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ATI Respiratory Questions with Complete Solution
1.A nurse is assessing a patient who has a chest tube in place following a thoracic
surgery. Which of the following findings indicates a need for inter- vention:
1. Fluctuation of drainage in the tubing with inspiration.
2. Continuous bubbling in the water seal chamber.
3. Drainage of 75 mL in the first hour after surgery.
4. Several small, dark-red blood clots in the tubing.: 2. Continuous bubbling in the
water seal chamber. Continuous bubbling in the water seal chamber suggests an air leak.
2.A nurse is caring for an elderly patient who suffers from COPD with pneumo- nia. The
nurse should monitor the patient for which of the following acid-base imbalances?
1. Respiratory alkalosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Metabolic acidosis: 2. Respiratory acidosis
Respiratory acidosis is a common complication of COPD. This complication occurs because patients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
3.A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The
nurse should identify that which of the following findings is an adverse effect of this medication?
1. Hallucinations
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2. Pruritis
3. Hand and foot syndrome
4. Tinnitis: 4. Tinnitis
An adverse effect of cisplatin is ototoxicity, which can cause tinnitis.
4.A nurse is preparing to assist a provider to withdraw arterial blood from a patient's
radial artery for measurement of ABG. Which of the following actions should the nurse plan to take?
- Hyperventilate the patient with 100% oxygen prior to obtaining the speci- men.
- Apply ice to the site after obtaining the specimen.
- Perform an Allen's test prior to obtaining the specimen.
- Release pressure applied to the puncture site 1 minute after the needle is withdrawn.: 3. Perform an Allen's test prior to obtaining the specimen. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
- A nurse is providing instructions about pursed-lip breathing for a patient who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following:
1. Increases oxygen intake
2. Promotes carbon dioxide elimination
3. Uses the intercostal muscles
4. Strengthens the diaphram: 2. Promotes carbon dioxide elimination
A patient who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It
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- A nurse is planning care for a patient who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan:
1. Eat high-calorie foods first
2. Increase intake of water at meal times
3. Perform active range of motion exercises before meals
4. Keep saltine crackers nearby for snacking: 1. Eat high-calorie foods first
The client who has COPD often experiences early satiety. Therefore, the patient should eat high-calorie foods first.
- A nurse is developing a teaching plan for a patient about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first:
1. How to eliminate environmental triggers that precipitate attacks
2. The patient's perception of the disease process and what might have trig- gered
attacks in the past
3. The patient's medication regimen
4. Manifestations of respiratory infections: 2. The patient's perception of the
disease process and what might have triggered attacks in the past The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan patient care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in a patient's status, the nurse must first collect adequate data from the patient. Assessing the patient will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the patient's current knowledge.
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- A nurse in a provider's office is assessing a patient who states he was recently exposed to TB. Which of the following findings is a clinical manifes- tation of pulmonary TB:
1. Pericardial friction rub
2. Weight gain
3. Night sweats
4. Cyanosis of the fingertips: 3. Night sweats
Night sweats and fevers are clinical manifestations of TB.
- A nurse is planning care for a patient following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care:
1. Clamp the chest tube if there is continuously bubbling in the water seal chamber
2. Keep the chest tube drainage system at the level of the right atrium
3.Tape all of the connections between the chest tube and the drainage system
4. Empty the collection chamber and record the amount of drainage every 8 hours:
- Tape all of the connections between the chest tube and the drainage system The nurse should tape all of the connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.
- A nurse on a medical unit is caring for a patient who aspirated gastric con- tents prior to admission. The nurse administers 100% oxygen by nonbreathier mask after the patient reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS):
1. Tympanic temperature of 38 C (100.4 F)
2. PaO2 50 mm Hg
7 / 34 the end maximum inhalation:
1. Total lung capacity
2. Vital lung capacity
3. Functional residual capacity
4. Residual volume: 1. Total lung capacity
Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.
- A nurse is preparing discharge teaching to a patient who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include:
1. Apply warm compresses to the face
2. Take aspirin 650mg by mouth for mild pain
3. Close your mouth while sneezing
4. Lie on your back with your head elevated 30 degrees while resting: 4. Lie on your
back with your head elevated 30 degrees while resting The nurse should instruct the patient to rest in the semi-fowlers position to prevent aspiration of nasal secretions.
