CM4 Exam 3
ATI BACK OF BOOK Questions
Exam Chapters 28, 31, 32
Chapter 17 Respiratory Diagnostic Procedures
1. A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure,
which of the following actions should the nurse take?
A. Position the client in an upright position, leaning over the bedside table
B. Explain the procedure to the client
C. Obtain ABGs from the client
D. Administer benzocaine pray to the client
Positioning the client in an upright position and bent over the bedside table widens the pleural space
for the provider to access the pleural fluid
2. A nurse is assessing a client who is in respiratory distress. The nurse should recognize that
which of the following can cause a low pulse oximetry reading? (Select all that apply)
A. Nail polish
B. Inadequate peripheral circulation
C. Hyperthermia
D. Increased Hgb level
E. Edema
Nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse oximetry level
Inadequate peripheral circulation can result in a low reading while obtaining client's pulse oximetry
level
Edema can result in a low reading while obtaining a client's pulse oximetry level
3. A nurse is assessing a client following a bronchoscopy. Which of the following findings should
the nurse report to the provider?
A. Blood-tinged sputum
B. Dry, nonproductive cough
C. Sore throat
D. Bronchospasms
Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse
should notify the provider immediately
4. A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following
supplies should the nurse ensure is in the client's room? (Select all that apply)
A. oxygen equipment
B. Incentive spirometer
C. Pulse oximeter
D. Sterile dressing
E. Suture removal kit
Oxygen equipment is necessary to have in the client's room if the client becomes short of breath
following the procedure
Pulse oximetry is necessary to monitor the client's oxygen saturation level during the procedure
A sterile dressing is necessary to apply to the puncture site following the procedure
, 5. A nurse is caring for a client following a thoracentesis. Which of the following manifestations
should the nurse recognize as risks for complications? (Select all that apply)
A. Dysnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the punture site
Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the
provider immediately
Fever can indicate an infection. The nurse should notify the provider immediately
Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately.
Chapter 18 Chest tube insertion and monitoring
1. A nurse preparing to care for a client following chest tube placement. Which of the following
items should be available in the client's room? (Select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing
Oxygen should be readily available in case the client develops respiratory distress following chest
tube placement.
If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to
restore the water seal
Hemostat clamps should be available for the nurse to use to check air leaks
Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected.
This allows air to escape and reduces the risk for a tension pneumothorax
2. A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the client's chest tube was accidentally removed. Which of the following actions
should the nurse take first?
A. Place the tubing in sterile water to restore the water seal
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess the client's respiratory status
Using ABC priority framework, the application of a sterile gauze to the site should be the first action
for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax
3. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the
following are expected findings? (Select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
Gentle bubbling in the suction control chamber is an expected finding as air is being removed
A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that
the drainage system is functioning properly
ATI BACK OF BOOK Questions
Exam Chapters 28, 31, 32
Chapter 17 Respiratory Diagnostic Procedures
1. A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure,
which of the following actions should the nurse take?
A. Position the client in an upright position, leaning over the bedside table
B. Explain the procedure to the client
C. Obtain ABGs from the client
D. Administer benzocaine pray to the client
Positioning the client in an upright position and bent over the bedside table widens the pleural space
for the provider to access the pleural fluid
2. A nurse is assessing a client who is in respiratory distress. The nurse should recognize that
which of the following can cause a low pulse oximetry reading? (Select all that apply)
A. Nail polish
B. Inadequate peripheral circulation
C. Hyperthermia
D. Increased Hgb level
E. Edema
Nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse oximetry level
Inadequate peripheral circulation can result in a low reading while obtaining client's pulse oximetry
level
Edema can result in a low reading while obtaining a client's pulse oximetry level
3. A nurse is assessing a client following a bronchoscopy. Which of the following findings should
the nurse report to the provider?
A. Blood-tinged sputum
B. Dry, nonproductive cough
C. Sore throat
D. Bronchospasms
Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse
should notify the provider immediately
4. A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following
supplies should the nurse ensure is in the client's room? (Select all that apply)
A. oxygen equipment
B. Incentive spirometer
C. Pulse oximeter
D. Sterile dressing
E. Suture removal kit
Oxygen equipment is necessary to have in the client's room if the client becomes short of breath
following the procedure
Pulse oximetry is necessary to monitor the client's oxygen saturation level during the procedure
A sterile dressing is necessary to apply to the puncture site following the procedure
, 5. A nurse is caring for a client following a thoracentesis. Which of the following manifestations
should the nurse recognize as risks for complications? (Select all that apply)
A. Dysnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the punture site
Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the
provider immediately
Fever can indicate an infection. The nurse should notify the provider immediately
Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately.
Chapter 18 Chest tube insertion and monitoring
1. A nurse preparing to care for a client following chest tube placement. Which of the following
items should be available in the client's room? (Select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing
Oxygen should be readily available in case the client develops respiratory distress following chest
tube placement.
If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to
restore the water seal
Hemostat clamps should be available for the nurse to use to check air leaks
Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected.
This allows air to escape and reduces the risk for a tension pneumothorax
2. A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the client's chest tube was accidentally removed. Which of the following actions
should the nurse take first?
A. Place the tubing in sterile water to restore the water seal
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess the client's respiratory status
Using ABC priority framework, the application of a sterile gauze to the site should be the first action
for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax
3. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the
following are expected findings? (Select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
Gentle bubbling in the suction control chamber is an expected finding as air is being removed
A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that
the drainage system is functioning properly
