ATI - Respiratory
A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?
Cheyne-Stokes breathing
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
Elevate the head of the clients bed
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation:
Inspiratory wheeze auscultated at left lateral chest.
A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax?
The client is experiencing unequal movement of the posterior chest.
A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make?
"You should make every effort to receive a flu vaccine every year."
A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"Clubbing of the fingers indicates a chronic state of impaired perfusion."
A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use?
"Smoking is linked to various forms of cancer." "It might take several attempts to finally stop smoking." "There are pharmacologic therapies that can help a person stop smoking."
A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub?
Coarse grating tone Hard on inspiration and expiration Pain with breathing
A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions?
Expose the posterior chest with the client sitting with their arms folded across their chest. Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in te same location. Auscultate down the spine, moving the stethoscope from one side to the otner until the lower thoracic spine is reached Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib.
A nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation?
Nail beds Oral mucosa Lips
A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation?
Numbness and tingling of extremities Lightheadedness Chest pain
A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data?
Report from client says they sleep while propped on two pillows at night. Client says they quit smoking 2 years ago. Client states, "Being short of breath all of the time is making me depressed."
A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty?
The client is sitting in a tripod position. The client is using pursed lipped breathing. The client appears confused.
A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene?
The nurse is auscultating through the client's gown.
