it facilitates the client's deep breathing C. it suppresses the client's cough reflex D. it reduces the client's RR

B. it facilitates the client's deep breathing

10. A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response? A. urticaria B. stridor C. tachypnea D. angioedema

B. stridor

7. A nurse is caring for a client who has sustained life-threatening injuries due to a motor-vehicle accident. Identify the sequence the nurse should take in treating the client. A. Control bleeding B. Treat shock C. Check breathing D. Use head-tilt method if airway is obstructed

C. Check breathing D. Use head-tilt method if airway is obstructed A. Control bleeding B. Treat shock

1. A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the nurse's monitoring priority? A. Palpating peripheral pulses B. Auscultating heart sounds C. Confirming the gag reflex D. Measuring blood pressure

C. Confirming the gag reflex

11. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. initiating oxygen therapy B. providing immediate rest for the client C. positioning the client in high-Fowler's D. administering a nebulized beta-adrenergic

D. administering a nebulized beta-adrenergic

2. A nurse is caring for a client admitted to the nursing unit from the PACU following a craniotomy. The initial nursing assessments should focus on A. intracranial pressure B. pupillary reflexes C. level of consciousness D. airway patency

D. airway patency

9. A nurse is caring for a client who had an evacuation of a subdural hematoma. Immediately after the evacuation, which of the following nursing actions is a priority? A. observe for CSF leaks from the evacuation site B. assess for an increase in temperature C. check the oximeter D. monitor for signs of increasing ICP

C. check the oximeter

3. A nurse is planning to prioritize client care after receiving report and rounded on assigned patients. Which of the following client's is a high priority for the nurse to see first? A. a client who is ambulatory and going for an x-ray at 10am B. a client who is to be discharged at 11am C. a client who received pain medication 30 min ago D. a client who is SOB

D. a client who is SOB

13. A nurse is caring for a client following a total laryngectomy. Which of the following should the nurse be aware of as the priority observation in the client's care? A. patency of the IV line B. level of pain C. integrity of the dressing D. need for suctioning

D. need for suctioning