ATI MED SURG EXAM 2 PREP UP: ACHIEVE A+ WITH
COMPREHENSIVE QUESTIONS AND ANSWERS.
A client with chronic obstructive pulmonary disease (COPD) is intubated and
placed on continuous mechanical ventilation. Which equipment is most important
for the nurse to keep at this client's bedside?
Manual resuscitation bag
Why? The client with COPD depends on mechanical ventilation for adequate tissue
oxygenation. The nurse must keep a manual resuscitation bag at the bedside to
ventilate and oxygenate the client in case the mechanical ventilator malfunctions.
Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal
chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary.
Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate
the effectiveness of ventilation, this equipment is less important than the manual
resuscitation bag.
A nurse prepares to perform postural drainage. How should the nurse ascertain
the best position to facilitate clearing the lungs?
Auscultation
Why? The nurse should assess breath sounds before doing postural drainage to
determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all
assessment parameters that give good information about respiratory function but aren't
necessary to determine lung areas requiring postural drainage.
The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which
statement by the client tells the nurse that the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
Why? When performing CPT, the nurse ensures that the client is comfortable, is not
wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain,
as prescribed, before percussion and vibration, splints any incision, and provides pillows
,for support, as needed. A goal of CPT is for the client to be able to mobilize secretions;
the client who has an unproductive cough is a candidate for CPT.
A patient is being educated in the use of incentive spirometry prior to having a
surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
Why? The patient should be instructed to perform the procedure approximately 10 times
in succession, repeating the 10 breaths with the spirometer each hour during waking
hours. The patient should assume a semi-Fowler's position or an upright position before
initiating therapy, not be supine. Coughing during and after each session is encouraged,
not discouraged. The patient should Splint the incision when coughing postoperatively.
The patient should still use the spirometer when in pain.
A new ICU nurse is observed by her preceptor entering a patient's room to
suction the tracheostomy after performing the task 15 minutes before. What
should the preceptor educate the new nurse to do to ensure that the patient
needs to be suctioned?
Auscultate the lung for adventitious sounds.
Why? When a tracheostomy or endotracheal tube is in place, it is usually necessary to
suction the patient's secretions because of the decreased effectiveness of the cough
mechanism. Tracheal suctioning is performed when adventitious breath sounds are
detected or whenever secretions are obviously present. Unnecessary suctioning can
initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
For a client with an endotracheal (ET) tube, which nursing action is the most
important?
Auscultating the lungs for bilateral breath sounds
Why? For the client with an ET tube, the most important nursing action is auscultating
the lungs regularly for bilateral breath sounds to ensure proper tube placement and
effective oxygen delivery. Although turning the client from side to side every 2 hours,
monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene
,are appropriate actions for this client, they're secondary to ensuring adequate
oxygenation.
Which range of water pressure within the endotracheal tube cuff is believed to
prevent both injury and aspiration?
15 to 20 mm Hg
Explanation:
Usually the pressure is maintained at <25 mmHG water pressure to prevent injury and
at >20 mm HG water pressure to prevent aspiration. High cuff pressure can cause
tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can
increase the risk of aspiration pneumonia. A water pressure of 0-5 or 10-15 mm Hg
would indicate that the cuff is underinflated. A water pressure of 30-35 mm Hg would
indicate that the cuff is overinflated.
The nurse is assisting a client with postural drainage. Which of the following
demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to
15 minutes.
Explanation:
Postural drainage is usually performed two to four times daily, before meals (to prevent
nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or
saline may be nebulized and inhaled before postural drainage to dilate the bronchioles,
reduce bronchospasm, decrease the thickness of mucus and sputum, and combat
edema of the bronchial walls. The nurse instructs the client to remain in each position
for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through
pursed lips to help keep the airways open so that secretions can drain while in each
position. If the sputum is foul-smelling, it is important to perform postural drainage in a
room away from other patients or family members. (Deodorizers may be used to
counteract the odor. Because aerosol sprays can cause bronchospasm and irritation,
they should be used sparingly and with caution.)
, A patient is being educated in the use of incentive spirometry prior to having a
surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
Explanation:
The patient should be instructed to perform the procedure approximately 10 times in
succession, repeating the 10 breaths with the spirometer each hour during waking
hours. The patient should assume a semi-Fowler's position or an upright position before
initiating therapy, not be supine. Coughing during and after each session is encouraged,
not discouraged. The patient should Splint the incision when coughing postoperatively.
The patient should still use the spirometer when in pain.
After lobectomy for lung cancer, a client receives a chest tube connected to a
disposable chest drainage system. The nurse observes that the drainage system
is functioning correctly when she notes tidal movements or fluctuations in which
compartment of the system as the client breathes?
Water-seal chamber
Explanation:
Fluctuations in the water-seal compartment are called tidal movements and indicate
normal function of the system as the pressure in the tubing changes with the client's
respirations. The air-leak meter — not chamber — detects air leaking from the pleural
space. The collection chamber connects the chest tube from the client to the system.
Drainage from the tube drains into and collects in a series of calibrated columns in this
chamber. The suction control chamber provides the suction, which can be controlled to
provide negative pressure to the chest.
A client has a sucking stab wound to the chest. Which action should the nurse
take first?
Apply a dressing over the wound and tape it on three sides.
