ATI – Respiratory Assessment – Med-surg

A client w/ Respiratory Failure who is receiving mechanical ventilation. Which assessment is the priority for the nurse to evaluate the effectiveness of the ventilation.
(When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gasses to determine serum oxygen saturation and acid-base balance)

A client who has acute resp failure. Which lab findings should the nurse expect?
– Arterial PH 7.5
-PaCO2 – 25
SaO2 – 92%
PaO2 – 58
PaO2 58
(the nurse should expect the client who has acute respiratory failure to have lower partial pressures of oxygen)

A client w/ resp. distress. Which device should the nurse use to provide the highest level of oxygen via a low-flow system?
Non-rebreather mask

Patient taking rifampin for tuberculosis. What is an important teaching?
Urine and other secretions will be orange

A client w/ pulmonary embolism. What intervention is priority?
Administering heparin via continuous IV infusion
(The nurse should prioritize stabilizing circulation to the lungs with heparin to prevent further clot formation)

A nurse is assessing a client who has emphysema. The nurse should report?
Elevated temp
(Clients who have emphysema are at risk for development of pneumonia and other respiratory infections. A nurse should report an elevated temp. to the provider, as this indicates a possible resp. infection.)

You are a nurse working in the emergency department w/ a client following a chest trauma. Which finding indicates a tension pneumothorax?
Tracheal deviation to the unaffected side.
(a tracheal pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side)

A client who is postoperative and develops acute onset of severe chest pain that worsens upon inspiration. Client is anxious and tachypneic. What should the nurse do?
Apply supplemental oxygen
(the greatest risk to the patient is hypoxemia)

A nurse is planning care for COPD client. What intervention should the nurse include?
Provide a diet high in calories and protein.
Also low on carbs

A nurse caring for a client receiving mech ventilation. The low pressure alarm sounds. What should the nurse expect caused the alarm?
Artificial airway cuff leak.
(an artificial cuff leak interferes w/ oxygenation and causes the low pressure alarm to sound)

A nurse should question nasopharyngeal suctioning for which client?
Closed-head injury and is lethargic
(A recent head injury is a contraindication for nasopharyngeal suctioning because suctioning can increase intracranial pressure

A client who is 1 hour post-op following thoracentesis. what condition is the priority assessment finding?
Tracheal deviation to the unaffected side
(tracheal deviation indicates a tension pneumothorax, which is a medical emergency)

client who is 4 hour PO a total laryngectomy for laryngeal cancer. what is the priority assessment?
– bleeding at the surgical site
-oxygen saturation
-urinary retention
-level of consciousness
Oxygen saturation
(A client post-op total laryngectomy is at risk for hypoxia r/t airway obstruction. A decreased O2 sat is an indication of an obstructed airway)

What should the nurse plan to have while caring for a client following the insertion of a chest tube?
Container of sterile water
(The nurse should plan to place the open end of the tubing if it becomes disconnected into sterile water to prevent pneumothorax. The tubing and sterile water are then placed below the client’s chest)

A nurse assessing client who has a chest tube in place following thoracic surgery. what finding indicates a need for intervention?
Continuous bubbling in the water seal chamber.
(Continuous bubbling in the water seal chamber suggests an air leak)

PH – 7.30
PaCO2 – 55
HCO3 – 22
respiratory acidosis

The nurse should monitor for _____ adverse effect after administration of albuterol?

____ is an expected finding w/ a client who has lung cancer.
Blood-tinged sputum
(Blood tinged sputum secondary to bleeding from the tumor)

A nurse is assisting w/ thoracentesis. What actions are appropriate for the nurse to take when assisting w/ this procedure?
– wear goggles and mask during the procedure
– cleanse the are w/ an antiseptic solution
– apply pressure to the site after the needle is withdrawn.

A nurse is preparing a client for d/c following a bronchoscopy w/ the use of moderate (conscious) sedation. what assessment is priority?
Gag reflex
(The greatest risk to the client is aspiration due to the depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex)

A nurse is caring for client w/ bacterial pneumonia. the nurse should expect which of the following findings?
Temperature 101.8 Degrees F

A nurse is caring for a client who has acute resp. distress syndrome. Which assessment finding indicates a decline the client’s condition?
Increase in resp rate.
(An increase in resp. rate indicates the increased work of breathing and the need for improvement in O2 delivery)

A nurse is providing instructions to a client on how to use montelukast to treat chronic asthma. The following statement indicates they understand.
I will take this medication every evening, even when I don’t have symptoms.
(montelukast is used for prophylaxis of asthma exacerbation and is taken on a daily basis, and should taken every day as maintenance therapy)

A nurse is carping for a client with COPD. Which of the following finding should be reported?
Productive cough with green sputum.
(A productive cough with green sputum indicates an infection.)

A nurse is planning care for a client w/ asthma. Which medication should be administered during an acute asthma attack?
(Albuterol is a short-acting beta 2 adrenergic agonist, and acts quickly to produce bronchodilation.)

A nurse is caring for a client with active TB. What isolation precautions should be taken.
(TB is a respiratory infection, and it’s spread through the air)

A nurse is positioning a client with emphysema to promote effective breathing. The client should be placed in what position?
High-fowler’s with arms supported on over bed table.

A nurse is caring for a client in respiratory distress needing endotracheal suctioning. What action should the nurse take?
Sterile technique. Use a rotating motion to remove the catheter. Only suction when needed to reduce hypoxia, tissue damage, and bronchospasams.

Which client is at the greatest risk for pulmonary embolism.
-pt 12 hr post-op total hip arthroplasty
-pt 8 hr post-op open surgical appendectomy
-pt 2 hr post-op open reduction external fixation of right radius
-pt 4 hr post-op laparoscopic cholecystectomy
Total hip arthroplasty
(Total hip surgery is th egreatest risk due to decreased mobility of the affected extremity)

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax? Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, …

A nurse is caring for a client who has lung cancer. which of the following assessment findings should the nurse expect? Blood-tinged sputum A nurse is caring for a client who is 4 hr postoperative following a total laryngectomy for …

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? Fit all employees with protective masks. A recent immigrant is diagnosed with pulmonary …

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? Discontinue the heparin. The nurse is caring for a postoperative …

Following a motor-vehicle crash a client is admitted with multiple trauma, including significant bruising of the left chest from striking the steering wheel. The client is alert and reports severe left pain on inspiration. The nurse should assess the client …

A nurse is caring for a client who is taking albuterol. For which of the following adverse effects should the nurse monitor the client? 1. Hyperkalemia 2. Dyspnea 3. Tachycardia 4. Candidiasis Tachycadia A nurse is assessing a client who …

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