ATI Respiratory Med-Surg

ATI Respiratory Med-Surg a nurse is reinforcing preoperative teaching with a client who has lung cancer and will undergo a pneumonectomy. Which of the following pieces of information should the nurse include? (Select all that apply.) A. "You will have a chest tube in place after surgery." B. "We'll help you turn, cough, and breathe deeply frequently after surgery." C. "You will have to remain in bed for about 2 days after the surgery." D. "We'll give you oxygen to support your breathing if you need it." E. "You should expect pain for the first few days after surgery." - CORRECT ANSWER a,b,d A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for the possibility of endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication - CORRECT ANSWER c A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A. Measuring heart rate B. Palpating peripheral pulses C. Observing sputum for blood D. Confirming the gag reflex - CORRECT ANSWER d A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place, 1 in the lower portion of the thorax and the other higher up on the chest wall. When the family asks the nurse why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first." - CORRECT ANSWER c A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at mealtimes C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking - CORRECT ANSWER a A nurse is collecting data from a client who has a positive tuberculin skin test. Which of the following findings should the nurse identify as an indication that the client has active tuberculosis? A. Rhinitis B. Air hunger C. Night sweats D. Weight gain - CORRECT ANSWER c A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following pieces of information should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1,500 mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94% - CORRECT ANSWER a A nurse is assisting with the plan of care for a client following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hours - CORRECT ANSWER c A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus - CORRECT ANSWER d A nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. The provider prescribed 100% oxygen by nonrebreather mask aer the client reported severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 38°C (100.4°F) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea - CORRECT ANSWER b A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. "Apply warm compresses to the face." B. "Take aspirin 650 milligrams by mouth for mild pain." C. "Close your mouth when sneezing." D. "Lie on your back with your head elevated 30° when resting." - CORRECT ANSWER d A nurse is reinforcing teaching with a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume - CORRECT ANSWER a A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow B. Add contact precautions to the client's plan of care C. Wear an N95 respirator when entering the client's room D. Ensure the client's environment provides 4 exchanges of fresh air per minute E. Institute protective environment precautions as soon as the client arrives on the unit - CORRECT ANSWER a,c A nurse is reinforcing teaching about breathing techniques with a client who has emphysema. Which of the following statements should the nurse identify as an indication that the client understands the mechanics behind pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises." - CORRECT ANSWER d A nurse is collecting data from a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. Elevated temperature B. Swollen cervical lymph nodes C. Inspiratory stridor D. Purulent nasal discharge - CORRECT ANSWER c A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tendern