Ati lpn level 3 med surg resp test
Total Questions : 14
Showing 14 questions, Sign in for moreThe nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
Explanation
A. Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
B. Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
C. Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
D. Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.
A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?
Explanation
A. Continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber indicates a possible air leak in the system, which needs to be assessed and potentially reported to the charge nurse for further evaluation.
B. Patient respiratory status is stable and denies pain to chest tube site: This is a normal finding and does not require reporting.
C. Tidalling, fluctuations in the fluid level in the water-seal chamber: This is a normal finding, indicating that the chest tube is functioning properly and that the lungs are expanding.
D. Occasional bubbling in the water-seal chamber: This may be acceptable, especially with respiratory movements, as it could indicate that the patient is exhaling, but continuous bubbling is concerning.
A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?
Explanation
A. Decreasing respiratory rate: This is not expected; respiratory rate may increase as the body attempts to compensate for reduced oxygenation.
B. Facial flushing: This is not a common symptom of atelectasis and may indicate other issues such as anxiety or fever.
C. Dry cough: While a cough may be present, it is more likely to be productive due to retained secretions.
D. Increasing dyspnea: Atelectasis often leads to decreased lung volume, which can cause increasing dyspnea as the lung tissue collapses.
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
Explanation
A. Plan to administer insulin to the client: Insulin is not indicated for respiratory alkalosis; it is used for managing hyperglycemia in diabetic patients.
B. Plan to administer sodium bicarbonate to the client: Sodium bicarbonate is not appropriate for respiratory alkalosis and could worsen the condition.
C. Have the client breathe into a paper bag: Breathing into a paper bag can help increase carbon dioxide levels in the blood, which is often helpful in treating respiratory alkalosis due to hyperventilation.
D. Have the client place their head between their knees: This position does not directly address hyperventilation or help regulate breathing.
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
Explanation
A. "It delivers the highest concentration of oxygen possible." This is inaccurate; other methods (like non-rebreather masks) deliver higher concentrations.
B. "It delivers a specific concentration of oxygen constantly." While it does provide a specific concentration, it is not as constant as other devices because it can vary based on the client's breathing patterns.
C. "It delivers the low concentration of oxygen you need." A nasal cannula typically delivers a low concentration of oxygen (approximately 24-44% oxygen depending on the flow rate), which is appropriate for clients who need supplemental oxygen but do not require a high concentration.
D. "It allows you to remove it for a while when it gets uncomfortable." This is misleading; while the client can remove it temporarily, it is essential to maintain oxygen therapy as prescribed for adequate oxygenation.
A nurse is collecting data on a client who has respiratory alkalosis. Which of the following findings should the nurse expect?
Explanation
A. Abdominal pain: This is not typically associated with respiratory alkalosis, which primarily affects respiratory and neurologic systems.
B. Hyperventilation: Respiratory alkalosis occurs when a person exhales too much carbon dioxide, typically from hyperventilation, which can result from anxiety, pain, or other conditions.
C. Constipation: This is not a symptom of respiratory alkalosis; it might be seen in other metabolic disorders but not this one.
D. Dry skin: Dry skin is not a common manifestation of respiratory alkalosis; symptoms are usually respiratory and neurological (e.g., lightheadedness, tingling).
A nurse is reinforcing teaching with a client who has a new prescription for nebulizer treatments. Which of the following client statements indicates to the nurse a need for further teaching?
Explanation
A. "I will seal my lips around the mouthpiece and take slow, deep breaths.": This is a correct technique for nebulizer use, ensuring proper delivery of the medication.
B. "I should wash the mouthpiece with warm, soapy water each day.": Proper cleaning of the mouthpiece daily is recommended to prevent infection and maintain hygiene.
C. "I will store my nebulizer at room temperature.": Storing the nebulizer at room temperature is appropriate to ensure its functionality.
D. "I should keep medication in my nebulizer at all times." Nebulizer medication should not be left in the device when it is not in use. Leaving medication in the nebulizer can lead to contamination or improper dosing. The medication should be added only before each treatment.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?
Explanation
A. Perform chest physiotherapy prior to suctioning: While chest physiotherapy helps mobilize secretions, it does not thin them, which is the main concern in this situation.
B. Provide humidified oxygen. Humidified oxygen helps to moisten secretions, making them easier to expectorate or suction, which is especially important for tracheostomy care.
