Detailed Answer Key
Complex Oyxgenation ATI Practice
ATI_OXYGENATION_PRACTICE_9.KEY.
1.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to
a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into
the box on the right, placing them in the selected order of performance. Use all the steps.)
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
B. Establish IV access.
A. Perform a Glasgow Coma Scale assessment.
E. Remove clothing for a thorough assessment.
2.A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on
intravenous rifampin therapy. The nurse should instruct the client that this medication can cause
which of the following adverse effects?
A. Constipation
Rationale: Rifampin does not cause constipation. More common gastrointestinal effects are
diarrhea and nausea.
B. Black colored stools
Rationale: It is most commonly iron supplements that cause stools to turn black, not rifampin.
C. Staining of teeth
Rationale: Teeth may be stained from taking liquid iron preparations, not from taking rifampin.
D. Body secretions turning a red-orange color
Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause
the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-
brown.
3.A nurse is caring for a client who has returned from the surgical suite following surgery for a
fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which
of the following actions is the priority for the nurse to take?
A. Prevent aspiration.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority goal is to prevent the client from aspirating.
Because the client's jaws are wired together, aspiration of emesis is a possibility.
Therefore, the client should be given medication for nausea, and wire cutters
should be kept at the bedside in case of vomiting.
B. Ensure adequate nutrition.
Created Page 1
on:08/03/2018
, Detailed Answer Key
Complex Oyxgenation ATI Practice
Rationale:
Created Page 2
on:08/03/2018
, Detailed Answer Key
Complex Oyxgenation ATI Practice
The client should be NPO initially after surgery until the gag reflex has returned.
Once the client is able to eat, the client may advance to a calorie-appropriate,
high-protein liquid diet. However, this is not the priority at this time.
C. Promote oral hygiene
Rationale: The client will have an incision inside the mouth. While it is important that the client
receive frequent mouth cleaning, this is not the priority at this time.
D. Relieve the client's pain.
Rationale: While the client may be in pain and will need to be medicated, this is not the priority
at this time.
4.A nurse caring for a client who has hypertension and asks the nurse about a prescription for
propranolol. The nurse should inform the client that this medication is contraindicated in clients who
have a history of which of the following conditions?
A. Asthma
Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can
cause bronchospasms. Propranolol blocks the sympathetic stimulation, which
prevents smooth muscle relaxation.
B. Glaucoma
Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock,
but are not contraindicated in a client who has glaucoma.
C. Depression
Rationale: Beta-blockers are contraindicated in clients who have AV heart block,
but are not contraindicated in clients who have depression.
D. Migraines
Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.
5.A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires
mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes
that this medication is for which of the following purposes?
A. Decrease chest wall compliance
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis by
relaxing skeletal muscles, which improves chest wall compliance.
B. Suppress respiratory effort
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and
suppress the client's respiratory efforts to the point of apnea, allowing the
mechanical ventilator to take over the work of breathing for the client. This
therapy is especially helpful for a client who has ARDS
Created Page 3
on:08/03/2018
, Detailed Answer Key
Complex Oyxgenation ATI Practice
and poor lung compliance.
C. Induce sedation
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and have no
sedative effect at all. A sedative or analgesic should be prescribed as an adjunct to
the pancuronium.
D. Decrease respiratory secretions
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis. An
adverse effect of this medication is increased production of respiratory
secretions.
ATI_OXYGENATION_PRACTICE_9.KEY.
6.A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for
several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs.
The nurse should realize that this finding is most likely an indication of which of the following
conditions?
A. An upper respiratory infection
Rationale: Although the spleen plays a role in immunity against bacterial infections, the
nurse would be more concerned about the risk of an upper respiratory infection in
a client who has undergone splenectomy, or removal of the spleen.
B. Pulmonary edema
Rationale: Pulmonary edema may develop in a client who is on bedrest following trauma, but
this is not the most likely cause of decreased breath sounds in this client.
C. Atelectasis
Rationale: Atelectasis is the collapse of part or all of a lung by blockage of the air passages
(bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few
changes in position, ineffective coughing, and underlying lung disease are risk
factors for the development of atelectasis.
D. Delayed gastric emptying
Rationale: Although delayed gastric emptying may result in ineffective coughing, this is not
the most likely cause of decreased breath sounds in this client.
7.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.
Rationale: This action is used to determine why a water seal chamber has continuous
bubbling, not slow, steady bubbling.
