ATI - Medical Surgical Respiratory Quiz.docx

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1. A nurse working in the emergency department is caring for a client following a chest trauma. Which of the following findings indicates a tension pneumothorax?  Collapsed neck veins on the affe ... cted side  Collapsed neck veins on the unaffected side  Tracheal deviation to the affected side  Tracheal deviation to the unaffected side (a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side) 2. A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with rifampim. The nurse should plan to include which of the following in the clients discharge teaching plan?  Ringing in the ear is expected  Purified protein derivative (PPD) skin test results will improve in 4 months  Urine and other secretions will be orange  Take the medication with meals 3. A nurse is caring for a client who has bacterial pneumonia. The nurse should expect which of the following assessment findings?  Decreased fremitus  SaO2 95% on room air  Temperature 38.80 C (101.80F)  Bradypnea 4. A nurse is assessing a client who has a chest tube in place followings thoracic surgery. Which of the following findings indicates a need for intervention?  Fluctuation of drainage in the tubing with inspiration  Continuous bubbling in the water seal chamber (suggests and air leak)  Drainage of 75 mL in the first hour after surgery  Several small, dark-red blood clots in the tubing 5. A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm sounds. Which of the following should the nurse recognize as a cause of alarm?  Excess secretions (causes the high pressure alarm to sound)  Kinks in the tubing (causes the high pressure alarm to sound)  Artificial airway cuff leak (interferes w/ oxygenation and causes the low pressure alarm to sound)  Biting on the endotracheal tube (causes the high pressure alarm to sound) 6. A nurse is caring for a client who has acute respiratory distress syndrome. Which of the following assessment findings indicates a decline in the client’s condition?  Increase in respiratory rate (indicates work of breathing & the need for improvement in oxygen delivery)  Increase in oxygen saturation (indicates gas exchange is improving)  Decrease in carbon dioxide retention (indicates gas exchange is improving) [Show More]

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