Ati Med Surg 2 respiratory exam
Total Questions : 20
Showing 20 questions, Sign in for moreA nurse is assessing a client who is 2 weeks postoperative following a kidney transplant.Which of the following manifestations should the nurse identify as possible organ rejection?
Explanation
Choice A rationale
Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.
Choice B rationale
Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.
Choice C rationale
Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.
Choice D rationale
Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.
A nurse is planning care for a client who has cirrhosis of the liver.Which of the following actions should the nurse include in the plan? (Select all that apply.)
Explanation
Choice A rationale
Implementing a low-sodium diet helps reduce fluid retention and ascites in clients with cirrhosis, improving their condition.
Choice B rationale
Furosemide is a diuretic that helps reduce fluid overload and ascites in clients with cirrhosis by promoting excretion of excess fluid.
Choice C rationale
Warfarin is an anticoagulant and is not typically used in the management of cirrhosis as it could increase the risk of bleeding complications, especially in clients with liver dysfunction.
Choice D rationale
Measuring the client's abdominal girth is crucial for monitoring the progression of ascites, a common complication of cirrhosis.
Choice E rationale
Encouraging weight lifting is not advisable as it can exacerbate varices and increase the risk of bleeding in clients with cirrhosis.
A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.The nurse should identify which of the following findings as indicative of an infection?
Explanation
Choice A rationale
Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.
Choice B rationale
Bloody fluid may indicate trauma or malignancy but not necessarily infection.
Choice C rationale
Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.
Choice D rationale
Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?
Explanation
Choice A rationale
A breast cancer survivor for 8 years without recurrence is generally considered for transplantation if otherwise healthy.
Choice B rationale
Age 65 is not an absolute contraindication for kidney transplantation. Many factors such as overall health status are considered.
Choice C rationale
Alcohol use disorder is a contraindication due to the potential for poor adherence to post-transplant care and medication, as well as the increased risk of liver damage.
Choice D rationale
Having a pacemaker is not an absolute contraindication for a kidney transplant; individuals with pacemakers can still be eligible for transplantation if otherwise healthy.
A nurse is assessing a client who has a pneumothorax with a chest tube in place.For which of the following findings should the nurse notify the provider?
Explanation
Choice A rationale
Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.
Choice B rationale
Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.
Choice C rationale
Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.
Choice D rationale
Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.
A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DKA). Which of the following characteristics are associated with DKA? (Select all that apply.)
Explanation
Choice A rationale
Acidosis is a key characteristic of diabetic ketoacidosis due to the accumulation of ketoacids in the body from fat metabolism.
Choice B rationale
Low blood sugar is not associated with diabetic ketoacidosis; it is characterized by hyperglycemia.
Choice C rationale
Ketosis occurs in DKA due to the breakdown of fats instead of glucose for energy, leading to an accumulation of ketones.
Choice D rationale
Fluid overload is not typical of diabetic ketoacidosis; dehydration is more common due to osmotic diuresis.
Choice E rationale
Hyperglycemia is a hallmark of diabetic ketoacidosis, resulting from the lack of insulin and the consequent high levels of glucose in the blood.
Choice F rationale
Alkalosis is not associated with diabetic ketoacidosis; the condition is defined by metabolic acidosis. .
A nurse is caring for a client who has acute pancreatitis.After treating the client's pain, which of the following should the nurse address as the priority intervention?
Explanation
Choice A rationale
Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation of the pancreas.
Choice B rationale
Auscultating the client's lungs is important to check for complications such as pleural effusion or atelectasis, but it is not the immediate priority after pain management.
Choice C rationale
Assisting the client to a side-lying position can help with comfort and may ease breathing, but it does not directly address the underlying issue of pancreatic inflammation.
Choice D rationale
Providing oral hygiene is essential for overall care but does not impact the acute management of pancreatitis.
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down.Antacids do not help.The provider suspects acute pancreatitis.Which of the following laboratory test results should the nurse expect to see?