Explanation:
The nurse should immediately apply a dressing over the stab wound and tape it on
COMPREHENSIVE QUESTIONS AND ANSWERS.
A client with chronic obstructive pulmonary disease (COPD) is intubated and
placed on continuous mechanical ventilation. Which equipment is most important
for the nurse to keep at this client's bedside?
Manual resuscitation bag
Why? The client with COPD depends on mechanical ventilation for adequate tissue
oxygenation. The nurse must keep a manual resuscitation bag at the bedside to
ventilate and oxygenate the client in case the mechanical ventilator malfunctions.
Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal
chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary.
Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate
the effectiveness of ventilation, this equipment is less important than the manual
resuscitation bag.
A nurse prepares to perform postural drainage. How should the nurse ascertain
the best position to facilitate clearing the lungs?
Auscultation
Why? The nurse should assess breath sounds before doing postural drainage to
determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all
assessment parameters that give good information about respiratory function but aren't
necessary to determine lung areas requiring postural drainage.
The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which
statement by the client tells the nurse that the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
Why? When performing CPT, the nurse ensures that the client is comfortable, is not
wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain,
as prescribed, before percussion and vibration, splints any incision, and provides pillows
,for support, as needed. A goal of CPT is for the client to be able to mobilize secretions;
the client who has an unproductive cough is a candidate for CPT.
A patient is being educated in the use of incentive spirometry prior to having a
surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
Why? The patient should be instructed to perform the procedure approximately 10 times
in succession, repeating the 10 breaths with the spirometer each hour during waking
hours. The patient should assume a semi-Fowler's position or an upright position before
initiating therapy, not be supine. Coughing during and after each session is encouraged,
not discouraged. The patient should Splint the incision when coughing postoperatively.
The patient should still use the spirometer when in pain.
A new ICU nurse is observed by her preceptor entering a patient's room to
suction the tracheostomy after performing the task 15 minutes before. What
should the preceptor educate the new nurse to do to ensure that the patient
needs to be suctioned?
Auscultate the lung for adventitious sounds.
Why? When a tracheostomy or endotracheal tube is in place, it is usually necessary to
suction the patient's secretions because of the decreased effectiveness of the cough
mechanism. Tracheal suctioning is performed when adventitious breath sounds are
detected or whenever secretions are obviously present. Unnecessary suctioning can
initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
For a client with an endotracheal (ET) tube, which nursing action is the most
important?
Auscultating the lungs for bilateral breath sounds
Why? For the client with an ET tube, the most important nursing action is auscultating
the lungs regularly for bilateral breath sounds to ensure proper tube placement and
effective oxygen delivery. Although turning the client from side to side every 2 hours,
monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene
,are appropriate actions for this client, they're secondary to ensuring adequate
oxygenation.
Which range of water pressure within the endotracheal tube cuff is believed to
prevent both injury and aspiration?
15 to 20 mm Hg
Explanation:
Usually the pressure is maintained at <25 mmHG water pressure to prevent injury and
at >20 mm HG water pressure to prevent aspiration. High cuff pressure can cause
tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can
increase the risk of aspiration pneumonia. A water pressure of 0-5 or 10-15 mm Hg
would indicate that the cuff is underinflated. A water pressure of 30-35 mm Hg would
indicate that the cuff is overinflated.
The nurse is assisting a client with postural drainage. Which of the following
demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to
15 minutes.
Explanation:
Postural drainage is usually performed two to four times daily, before meals (to prevent
nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or
saline may be nebulized and inhaled before postural drainage to dilate the bronchioles,
reduce bronchospasm, decrease the thickness of mucus and sputum, and combat
edema of the bronchial walls. The nurse instructs the client to remain in each position
for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through
pursed lips to help keep the airways open so that secretions can drain while in each
position. If the sputum is foul-smelling, it is important to perform postural drainage in a
room away from other patients or family members. (Deodorizers may be used to
counteract the odor. Because aerosol sprays can cause bronchospasm and irritation,
they should be used sparingly and with caution.)
, A patient is being educated in the use of incentive spirometry prior to having a
surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
Explanation:
The patient should be instructed to perform the procedure approximately 10 times in
succession, repeating the 10 breaths with the spirometer each hour during waking
hours. The patient should assume a semi-Fowler's position or an upright position before
initiating therapy, not be supine. Coughing during and after each session is encouraged,
not discouraged. The patient should Splint the incision when coughing postoperatively.
The patient should still use the spirometer when in pain.
After lobectomy for lung cancer, a client receives a chest tube connected to a
disposable chest drainage system. The nurse observes that the drainage system
is functioning correctly when she notes tidal movements or fluctuations in which
compartment of the system as the client breathes?
Water-seal chamber
Explanation:
Fluctuations in the water-seal compartment are called tidal movements and indicate
normal function of the system as the pressure in the tubing changes with the client's
respirations. The air-leak meter — not chamber — detects air leaking from the pleural
space. The collection chamber connects the chest tube from the client to the system.
Drainage from the tube drains into and collects in a series of calibrated columns in this
chamber. The suction control chamber provides the suction, which can be controlled to
provide negative pressure to the chest.
A client has a sucking stab wound to the chest. Which action should the nurse
take first?
Apply a dressing over the wound and tape it on three sides.
Explanation:
The nurse should immediately apply a dressing over the stab wound and tape it on