- A nurse in the emergency department is assessing a patient for a closed pneumothorax and significant bruising of the left chest following a MVA. The client reports severe left chest pain on inspiration. The nurse should assess the patient for which of the following manifestations of a pneumothorax:
1. Absence of breath sounds
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2. Expiratory wheezing
3. Inspiratory stridor
4. Rhonchi: 1. Absence of breath sounds
A patient who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
- A nurse in a clinic is providing teaching for a patient who is to have a tuberculin skin test. Which of the following information should the nurse include:
1. If the test is positive, then you have an active case of TB.
2. If the test is positive, you should have another tuberculin skin test in 3 weeks.
3. You must return to the clinic to have the test read in 2 to 3 days.
4. A nurse will use a small lancet to scratch the skin of your forearm before applying
the tuberculin substance.: 3. You must return to the clinic to have the test read in 2 to 3 days. The patient should have the test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to tubercle bacillus. If the patient does not return to have the test read within 72 hours, another skin test is necessary.
- A nurse is teaching about daily chest physiotherapy with a patient who has cystic fibrosis. The nurse should instruct the patient that which of the following is the purpose of the treatments:
1. To encourage deep breaths
2. To mobilize secretions in the airways
3. To dilate the bronchioles
4. To stimulate the cough reflex: 2. To mobilize secretions in the airways
10 / 34 remaining lung. The nurse should show how to splint the incision to reduce pain while coughing.
- A patient is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the patient's chest. After notifying the provider, the nurse should document the finding as which of the following:
1. Friction rub
2. Crackles
3. Crepitus
4. Tactile ferments: 3. Crepitus
Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the patient's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.
- A nurse is caring for a patient who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the patient's airway secretions:
1. The patient is unable to speak.
2. The patient's airway secretions were last suctioned 2 hours ago.
3. The patient coughs and expectorates a large mucous plug.
4.The nurse auscultates course crackles in the lung field.: 4. The nurse auscul- tates
course crackles in the lung field. The nurse should auscultate coarse crackles of rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the patient's airway secretions.
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- A nurse working in the ED is caring for a patient following a chest trauma. Which of the following findings indicates a tension pneumothorax:
- Collapsed neck veins on the affected side
- Collapsed neck veins on the unaffected side
- Tracheal deviation to the affected side
- Tracheal deviation to the unaffected side: 4. Tracheal deviation to the unaffect- ed 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.
- A nurse is caring for a patient who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take:
1. Position the client in an upright position, leaning over the bedside table.
2. Explain the procedure.
3. Obtain ABGs.
4. Administer benzocaine spray.: 1. Position the client in an upright position,
leaning over the bedside table. Positioning the patient in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid.
- A nurse is reviewing ABG laboratory results of a patient who is in respira- tory distress. The results are pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances:
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
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3.Pule oximeter
Pulse oximetry is necessary to monitor oxygen saturation level during the procedure.
4.Sterile dressing
A sterile dressing is necessary to apply to the puncture site following the procedure.
- A nurse is caring for a patient following a throacentesis. Which of the fol- lowing manifestations should the nurse recognize as risks for complications? (Select all that apply)
1. Dyspnea
2. Localized bloody drainage on the dressing
3. Fever
4. Hypotension
5. Report of pain at the puncture site: 1. Dyspnea
Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately.
- A nurse is preparing to care for a patient following chest tube placement. Which of the following items should be available in the patient's room? (Select all that apply)
1. Oxygen
2. Sterile water
3. Enclosed hemostat clamps
4. Indwelling urinary catheter
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5. Occlusive dressing: 1. Oxygen
Oxygen should be readily available in case the patient develops respiratory distress following chest tube placement
- Sterile water If the chest tubing becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal.
5.Occlusive dressing
If the chest tubing becomes disconnected, the nurse should immediately place a gauze dressing of the site. An occlusive dressing can also be necessary to prevent the redevelopment of a pneumothrorax.
