ATI MED-SURG RESPIRATORY SYSTEM
EXAM QUESTIONS WITH RATIONALES AND
CORRECT ANSWERS (2024-2025).
1. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the
following room assignments should the nurse make for the client?
A. A room with air exhaust directly to the outdoor environment
Rationale: A room with air exhaust directly to the outside environment eliminates contamination
of other client-care areas. This type of ventilation system is referred to as an airborne
infection isolation room.
B. A room with another nonsurgical client
Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis.
A client who has tuberculosis should have a private room.
C. A room in the ICU
Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill.
D. A room that is within view of the nurses' station
Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be
close to the nurses' station.
2. 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.
,3. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse
expect to assess in this client? (Select all that apply.)
A. Dyspnea
B. Bradycardia
C. Barrel chest
D. Clubbing of the fingers
E. Deep respirations
Rationale:
Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in
which they become weakened and collapse. Dyspnea is seen in clients with emphysema
as the lungs try to increase the amount of oxygen available to the
tissues.</br></br>Bradycardia is incorrect. With emphysema, the heart rate will
increase as the heart tries to compensate for less oxygen to the tissues. </br></br>Barrel
chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes
permanently flattened by hyperinflation of the lungs; the muscles of the rib cage
become rigid; and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.</br></br>Clubbing of the fingers is correct. Clubbing results from
chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become
extremely curved from front to back.</br></br>Deep respirations is incorrect. Clients
with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations
become increasingly shallow.
4. 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.
Rationale: 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.
5. A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
manifestations should the nurse monitor?
A. Confusion
Rationale: Myasthenia gravis does not affect cognition, level of consciousness, or orientation.
B. Weakness
Rationale: Generalized weakness of the diaphragmatic and intercostal muscles may produce
respiratory distress or predispose the client to respiratory infections.
C. Increased intracranial pressure
Rationale:
, Myasthenia gravis does not affect pressure within the brain.
D. Increased urinary output
Rationale: Myasthenia gravis does not cause increased urine output.
6. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer.
The nurse should anticipate that the client will report that her earliest manifestation was
A. dysphagia.
Rationale: Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It
occurs as the tumor grows in size and impedes the esophagus.
B. hoarseness.
Rationale: Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long
exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the
earliest manifestation of cancer of the larynx because the tumor impedes the action of the
vocal cords during speech. The voice may sound harsh and lower in pitch than normal.
C. dyspnea.
Rationale: Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the
tumor grows in size and impedes the airway opening.
D. weight loss.
Rationale: Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
7. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness
burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the
following risks as the priority for assessment and intervention?
A. Airway obstruction
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority risk is airway obstruction. Burns of the head, neck, and chest
often involve damage to the pulmonary tree due to heat as well as smoke and soot
inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain
a patent airway should take priority in this client's care.
B. Infection
EXAM QUESTIONS WITH RATIONALES AND
CORRECT ANSWERS (2024-2025).
1. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the
following room assignments should the nurse make for the client?
A. A room with air exhaust directly to the outdoor environment
Rationale: A room with air exhaust directly to the outside environment eliminates contamination
of other client-care areas. This type of ventilation system is referred to as an airborne
infection isolation room.
B. A room with another nonsurgical client
Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis.
A client who has tuberculosis should have a private room.
C. A room in the ICU
Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill.
D. A room that is within view of the nurses' station
Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be
close to the nurses' station.
2. 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.
,3. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse
expect to assess in this client? (Select all that apply.)
A. Dyspnea
B. Bradycardia
C. Barrel chest
D. Clubbing of the fingers
E. Deep respirations
Rationale:
Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in
which they become weakened and collapse. Dyspnea is seen in clients with emphysema
as the lungs try to increase the amount of oxygen available to the
tissues.</br></br>Bradycardia is incorrect. With emphysema, the heart rate will
increase as the heart tries to compensate for less oxygen to the tissues. </br></br>Barrel
chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes
permanently flattened by hyperinflation of the lungs; the muscles of the rib cage
become rigid; and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.</br></br>Clubbing of the fingers is correct. Clubbing results from
chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become
extremely curved from front to back.</br></br>Deep respirations is incorrect. Clients
with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations
become increasingly shallow.
4. 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.
Rationale: 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.
5. A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
manifestations should the nurse monitor?
A. Confusion
Rationale: Myasthenia gravis does not affect cognition, level of consciousness, or orientation.
B. Weakness
Rationale: Generalized weakness of the diaphragmatic and intercostal muscles may produce
respiratory distress or predispose the client to respiratory infections.
C. Increased intracranial pressure
Rationale:
, Myasthenia gravis does not affect pressure within the brain.
D. Increased urinary output
Rationale: Myasthenia gravis does not cause increased urine output.
6. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer.
The nurse should anticipate that the client will report that her earliest manifestation was
A. dysphagia.
Rationale: Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It
occurs as the tumor grows in size and impedes the esophagus.
B. hoarseness.
Rationale: Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long
exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the
earliest manifestation of cancer of the larynx because the tumor impedes the action of the
vocal cords during speech. The voice may sound harsh and lower in pitch than normal.
C. dyspnea.
Rationale: Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the
tumor grows in size and impedes the airway opening.
D. weight loss.
Rationale: Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
7. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness
burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the
following risks as the priority for assessment and intervention?
A. Airway obstruction
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority risk is airway obstruction. Burns of the head, neck, and chest
often involve damage to the pulmonary tree due to heat as well as smoke and soot
inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain
a patent airway should take priority in this client's care.
B. Infection