Explanation
Choice A rationale
Decreased serum lipase is not expected in acute pancreatitis; rather, lipase levels are typically elevated due to pancreatic enzyme leakage into the bloodstream.
Choice B rationale
Increased serum calcium is not a typical finding in acute pancreatitis; instead, hypocalcemia can occur due to fat necrosis and soap formation.
Choice C rationale
Decreased WBC is not expected; an elevated WBC count is common due to the inflammatory response associated with pancreatitis.
Choice D rationale
Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.
A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following actions should the nurse take first?
Explanation
Choice A rationale
Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.
Choice B rationale
Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.
Choice C rationale
Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.
Choice D rationale
Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.
A nurse is assessing a client for hypoxemia during an asthma attack.Which of the following manifestations should the nurse expect?
Explanation
Choice A rationale
Agitation is a common manifestation of hypoxemia due to insufficient oxygen reaching the brain and other vital organs.
Choice B rationale
Dysphagia, or difficulty swallowing, is not a typical manifestation of hypoxemia during an asthma attack.
Choice C rationale
Nausea can occur but is not a primary indicator of hypoxemia.
Choice D rationale
Hypotension may occur with severe hypoxemia but is not a direct manifestation of asthma-related hypoxemia.
A nurse is reviewing the arterial blood gas values for a client.The pH is 7.32, PaCO₂ 48 mm Hg and the HCO₃ is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base balances?
Explanation
Choice A rationale
Metabolic acidosis is characterized by a low pH and decreased HCO₃ levels, not increased PaCO₂.
Choice B rationale
Metabolic alkalosis presents with an elevated pH and increased HCO₃ levels, which do not match the given values.
Choice C rationale
Respiratory alkalosis is indicated by a high pH and decreased PaCOâ‚‚, opposite of the provided values.
Choice D rationale
Respiratory acidosis is identified by a low pH, elevated PaCO₂, and normal HCO₃, aligning with the provided values.
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.Which of the following should the nurse include in the teaching?
Explanation
Choice A rationale
Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes to reduce the risk of infections that can exacerbate their condition.
Choice B rationale
Injecting insulin in the deltoid muscle is not standard practice as subcutaneous tissue in the abdomen or thigh is preferred for insulin absorption.
Choice C rationale
Administering glucagon is for hypoglycemia, not hyperglycemia; insulin or other medications manage hyperglycemia.
Choice D rationale
Taking glyburide is not suitable for type 1 diabetes as it requires insulin management.
A nurse is assessing a client who has suspected acute respiratory distress syndrome (ARDS). The nurse should identify which of the following is the most common presenting manifestation of ARDS?
Explanation
Choice A rationale
Cyanosis is a late sign of hypoxemia and not the most common initial manifestation of ARDS. It indicates severe oxygen deprivation but doesn’t typically appear first.
Choice B rationale
Diaphoresis, or excessive sweating, can occur with many conditions causing distress, but it’s not specifically the most common presenting symptom of ARDS. It's more of a nonspecific symptom of stress.
Choice C rationale
Somnolence, or drowsiness, might occur in severe respiratory distress when oxygen levels drop significantly, but it’s not the primary or most common presenting manifestation of ARDS.
Choice D rationale
Dyspnea, or difficulty breathing, is the hallmark of ARDS and the most common presenting symptom. It occurs due to the acute onset of severe hypoxemia caused by the underlying pathophysiology of ARDS.
A nurse is caring for a child who has Addison's disease.Which of the following actions should the nurse take?
Explanation
Choice A rationale
Discussing hyperglycemia manifestations is not specific to Addison's disease, as Addison's is characterized by hypoglycemia due to cortisol deficiency.
Choice B rationale
Teaching the parents about cortisol replacement therapy is essential in Addison's disease management. Cortisol deficiency is the primary issue, so educating on proper administration and monitoring is crucial.
Choice C rationale
Placing the child on a low-sodium diet is not recommended because Addison's disease often involves salt wasting, so adequate sodium intake is necessary.
