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Complex Oyxgenation ATI Practice
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- A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. B. Establish IV access. A. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment.
- A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects? A. Constipation Rationale: Rifampin does not cause constipation. More common gastrointestinal effects are diarrhea and nausea. B. Black colored stools Rationale: It is most commonly iron supplements that cause stools to turn black, not rifampin. C. Staining of teeth Rationale: Teeth may be stained from taking liquid iron preparations, not from taking rifampin. D. Body secretions turning a red-orange color Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
- A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A. Prevent aspiration. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and wire cutters should be kept at the bedside in case of vomiting. B. Ensure adequate nutrition. Rationale:
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Complex Oyxgenation ATI Practice
The client should be NPO initially after surgery until the gag reflex has returned. Once the client is able to eat, the client may advance to a calorie-appropriate, high-protein liquid diet. However, this is not the priority at this time. C. Promote oral hygiene Rationale: The client will have an incision inside the mouth. While it is important that the client receive frequent mouth cleaning, this is not the priority at this time. D. Relieve the client's pain. Rationale: While the client may be in pain and will need to be medicated, this is not the priority at this time.
- A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? A. Asthma Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation. B. Glaucoma Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not contraindicated in a client who has glaucoma. C. Depression Rationale: Beta-blockers are contraindicated in clients who have AV heart block, but are not contraindicated in clients who have depression. D. Migraines Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.
- A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A. Decrease chest wall compliance Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis by relaxing skeletal muscles, which improves chest wall compliance. B. Suppress respiratory effort Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. This therapy is especially helpful for a client who has ARDS
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Complex Oyxgenation ATI Practice
C. Clamp the chest tube. Rationale: The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage system. This is not an appropriate action for the nurse to take at this time. D. Continue to monitor the client's respiratory status. Rationale: Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.
- A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? A. Decreased serum calcium level Rationale: A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. B. Decreased level of serum lipids Rationale: An increase serum lipid level is an expected finding for FES, although the reason for this finding is unknown. C. Decreased erythrocyte sedimentation rate (ESR) Rationale: An increased ESR is an expected finding for FES, although the reason for this finding is unknown. D. Increased platelet count Rationale: A decreased platelet count is an expected finding for FES, although the reason for this finding is unknown.
- A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? A. Kussmaul respirations Rationale: Kussmaul respirations are deep, rapid, regular respirations and are commonly seen in clients who are experiencing metabolic acidosis. B. Apneustic respirations Rationale: Apneustic respirations are characterized by a prolonged inspiratory phase alternating with expiratory pauses. C. Cheyne-Stokes respirations Rationale: Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR
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Complex Oyxgenation ATI Practice
D. Stridor are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death). Rationale: Stridor is a continuous, high-pitched sound heard on inspiration in clients who have partial airway obstruction of the larynx or trachea. 10.A A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." Rationale: The flat, supine position increases the chance of obstructing the airway. B. "I'll sleep better if I take a sleeping pill at night." Rationale: Hypnotics (sleeping pills) aggravate sleep apnea and can also cause increased daytime somnolence (sleepiness). C. "I'll get a humidifier to run at my bedside at night." Rationale: Bedside humidifiers are an effective way to help clients who have thick pulmonary secretions, but they do not help sleep apnea. D. "If I could lose about 50 pounds, I might stop having so many apneic episodes." Rationale: Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea. 11.A A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. Rationale: Clamping the tube can lead to a tension pneumothorax (collapse of the lung) due to increased intrathoracic pressure from gas and fluid that cannot be drained from the pleural space. B. Disconnect the chest tube from the drainage system during transport. Rationale: The chest tube should not be disconnected from the drainage system. C. Keep the drainage system below the level of the client's chest at all times. Rationale: During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity. D. Empty the collection chamber prior to transport. Rationale:
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Complex Oyxgenation ATI Practice
chamber indicates air is being removed from the client’s pleural space, allowing re-expansion of the lung. It should occur during exhalation, coughing, and sneezing. When the air from the pleural space is removed, the bubbling will stop. Excessive bubbling in this chamber may indicate an air leak and should be further investigated by the nurse. C. Crepitus in the area above and surrounding the insertion site Rationale: Crepitus, or subcutaneous emphysema, sounds like a crackling noise when palpated. It can be an expected finding in the client who has a pneumothorax and will persist for several hours (or longer, depending on how long it takes the air to be reabsorbed) following evacuation of the pneumothorax. D. Eyelets are not visible Rationale: The observation of eyelets would indicate to the nurse that the chest tube has been become dislodged from the pleural space and would necessitate reporting to the provider. 14.A A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. Rationale: Trendelenburg position increases pressure on the heart and lungs and is contraindicated for a client who has an open chest wound. The nurse should place the client in a moderate to high-Fowler’s position. B. Remove the dressing to inspect the wound. Rationale: A dressing should not be removed from a sucking chest wound until immediately prior to chest tube insertion. Removal of the dressing will cause an increase in size of the pneumothorax and increased respiratory difficulty. C. Prepare to insert a central line. Rationale: Although the client may need IV access, a central line is not usually needed in this situation. D. Administer oxygen via nasal cannula. Rationale: The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues. 15.A A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. Rationale: These manifestations are not related to a cardiac condition in this situation.
