ATI RESPIRATORY LEARNING SYSTEM MED-SURG
REVISION QUESTION /VERIFIED ANSWERS
1.A nurse is assessing a patient who has a chest tube in place following a thoracic
surgery. Which of the following findings indicates a need for inter- vention:: 2.
Continuous bubbling in the water seal chamber.
Continuous bubbling in the water seal chamber suggests an air leak.
2.A nurse is caring for an elderly patient who suffers from COPD with pneumo- nia. The
nurse should monitor the patient for which of the following acid-base imbalances?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis: 2. Respiratory acidosis
Respiratory acidosis is a common complication of COPD. This
complication occurs because patients who have COPD are unable to
exhale carbon dioxide due to a loss of elastic recoil in the lungs.
3.Respiratory alkalosis: hyperventilation
Occurs when pt exhales too much carbon dioxide
4.Metabolic alkalosis: high pH, high HCO3
Pt has excessive amount of
bicarbonate
Clients who use bicarbonate of soda as an antacid are at risk for the
development of metabolic alkalosis.
Excessive vomiting also places a client at risk for development of
metabolic alkalosis.
,5.A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The
nurse should identify that which of the following findings is an adverse effect of this
medication?
A. Hallucinations
B. Pruritus
C. Hand and foot syndrome
D. Tinnitus: Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
Hand and foot syndrome = adverse effect of capecitabine, an
antineoplastic
- medication used to treat breast and colorectal cancer.
Pruritus is an adverse effect of methotrexate, which is used to treat
cancer and rheumatoid arthritis.
Hallucinations are an adverse effect of asparaginase, which is an
antineoplastic medication used to treat acute lymphocytic leukemi
6.A nurse is preparing to assist a provider to withdraw arterial blood from a patient's
radial artery for measurement of ABG. Which of the following actions should the nurse
plan to take?
A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen.
B. Apply ice to site after obtaining the specimen
C. Perform an Allen's test prior to obtaining the specimen
D. Release pressure applied to puncture site 1 min after needle is withdrawn: 3.
Perform an Allen's test prior to obtaining the specimen.
The nurse should ensure that circulation to the hand is adequate from
the ulnar artery in case the radial artery is injured from the blood draw.
The most common site for withdrawal of arterial blood gases is the
radial artery.
The nurse should apply pressure to the puncture site for 5 to 10 min
after the needle is withdrawn. High pressure of the blood in the arteries
places the client at risk for hemorrhage from the withdrawal site.
, The nurse should use ice to preserve the arterial blood gas specimen
during transport to the laboratory. If the sample is not placed on ice, the
pH and PO2 values can be inaccurate. It is not necessary to place ice on
the withdrawal site.
The nurse should not administer oxygen prior to the blood draw,
because the test measures the client's arterial blood gases when
breathing room air.
7.A nurse is providing instructions about pursed-lip breathing for a patient who has
COPD with emphysema. The nurse should explain that this breathing technique
accomplishes which of the following:
A. Increases oxygen intake
B. Promotes carbon dioxide elimination
C. Uses the intercostal muscles
D. Strengthens the diaphragm: B. Promotes carbon dioxide elimination
The client who has COPD with emphysema should use pursed-lip
breathing when experiencing dyspnea. This is one of the simplest ways
to control dyspnea. It slows the client's pace of breathing, making each
breath more effective. Pursed-lip breathing releases trapped air in the
lungs and prolongs exhalation to slow the breathing rate. This improved
breathing pattern moves carbon dioxide out of the lungs more
efficiently.
8.Pursed lip breathing: The client who uses pursed-lip breathing breathes
in through the nares and out through pursed lips, rather than
concentrating on using chest-wall muscles.
- uses the intercostal muscles
- Strengthens the diaphragm
- Prolongs exhalation
9.A nurse is preparing a patient for a thoracentesis. In which of the following positions
should the nurse place the patient:
A. lying flat on affected side
B. Prone with arms raised over head
C. Supine with HOB elevated
D. Sitting while leaning forward over the bedside table: 4. Sitting while leaning
forward over the bedside table
REVISION QUESTION /VERIFIED ANSWERS
1.A nurse is assessing a patient who has a chest tube in place following a thoracic
surgery. Which of the following findings indicates a need for inter- vention:: 2.