Choice D rationale
Monitoring for fluid volume excess is more applicable to conditions like heart failure, not Addison's disease, which is associated with dehydration and hypovolemia.
A nurse is preparing discharge instructions for a client who has cirrhosis of the liver.Which of the following statements should be included in the education materials?
Explanation
Choice A rationale
Acetaminophen can be hepatotoxic in clients with liver damage, so it should be avoided. This is especially critical for clients with cirrhosis, where liver function is already compromised.
Choice B rationale
Eating three large meals can be overwhelming for someone with cirrhosis, as the liver is less able to process nutrients efficiently. Smaller, more frequent meals are advised.
Choice C rationale
Avoiding high-sodium foods is crucial because cirrhosis often leads to fluid retention and ascites, which can be exacerbated by a high-sodium diet.
Choice D rationale
Increasing activity as much as possible may not be safe for someone with cirrhosis, who often experiences fatigue and muscle wasting. Activity should be balanced with rest and tolerance levels.
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
Explanation
Choice A rationale
High-protein and high-carbohydrate foods are beneficial, but they do not directly address the immediate respiratory issues in ARDS.
Choice B rationale
Encouraging oral intake of fluids may not be appropriate as it can contribute to fluid overload and worsen pulmonary edema in ARDS patients.
Choice C rationale
Administering low-flow oxygen might be necessary but isn't the most crucial intervention for ARDS. High-flow oxygen or mechanical ventilation is typically required.
Choice D rationale
Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
A nurse is caring for a child who is experiencing status asthmaticus.Which of the following interventions is the priority for the nurse to take?
Explanation
Choice A rationale
Obtaining a peak flow reading provides information about the severity of asthma, but it is not the immediate priority during an acute exacerbation.
Choice B rationale
Administering an inhaled glucocorticoid can help in managing inflammation, but it takes time to work and is not the immediate priority.
Choice C rationale
Determining the cause of the acute exacerbation is important for long-term management but is not the immediate priority.
Choice D rationale
Administering a short-acting B2-agonist (SABA) is the priority because it provides rapid bronchodilation, helping to alleviate the airway obstruction quickly
A nurse is assessing a client who has an infection.Which of the following findings is a manifestation of sepsis? (Select all that apply.)
Explanation
Choice A rationale
Hypertension is not a typical manifestation of sepsis; sepsis usually involves hypotension.
Choice B rationale
Hypoglycemia is not a common manifestation of sepsis; hyperglycemia is more typical.
Choice C rationale
Altered mental status can occur due to the systemic inflammation and infection affecting the brain.
Choice D rationale
An elevated WBC count indicates an immune response to infection, which is a common sign of sepsis.
Choice E rationale
Vomiting can occur due to the body's response to the infection and systemic inflammation.
A nurse is providing education to a client who is suspected of having type 1 diabetes mellitus.Which of the following statements would the nurse include in client education?
Explanation
Choice A rationale
An HbA1c level of 5.7% or below indicates normal glucose tolerance, not impaired glucose tolerance.
Choice B rationale
In type 1 diabetes mellitus, the beta cells are destroyed, and dietary changes alone cannot restore insulin production.
Choice C rationale
Type 1 diabetes mellitus is a chronic condition and is not considered reversible.
Choice D rationale
Type 1 diabetes mellitus is characterized by the autoimmune destruction of beta cells in the pancreas, leading to an absolute lack of insulin production.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath.When reviewing the client's arterial blood gases (ABGs) which of the following conditions should the nurse anticipate the client to be experiencing?
Explanation
Choice A rationale
Respiratory alkalosis involves low carbon dioxide levels, which is not typical in COPD exacerbations.
Choice B rationale
Respiratory acidosis occurs due to impaired gas exchange and carbon dioxide retention in COPD.
Choice C rationale
Metabolic acidosis results from renal or metabolic issues, not primarily respiratory issues like in COPD.
Choice D rationale
Metabolic alkalosis involves high bicarbonate levels and is not typically associated with COPD exacerbations. .
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