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Complex Oyxgenation ATI Practice
B. Suction the client less frequently. Rationale: These manifestations are not the result of suctioning too frequently. C. Administer an antidysrhythmic medication. Rationale: These manifestations cannot be corrected with the use of an antidysrhythmic medication. D. Perform pre-oxygenation prior to suctioning. Rationale: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury.. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen. 16.A A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. Rationale: The expected finding would be a gentle bubbling of the water in the suction control chamber. B. Add more water to the suction control chamber of the drainage system. Rationale: More water should not be added to the closed system. C. Verify that the suction regulator is on and check the tubing for leaks. Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it. Rationale: Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the lung. Stripping is only done when specifically indicated.
- A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? A. Arterial blood gases Rationale: According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases. B. Urinary output Rationale: The nurse should monitor the client’s urinary output in order to monitor fluid status and cardiac output of the client who is postoperative; however, there is another assessment that would take
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Complex Oyxgenation ATI Practice
19.A A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. Rationale: Most clients with a baseline normal fluid status can tolerate being NPO overnight without risk of fluid volume deficit. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. Rationale: The client who has heart failure has ventricular impairment which prevents adequate filling or emptying of blood, resulting in fluid overload or inadequate tissue perfusion. An elevated BNP level is indicative of increased blood volume, thus fluid volume excess. C. The client who has end-stage renal failure and is scheduled for dialysis today. Rationale: The client who has end-stage renal failure is unable to appropriately filter blood and excrete waste products, including fluid. This client is likely to have a fluid excess that is managed with dialysis. D. The client who has gastroenteritis and is febrile. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.
- A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. Rationale: This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). Rationale: This change in temperature is not significant, as both values are within the expected reference range. A client who has a fat embolism may develop a high temperature, usually 39.5º C ( Fº). C. Increased blood pressure from 112/68 to 120/72 mm Hg. Rationale: This change in blood pressure is not significant, as both values are within the expected reference range. D. Increased heart rate from 68 to 72/min. Rationale:
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Complex Oyxgenation ATI Practice
This change in heart rate is not significant, as both values are within the expected reference range. 21.A A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises Rationale: This is not indicated to prevent pulmonary complications, but early ambulation is helpful to promote lung expansion and remove secretions. B. Place suction equipment at the bedside Rationale: Suction equipment should be readily available if needed, but its presence does not prevent pulmonary complications. C. Encourage the use of an incentive spirometer Rationale: Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications. D. Administer an expectorant Rationale: Administering an expectorant is not indicated to prevent pulmonary complications, but the nurse should encourage the client to cough and deep breathe. 22.A A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A. Constant bubbling in the suction-control chamber Rationale: Constant, gentle bubbling in the suction control chamber indicates that the suction is functioning. B. Continuous bubbling in the water-seal chamber Rationale: Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client’s chest. However, gentle bubbling on forceful exhalation or coughing is normal. C. Bloody drainage in the collection chamber Rationale: For the first few hours after surgery, the drainage is likely to be bloody, transitioning to blood-tinged after that. Since the nurse doesn’t empty a disposable system but replaces it when it is full, bloody drainage in the collection chamber at 12 hr is an expected finding. D. Fluid-level fluctuations in the water-seal chamber Rationale: Fluid in the water-seal chamber should fluctuate with inspiration and exhalation, a process called tidaling, because pressure in the pleural space changes during respiration.