C. Pre-lubricate the suction catheter tip with sterile saline when suctioning the airway: This is not a method to thin secretions, but rather to lubricate the catheter.
D. Hyperventilate the client with 100% oxygen before suctioning the airway: This is done to prevent hypoxia during suctioning but does not help with thinning secretions.
A nurse is assisting discharge planning for a client who has a new prescription for bi-level positive airway pressure (BIPAP). The nurse should plan to contact which of the following healthcare team members to educate the client?
Explanation
A. Case manager: A case manager can help coordinate care but is not responsible for the specific education on BiPAP use.
B. Occupational therapist: Occupational therapists focus on daily living activities, not respiratory therapy.
C. Physical therapist: Physical therapists work on mobility and musculoskeletal issues, not respiratory support or BiPAP education.
D. Respiratory therapist: A respiratory therapist is responsible for providing education on the use of BiPAP, as they are specialists in respiratory equipment and therapy. They ensure that the client knows how to use the machine properly at home.
A nurse is reinforcing discharge instructions with a parent of a 6-year-old child who has just had a tonsillectomy. Which of the following statements by the parent indicates an understanding of postoperative care?
Explanation
A. "It's okay for my child to have plenty of ice cream.": Cold, soft foods like ice cream are typically allowed, but dairy products like ice cream may increase mucus production, which could irritate the throat.
B. “I’ll help my child gargle with salt water a few times a day.": Gargling is contraindicated after a tonsillectomy as it can irritate the surgical site and potentially cause bleeding.
C. "I'll call the doctor if my child is swallowing continuously." Continuous swallowing can be a sign of bleeding after a tonsillectomy, which is a medical emergency. It is important for parents to recognize this as an early sign of hemorrhage.
D. "It's okay for my child to ride his bike in a few days.": Strenuous activities, including riding a bike, should be avoided for at least 1-2 weeks to reduce the risk of bleeding.
A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?
Explanation
A. Encourage the client to cough and deep breathe. Encouraging the client to cough and deep breathe promotes the clearance of secretions and improves lung expansion, which is critical in treating pneumonia.
B. Encourage the client to increase oral fluids: This helps to thin secretions, but encouraging deep breathing and coughing is more immediate and effective for clearing secretions.
C. Provide chest percussion on the client: Chest percussion helps mobilize secretions but is not the priority before ensuring the client is actively coughing and deep breathing.
D. Obtain the client’s temperature: While monitoring vital signs is important, clearing secretions is the priority for improving respiratory status in pneumonia.
A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility. Which of the following interventions should the nurse include in the plan?
Explanation
A. Provide prophylactic antibiotics for clients who have been exposed to influenza: Antibiotics are not effective against viral infections like influenza. Antiviral medications may be used for prophylaxis in exposed individuals.
B. Assign health care personnel to non-direct care activities for 24 hr after developing influenza symptoms: Healthcare personnel should not provide care while symptomatic. The recommended restriction period is typically longer than 24 hours.
C. Place restrictions on visitation. During an influenza outbreak, limiting visitation can reduce the spread of infection, especially in vulnerable populations like those in long-term care facilities.
D. Implement airborne precautions for clients who have influenza: Influenza is spread through droplets, not airborne particles. Droplet precautions are appropriate.
A nurse is reinforcing discharge teaching with a client following an episode of status asthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. "I will hold the inhaler with my non-dominant hand.": The hand used to hold the inhaler is not as important as the technique for inhaling the medication.
B. "I will tilt my head forward while inhaling the medication.": The head should be in a neutral or slightly tilted back position to ensure proper inhalation of the medication.
C. "I will hold my breath at least 10 seconds after inhaling the medication." Holding the breath for at least 10 seconds allows the medication to be deposited more effectively in the airways, increasing its therapeutic effect.
D. "I will wait 10 min between each inhalation.": The correct time to wait between puffs is usually about 1-2 minutes, not 10 minutes.
A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?
Explanation
A. Provide mouth care: Mouth care is important to prevent infection but is not the first priority in this procedure.
B. Position the client so that the lung area to be drained is above the client’s trachea: This is necessary for effective postural drainage, but auscultation should be done first to determine the area to drain.
C. Auscultate lung fields. Auscultating lung fields first helps to determine the location of secretions and identify which areas of the lungs need to be targeted during postural drainage and percussion.
D. Cup hands and tap on the client’s chest repeatedly: Chest percussion helps mobilize secretions, but it should be done after auscultation to target the correct areas.
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