B. Check the suction control outlet on the wall.
Created Page 4
on:08/03/2018
Complex Oyxgenation ATI Practice
ATI_OXYGENATION_PRACTICE_9.KEY.
1.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to
a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into
the box on the right, placing them in the selected order of performance. Use all the steps.)
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
B. Establish IV access.
A. Perform a Glasgow Coma Scale assessment.
E. Remove clothing for a thorough assessment.
2.A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on
intravenous rifampin therapy. The nurse should instruct the client that this medication can cause
which of the following adverse effects?
A. Constipation
Rationale: Rifampin does not cause constipation. More common gastrointestinal effects are
diarrhea and nausea.
B. Black colored stools
Rationale: It is most commonly iron supplements that cause stools to turn black, not rifampin.
C. Staining of teeth
Rationale: Teeth may be stained from taking liquid iron preparations, not from taking rifampin.
D. Body secretions turning a red-orange color
Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause
the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-
brown.
3.A nurse is caring for a client who has returned from the surgical suite following surgery for a
fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which
of the following actions is the priority for the nurse to take?
A. Prevent aspiration.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority goal is to prevent the client from aspirating.
Because the client's jaws are wired together, aspiration of emesis is a possibility.
Therefore, the client should be given medication for nausea, and wire cutters
should be kept at the bedside in case of vomiting.
B. Ensure adequate nutrition.
Created Page 1
on:08/03/2018
, Detailed Answer Key
Complex Oyxgenation ATI Practice
Rationale:
Created Page 2
on:08/03/2018
, Detailed Answer Key
Complex Oyxgenation ATI Practice
The client should be NPO initially after surgery until the gag reflex has returned.
Once the client is able to eat, the client may advance to a calorie-appropriate,
high-protein liquid diet. However, this is not the priority at this time.
C. Promote oral hygiene
Rationale: The client will have an incision inside the mouth. While it is important that the client
receive frequent mouth cleaning, this is not the priority at this time.
D. Relieve the client's pain.
Rationale: While the client may be in pain and will need to be medicated, this is not the priority
at this time.
4.A nurse caring for a client who has hypertension and asks the nurse about a prescription for
propranolol. The nurse should inform the client that this medication is contraindicated in clients who
have a history of which of the following conditions?
A. Asthma
Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can
cause bronchospasms. Propranolol blocks the sympathetic stimulation, which
prevents smooth muscle relaxation.
B. Glaucoma
Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock,
but are not contraindicated in a client who has glaucoma.
C. Depression
Rationale: Beta-blockers are contraindicated in clients who have AV heart block,
but are not contraindicated in clients who have depression.
D. Migraines
Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.
5.A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires
mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes
that this medication is for which of the following purposes?
A. Decrease chest wall compliance
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis by
relaxing skeletal muscles, which improves chest wall compliance.
B. Suppress respiratory effort
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and
suppress the client's respiratory efforts to the point of apnea, allowing the
mechanical ventilator to take over the work of breathing for the client. This
therapy is especially helpful for a client who has ARDS
Created Page 3
on:08/03/2018
, Detailed Answer Key
Complex Oyxgenation ATI Practice
and poor lung compliance.
C. Induce sedation
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and have no
sedative effect at all. A sedative or analgesic should be prescribed as an adjunct to
the pancuronium.
D. Decrease respiratory secretions
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis. An
adverse effect of this medication is increased production of respiratory
secretions.
ATI_OXYGENATION_PRACTICE_9.KEY.
6.A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for
several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs.
The nurse should realize that this finding is most likely an indication of which of the following
conditions?
A. An upper respiratory infection
Rationale: Although the spleen plays a role in immunity against bacterial infections, the
nurse would be more concerned about the risk of an upper respiratory infection in
a client who has undergone splenectomy, or removal of the spleen.
B. Pulmonary edema
Rationale: Pulmonary edema may develop in a client who is on bedrest following trauma, but
this is not the most likely cause of decreased breath sounds in this client.
C. Atelectasis
Rationale: Atelectasis is the collapse of part or all of a lung by blockage of the air passages
(bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few
changes in position, ineffective coughing, and underlying lung disease are risk
factors for the development of atelectasis.
D. Delayed gastric emptying
Rationale: Although delayed gastric emptying may result in ineffective coughing, this is not
the most likely cause of decreased breath sounds in this client.
7.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.
Rationale: This action is used to determine why a water seal chamber has continuous
bubbling, not slow, steady bubbling.
B. Check the suction control outlet on the wall.
Created Page 4
on:08/03/2018