Continuous bubbling in the water seal chamber.
Continuous bubbling in the water seal chamber suggests an air leak.
2.A nurse is caring for an elderly patient who suffers from COPD with pneumo- nia. The
nurse should monitor the patient for which of the following acid-base imbalances?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis: 2. Respiratory acidosis
Respiratory acidosis is a common complication of COPD. This
complication occurs because patients who have COPD are unable to
exhale carbon dioxide due to a loss of elastic recoil in the lungs.
3.Respiratory alkalosis: hyperventilation
Occurs when pt exhales too much carbon dioxide
4.Metabolic alkalosis: high pH, high HCO3
Pt has excessive amount of
bicarbonate
Clients who use bicarbonate of soda as an antacid are at risk for the
development of metabolic alkalosis.
Excessive vomiting also places a client at risk for development of
metabolic alkalosis.
,5.A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The
nurse should identify that which of the following findings is an adverse effect of this
medication?
A. Hallucinations
B. Pruritus
C. Hand and foot syndrome
D. Tinnitus: Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
Hand and foot syndrome = adverse effect of capecitabine, an
antineoplastic
- medication used to treat breast and colorectal cancer.
Pruritus is an adverse effect of methotrexate, which is used to treat
cancer and rheumatoid arthritis.
Hallucinations are an adverse effect of asparaginase, which is an
antineoplastic medication used to treat acute lymphocytic leukemi
6.A nurse is preparing to assist a provider to withdraw arterial blood from a patient's
radial artery for measurement of ABG. Which of the following actions should the nurse
plan to take?
A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen.
B. Apply ice to site after obtaining the specimen
C. Perform an Allen's test prior to obtaining the specimen
D. Release pressure applied to puncture site 1 min after needle is withdrawn: 3.
Perform an Allen's test prior to obtaining the specimen.
The nurse should ensure that circulation to the hand is adequate from
the ulnar artery in case the radial artery is injured from the blood draw.
The most common site for withdrawal of arterial blood gases is the
radial artery.
The nurse should apply pressure to the puncture site for 5 to 10 min
after the needle is withdrawn. High pressure of the blood in the arteries
places the client at risk for hemorrhage from the withdrawal site.
, The nurse should use ice to preserve the arterial blood gas specimen
during transport to the laboratory. If the sample is not placed on ice, the
pH and PO2 values can be inaccurate. It is not necessary to place ice on
the withdrawal site.
The nurse should not administer oxygen prior to the blood draw,
because the test measures the client's arterial blood gases when
breathing room air.
7.A nurse is providing instructions about pursed-lip breathing for a patient who has
COPD with emphysema. The nurse should explain that this breathing technique
accomplishes which of the following:
A. Increases oxygen intake
B. Promotes carbon dioxide elimination
C. Uses the intercostal muscles
D. Strengthens the diaphragm: B. Promotes carbon dioxide elimination
The client who has COPD with emphysema should use pursed-lip
breathing when experiencing dyspnea. This is one of the simplest ways
to control dyspnea. It slows the client's pace of breathing, making each
breath more effective. Pursed-lip breathing releases trapped air in the
lungs and prolongs exhalation to slow the breathing rate. This improved
breathing pattern moves carbon dioxide out of the lungs more
efficiently.
8.Pursed lip breathing: The client who uses pursed-lip breathing breathes
in through the nares and out through pursed lips, rather than
concentrating on using chest-wall muscles.
- uses the intercostal muscles
- Strengthens the diaphragm
- Prolongs exhalation
9.A nurse is preparing a patient for a thoracentesis. In which of the following positions
should the nurse place the patient:
A. lying flat on affected side
B. Prone with arms raised over head
C. Supine with HOB elevated
D. Sitting while leaning forward over the bedside table: 4. Sitting while leaning
forward over the bedside table