- A nurse is caring for a patient who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
- Obtain chest x-ray
- Apply sterile gauze to the insertion site
- Place tape around the insertion site
- Assess respiratory status: 2. Apply sterile gauze to the insertion site Using ABC, application of a sterile gauze to the site should be the first action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax.
- A nurse is assessing a patient who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply)
1. Continuous bubbling in the water seal chamber
16 / 34 drainage system. Which of the following should be included in the plan of care? (Select all that apply)
1. Encourage the patient to cough every 2 hours
2. Check for continuous bubbling in the suction chamber
3. Strip the drainage tubing every 4 hours
4. Clamp the tube once a day
5. Obtain a chest x-ray: 1. Encourage the patient to cough every 2 hours
The nurse should instruct the patient to cough every 2 hours. This promotes oxy- genation and lung reexpansion.
- Check for continuous bubbling in the suction chamber The nurse should check for continuous bubbling in the suction chamber to verify that
17 / 34 suction is being maintained at the appropriate level.
- Obtain a chest x-ray A chest x-ray is obtained following the procedure to verify chest tube placement.
- A nurse is discharging a patient who has pulmonary TB and is to start therapy with rifampin. The nurse should plan to include which of the following in the patient's teaching plan:
1. Ringing in the ears is expected.
2. Purified protein derivative skin test results will improve in 4 months.
3. Urine and other secretions will be orange.
4. Take the medication with meals.: 3. Urine and other secretions will be orange.
Rifampin will turn urine and other secretions orange.
- A nurse is caring for a patient who has bacterial pneumonia. The nurse should expect which of the following assessment findings:
1. Decreased fremitus
2. SaO2 95% on room air
3. Temperature 38.8 C ( 101.8 F)
4. Bradypnea: 3. Temperature 38.8 C ( 101.8 F)
An elevated temperature is an expected finding for a patient who has bacterial pneumonia.
- A nurse is caring for a patient receiving mechanical ventilation. The low pressure alarm sounds. Which of the following should the nurse recognize as a cause for the alarm:
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- A nurse is planning care for a patient who has COPD. Which of the following interventions should the nurse include in the plan of care:
1. Schedule respiratory treatments after meals
2. Have the patient sit in a chair for 2-hour periods 3x a day
3. Provide a diet high in calories and protein
4. Combine activities to allow for longer rest periods between activities: 3. Provide
a diet high in calories and protein The nurse should provide a patient who has COPD with a diet that is high in protein and low on carbs
- A nurse is caring for a patient who has COPD. Which of the following findings should the nurse report to the provider:
1. Oxygen saturation 89%
2. Productive cough with green sputum
3. Clubbing of fingers
4. Pursed lipped breathing with exertion: 2. Productive cough with green sputum
A nurse should report a productive cough with green sputum to the provider as it indicates an infection
- A nurse is caring for a patient who has acute respiratory failure. Which of the following laboratory findings should the nurse expect:
1. Arterial pH 7.
2. PaCO2 25 mm Hg
3. SaO2 92%
4. PaO2 58 mm Hg: 4. PaO2 58 mm Hg
20 / 34 The nurse should expect a patient who has acute respiratory failure to have lower partial pressures of oxygen.
- A nurse is caring for a patient who is postoperative and is hypoventilating secondary to general anesthesia effects and incisional pain. Which of the following ABG values support the nurse's suspicion of respiratory acidosis:
1. pH 7.50, PO2 99 mm Hg, PaCO2 25 mm Hg, HCO3 22 mEq/L
2. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3 30 mEq/L
3. pH 3.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3 20 mEq/L
4. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L: 4. pH 7.30, PO
80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
- A nurse is assisting with a thoracentesis. Which of the following actions is appropriate for the nurse to take when assisting with this procedure: (Select all that apply)
1. Wear goggles and mask during the procedure
2. Cleanse the area with an antiseptic solution
3. Instruct the patient to take deep breaths during insertion of the needle
4. Position the patient laterally on the affected side
5. Apply pressure to the site after the needle is withdrawn: 1. Wear goggles and mask
during the procedure
- Cleanse the area with an antiseptic solution
- Apply pressure to the site after the needle is withdrawn
