ATI Care
of Critically Ill Patients with Respiratory Problems, Questions and Answers
with Explanations, 100% Correct, Download to Score A
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client receiving
heparin and warfarin therapy for a pulmonary embolus. The client’s
international normalized ratio (INR) is 2.0. What is the nurse’s best action?
a. |
Increase the heparin
dose. |
b. |
Increase the warfarin
dose. |
c. |
Continue the current
therapy. |
d. |
Discontinue the
heparin. |
ANS: D
The client who is being
treated for pulmonary embolism usually continues on heparin and warfarin until
the INR reaches a therapeutic level between 2 and 3. Heparin can then be
discontinued because warfarin is therapeutic.
DIF: Cognitive Level: Application/Applying
or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Pharmacological and Parenteral
Therapy—Pharmacological Agents)
MSC: Integrated Process:
Nursing Process (Implementation)
2. The nurse is caring for a postoperative client
who suddenly reports difficulty breathing and sharp chest pain. After notifying
the Rapid Response Team, what is the nurse’s priority action?
a. |
Elevate the head of
the bed and apply oxygen. |
b. |
Listen to the client’s
lung sounds. |
c. |
Pull the call bell out
of the wall socket. |
d. |
Assess the client’s
pulse oximetry. |
ANS: A
The client’s immediate
need is to have oxygen applied. The nurse should then assess the client’s pulse
oximetry.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process:
Nursing Process (Implementation)
3. It is determined that a client has a large
pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse’s
priority action?
a. |
Monitor the client’s
oxygenation. |
b. |
Teach the client about
potential side effects. |
c. |
Monitor the IV
insertion site. |
d. |
Monitor for bleeding. |
ANS: A
Airway and breathing are
the top priority. The nurse would also need to monitor for bleeding when
administering fibrinolytic therapy, and would monitor the IV site as well.
Teaching the client is also a need, however. Oxygenation is the highest
priority.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process:
Nursing Process (Implementation)
4. A client with a large pulmonary embolism is
receiving alteplase (Activase). The nurse notes frank red blood in the Foley
catheter drainage bag. What is the nurse’s first action?
a. |
Irrigate the Foley. |
b. |
Administer an
antibiotic. |
c. |
Clamp the Foley. |
d. |
Notify the health care
provider. |
ANS: D
Alteplase is a
fibrinolytic agent that dissolves formed clots. The drug has an impact on clots
outside the pulmonary embolism, and the client is at great risk for hemorrhage
and shock. The nurse should realize the potential for a severe problem and
should call the health care provider immediately for orders. The other actions
would not be appropriate first actions in this situation.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
5. The nurse is caring for a client with a
pulmonary embolus who also has right-sided heart failure. Which symptom will
the nurse need to intervene for immediately?
a. |
Respiratory rate of 28
breaths/min |
b. |
Urinary output of 10
mL/hr |
c. |
Heart rate of 100
beats/min |
d. |
Dry cough |
ANS: B
Urinary output is very
low; this could indicate that the client has decreased cardiac output. The nurse
will need to intervene and notify the health care provider. A respiratory rate
that is slightly elevated is expected in this condition. Likewise, a heart rate
that is a little higher is expected in this situation. A dry cough is also
commonly found with pulmonary embolus.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
6. A client states, “At night, I usually need to
sleep propped up on two pillows in the chair, but now it seems I need three
pillows.” What is the nurse’s best response?
a. |
“You should try to rest more during the day.” |
b. |
“You should try to lie flat for short periods
of time.” |
c. |
“You need to stay in the hospital for further
evaluation.” |
d. |
“You can take medication at night so you can
sleep.” |
ANS: C
Orthopnea is the
sensation of dyspnea or breathlessness in the supine position. Clients feel
that they cannot catch their breath in the supine position and must rest or
sleep in a semi-sitting position by placing pillows behind their backs or by
using a reclining chair. The degree of breathlessness can be measured roughly
by the number of pillows needed to make the client less dyspneic (e.g.,
one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic
respiratory problems, a minor increase in dyspnea may indicate a severe
respiratory problem. Respiratory failure is a high risk. This client needs to stay
in the hospital to be evaluated more completely. The client should not be
instructed to try to lie flat, or to take a sleeping pill.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process:
Nursing Process (Assessment)
7. A client is admitted owing to difficulty
breathing. The nurse assesses the client’s color, lung sounds, and pulse
oximetry reading. The pulse oximetry is 90%. What is the nurse’s next action?
a. |
Give an intermittent
positive-pressure breathing treatment. |
b. |
Administer a rescue
inhaler. |
c. |
Call for a chest
x-ray. |
d. |
Assess an arterial
blood gas. |
ANS: D
When clients with
respiratory problems are assessed, an arterial blood gas is needed for the most
accurate assessment of oxygenation. No indications are known for a breathing
treatment or an inhaler, nor does the nurse have enough information to know
whether a chest x-ray is warranted.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process:
Nursing Process (Assessment)
8. A client with dyspnea is becoming very anxious.
An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the
nurse best intervene?
a. |
Increase the oxygen. |
b. |
Administer an
antianxiety medication. |
c. |
Administer a
bronchodilator. |
d. |
Assist with relaxation
techniques. |
ANS: D
The nurse should assess
the client’s oxygenation; however, this client’s arterial blood gas documents
that the client’s hypoxia has resolved. At this time it is not necessary to
increase the oxygen or administer a bronchodilator; both of these interventions
would be appropriate if the client were hypoxic. The client with respiratory
problems should not take an antianxiety medication as a first-line
intervention, because this may decrease the respiratory rate and/or alertness.
The best intervention at this time is to assist with relaxation techniques.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process:
Nursing Process (Analysis)
Category | ATI |
Release date | 2021-09-14 |
Pages | 23 |
Language | English |
Comments | 0 |
Sales | 0 |
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