NURS 406 - MED SURGE Respiratory ATI

1- 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 history of night sweats, anorexia, and

weight loss. Which of the following actions should the nurse take? (SATA)

-Assign the client to a private room with negative-pressure airflow

-Wear an N95 respirator when entering the client’s room.

2- A nurse is assisting a provider with a comprehensive physical examination of a client. When the

provider uses transillumination, the nurse should explain to the client that this technique help

evaluate which of the following structures?

-Maxillary sinuses

3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How

should the nurse assist the client with smoking cessation?

-Discuss ways the client can reduce the number of cigarettessmoked per day.

4- A nurse is planning 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?

-Eat high-calorie food first.

Rational: client who has COPD experience early satiety. Clientshould eat calorie-dense food first.

5- A nurse is preparing to administer cisplatin IV to a client who haslung cancer. The nurse should

identify that which of the following findings is an adverse effect of this medication?

-Tinnitus.

Rational: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.

6- 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?

-Stabbing chest pain

Rational: sudden chest pain that is sharp and stabbing is a manifestation of pulmonary

embolism. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood),

tachypnea, tachycardia, diaphoresis, and feeling of impending doom.

 NURS 406 - MED SURGE Respiratory ATI

7- A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and

a high-pitched inspiratory sound (stridor). The nurse should identify theses findings as

manifestations of which of the following complications?

-Respiratory obstruction

8- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the

following laboratory values should the nurse expect?

-ph 7.49,HCO3-32mEq/L, PaCO2 40mmHg

Rational: Metabolic alkalosis: pH and bicarbonate values are greater than the expected

references range, and the PaCO2 is within the expected reference range.

9- A nurse is providing teaching to a client who has a chronic cough and is scheduled for a

bronchoscopy. Which of the following clientstatementsindicates an understanding of the

teaching?

-“A tissue sample might be obtained during the procedure”

10- A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse

take? (SATA)

-Explain that the client will receive sedation and will not remember the procedure.

-Verify that the client understands the purpose and nature of the procedure.

11- A nurse is preparing a client for discharge following a bronchoscopy. Which of the following

assessment is the nurse’s monitoring priority?

-Confirming the gag reflex

Rational: The greater risk to the client’s safety is aspiration resulting from a depressed gag reflex.

12- 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 on the chest wall.

When a family member asks why the client has 2 chest tubes, which of the following responses

should the nurse make?

-“The lower tube will drain blood, and the higher tube will remove air.”

13- A nurse is providing teaching to a client who will undergo a total laryngectomy. Which of the

 NURS 406 - MED SURGE Respiratory ATI

following statements indicate that the client understands the impact of the surgery?

 NURS 406 - MED SURGE Respiratory ATI

- “I understandsthatI will have a permanenttracheostomy afterthe surgery.”

Rational: With a partial laryngectomy, the tracheostomy istemporary. With the total laryngectomy the

tracheostomy will be permanent.

14- A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse

tells the client to be careful while bathing to prevent which of the following complications?

-Aspiration of water.

Rational: This is a client with a tracheostomy,so he will need to use a shower shield over the

stoma when bathing or showering to keep water out of the airway.

15- A nurse is caring for a client who is extremely anxious and is hyperventilating. The client’s ABG

results are pH 7.50, PaCO2 27 mmHg, and HCO3-25 mEq/L. The nurse should identify that the

client has which of the following acid-base imbalances?

-Respiratory alkalosis.

16- A nurse is planning postoperative education for a client who will undergo a radical neck

dissection for cancer of the larynx. The nurse should include which of the following topics?

(SATA)

-NPO status

-Alternative methods of communication

- Changes in body image

-Swallowing exercises.

17- A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin

test. Which of the following pieces of information should the nurse include?

- “You must return to the clinic to have the test read in 2 or 3 days.”

18- A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty/

Which of the following instructions should the nurse include?

“Lie on your back with your head elevated 30º when resting.”

19- A nurse is preparing to assist provider with an arterial blood withdrawal from a client’s

radial artery for ABG measurements. Which of the following actions the nurse plan to