NUR 1700 Q2 ATI
A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A. Administer high-flow oxygen at 5 L/min by facemask to the client. B. Place the client in high-Fowler's position with legs dependent. C. Give the client sublingual nitroglycerin D. Reassure the client.
A. Administer high-flow oxygen at 5 L/min by facemask to the client. Rationale: A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen at 5 L/min by facemask to the client.
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? A. Arterial blood gases B. Urinary output C. Chest tube drainage D. Pain level
A. Arterial blood gases Rationale: According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.
A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds
A. Loud, scratchy sounds Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.
A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. B. Check the client for a positive Chvostek's sign C. Administer an IV vasopressor medication. D. Monitor the client for headache.
A. Provide high-flow oxygen. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop in the level of arterial oxygen, and the client can require mechanical ventilation.
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse determines that this finding indicates that: A. The tubing is kinked B. An air leak is present C. The lung has re-expanded D. The system is functioning as expected
Answer: D Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung re-expands and the client no longer requires chest drainage. If fluctuations are absent it could indicate occlusion of the tubing or that the lung has re-expanded. Bubbling in the water seal chamber indicates that an air leak is present.
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 lactated Ringer's. D. Initiate cardiac monitoring.
B. Administer oxygen therapy. Rationale: The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.
A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A. Constant bubbling in the suction-control chamber B. Continuous bubbling in the water-seal chamber C. Bloody drainage in the collection chamber D. Fluid-level fluctuations in the water-seal chamber
B. Continuous bubbling in the water-seal chamber Rationale: Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A. Atelectasis B. Flail chest C. Hemothorax D. Pneumothorax
B. Flail chest Rationale: Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A. Oxygen saturation of 95% B. No fluctuations in the water seal chamber C. No reports of pleuritic chest pain D. Occasional bubbling in the water-seal chamber
B. No fluctuations in the water seal chamber Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant
C. Encourage the use of an incentive spirometer Rationale: Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding B. Add more water to the suction control chamber of the drainage system. C. Verify that the suction regulator is on and check the tubing for leaks. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
C. Verify that the suction regulator is on and check the tubing for leaks. Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Administer oxygen via nasal cannula.
D. Administer oxygen via nasal cannula. Rationale: The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. B. Check the suction control outlet on the wall. C. Clamp the chest tube. D. Continue to monitor the client's respiratory status.
D. Continue to monitor the client's respiratory status. Rationale: Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.
A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. B. Administer prescribed analgesic medication C. Encourage coughing and deep breathing. D. Raise the head of the bed.
D. Raise the head of the bed. Rationale: Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.
A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? A. Clamp the catheter. B. Position the client in left lateral Trendelenburg. C. Initiate oxygen therapy. D. Auscultate breath sounds.
A. Clamp the catheter. Rationale: The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. B. Immediately notify the provider. C. Reposition the client toward the left side. D. Clamp the chest tube near the water seal
A. Continue to monitor the client. Rationale: The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube.
A client without history of respiratory disease has experienced sudden onset of chest pain and dyspnea and is diagnosed with pulmonary embolus. The nurse immediately implements which expected prescription for this client? A. Semi-fowler's position, oxygen, and morphine sulfate intravenously (IV) B. Supine position, oxygen, and meperidine hydrochloride (Demerol) intramuscularly (IM) C. High Fowler's position, oxygen, meperidine hydrochloride (Demerol) intravenously (IV) D. High Fowler's position, oxygen, and two tablets of acetaminophen with codeine (Tylenol #3)
Answer: A Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen and intravenous analgesics. the head of the bed is placed in semi-Fowler's position. High Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The supine position will increase the dyspnea that occurs with pulmonary embolism. The usual analgesic of choice is morphine sulfate administered IV. The medication reduces pain, relieves anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation. B. Administer oxygen via face mask. C. Prepare to administer a sedative. D. Assess for indications of pulmonary embolism.
B. Administer oxygen via face mask. Rationale: The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine
C. Heparin Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? A. Decreased serum calcium level B. Decreased level of serum lipids C. Decreased D. Increased platelet count sedimentation rate (ESR)
A. Decreased serum calcium level Rationale: A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). C. Increased blood pressure from 112/68 to 120/72 mm Hg. D. Increased heart rate from 68 to 72/min.
A. Increased respiratory rate from 18 to 44/min. Rationale: This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances.
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side B. Bubbling of the water in the water seal chamber with exhalation C. Crepitus in the area above and surrounding the insertion site D. Eyelets are not visible
A. Movement of the trachea toward the unaffected side Rationale: A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.
A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? A. Stridor B. Copious oral secretions C. Hoarseness D. Sore throat
A. Stridor Rationale: Stridor, or a high-pitched crowing sound heard during inspiration, is a result of laryngeal edema. This finding indicates possible obstruction of the client's airway. Therefore, the nurse should report it to the provider immediately.
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub
B. Increasing dyspnea Rationale: The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain.
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature
C. Increased heart rate Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? A. Chest tube eyelets not visible B. Continuous bubbling in the suction control chamber C. Presence of tidal fluctuation in the water seal chamber D. Development of subcutaneous emphysema
D. Development of subcutaneous emphysema Rationale: Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider.
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions
D. Intercostal retractions Rationale: Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs.
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client's wall suction. B. Strip the client's chest tube. C. Clamp the client's chest tube. D. Reposition the client.
D. Reposition the client. Rationale: The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.
A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? A. Continuous bubbling in the water-seal chamber B. Occasional bubbling in the water-seal chamber C. Constant bubbling in the suction-control chamber D. Fluctuations in the fluid level in the water-seal chamber
A. Continuous bubbling in the water-seal chamber Rationale: Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system.
A hospitalized client is dyspneic and has been diagnosed with a left tension pneumothorax by chest x-ray after insertion of a central venous catheter. Which of the following indicates that the pneumothorax is worsening? A. Hypertension B. Flat neck veins C. Pain with respiration D. Tracheal deviation to the right
Answer: D A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased or absent lung sounds, and worsening cyanosis. The increased intrathoracic pressure causes the blood pressure to fall, not rise. The chest could have pain with respiration.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times. D. Empty the collection chamber prior to transport.
C. Keep the drainage system below the level of the client's chest at all times. Rationale: During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. B. Suction the client less frequently. C. Administer an antidysrhythmic medication D. Perform pre-oxygenation prior to suctioning.
D. Perform pre-oxygenation prior to suctioning. Rationale: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.