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Complex Oyxgenation ATI Practice
notification of the provider immediately. D. Decreased temperature Rationale: Infection is possible after any invasive procedure; however, it takes time to develop and increases the body temperature. 25.A A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis Rationale: With uncompensated metabolic acidosis, the pH is less than 7.35 and the PaCO 2 is less than 35 mm Hg or within the expected reference range. B. Metabolic alkalosis Rationale: With uncompensated metabolic alkalosis, the pH is greater than 7.45 and the PaCO 2 is greater than 45 mm Hg or within the expected reference range. C. Respiratory acidosis Rationale: With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO 2 is greater than 45 mm Hg. D. Respiratory alkalosis Rationale: With uncompensated respiratory alkalosis, the pH is greater than 7.45 and the PaCO 2 is less than 45 mm Hg. 26.A A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A. Oxygen saturation of 95% Rationale: A client can have an oxygen saturation of 95% with or without lung re-expansion. B. No fluctuations in the water seal chamber Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning. C. No reports of pleuritic chest pain Rationale: The client might not report pain if his pain management is effective, not because his lung has re-expanded. D. Occasional bubbling in the water-seal chamber Rationale:
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Complex Oyxgenation ATI Practice
Occasional bubbling indicates the removal of air from the pleural space, indicating that the lung is not fully re-expanded. 27.A A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client’s wall suction. Rationale: The nurse increasing the wall suction does not affect the amount of negative pressure of the chest tube and would not relieve the client’s chest burning. B. Strip the client’s chest tube. Rationale: The nurse stripping the chest tube increases negative pressure and may damage lung tissue and would not resolve the client’s chest burning. C. Clamp the client’s chest tube. Rationale: The nurse clamping the chest tube briefly to change the chamber or check for an air leak is recommended but would not resolve the client’s chest burning. D. Reposition the client. Rationale: The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube. 28.A A nurse is caring for a client who has returned to the unit following a surgical procedure. The client’s oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. Rationale: The nurse should assess the client further and implement less invasive interventions before applying oxygen at 2 L/min. B. Administer prescribed analgesic medication. Rationale: Pain management promotes increased participation by the client in coughing and deep breathing, frequent position changes and use of the incentive spirometer, but this is not the first action the nurse should take. C. Encourage coughing and deep breathing. Rationale: Coughing and deep breathing promotes lung expansion and prevents respiratory infection, but these actions are not effective immediately in increasing oxygen saturation. D. Raise the head of the bed. Rationale: Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.
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Complex Oyxgenation ATI Practice
The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter. B. Position the client in left lateral Trendelenburg. Rationale: The nurse should position the client in the left lateral Trendelenburg to prevent the air from entering the coronary arteries; however, the nurse should take another action first. C. Initiate oxygen therapy. Rationale: The nurse should initiate oxygen therapy to treat any hypoxia the client may be experiencing; however, the nurse should take another action first. D. Auscultate breath sounds. Rationale: The nurse should auscultate breath sounds to determine if there is air movement within the lungs; however, the nurse should take another action first.
- A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? A. Continuous bubbling in the water-seal chamber Rationale: Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. B. Occasional bubbling in the water-seal chamber Rationale: The nurse should expect continuous bubbling in the water-seal chamber initially and occasional bubbling after that. The bubbles indicate the removal of air from the pleural space, which is the expected result. C. Constant bubbling in the suction-control chamber Rationale: The nurse should expect constant, gentle bubbling in the suction control chamber. D. Fluctuations in the fluid level in the water-seal chamber Rationale: The nurse should expect to see fluctuation with inspiration and exhalation, as this reflects the expected pressure changes in the pleural space during respiration. 33.A A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport Rationale: A client who is scheduled for an abdominal x-ray and is awaiting transport is stable. The nurse should see the client before allowing her to leave the unit; however, there is another client the nurse should see first. B. A client who has a prescription for discharge Rationale:
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Complex Oyxgenation ATI Practice
A client who has a prescription for discharge is stable; therefore, there is another client the nurse should see first. C. A client who received oral pain medication 30 min ago Rationale: A client who received oral pain medication 30 minutes ago is stable; therefore, there is another client the nurse should see first. The nurse should expect oral analgesia to reach peak effect after 1 hr. D. A client who told an assistive personnel he is short of breath Rationale: A client who has shortness of breath is unstable; therefore, this is the client the nurse should plan to see first. 34.A A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make? A. "We can teach you some relaxation techniques to minimize your pain." Rationale: The nurse should manage the client's pain by including pharmacological and nonpharmacological relief interventions; however, there is another statement that the nurse should identify as the priority. B. "Keep wire cutters with you at all times." Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to include is to tell the client to keep wire cutters available at all times. When the jaw is wired shut, the client is likely to aspirate if vomiting occurs. The client should use the wire cutters to clip the wires to keep the mouth clear of emesis, and should notify the provider so the jaw can be re-wired. C. "Use a water pick device to keep your teeth clean." Rationale: The nurse should teach the client about appropriate oral hygiene to prevent infection in the mouth, which could complicate healing. However, there is another statement that the nurse should identify as the priority. D. "Consume a high-protein, liquid diet." Rationale: The nurse should tell the client to consume a liquid diet that includes protein and other nutrients necessary for wound healing; however, there is another statement that the nurse should identify as the priority.
- A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop
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Complex Oyxgenation ATI Practice
opioids. B. Respiratory alkalosis Rationale: Alkalosis occurs when there is an imbalance in the amount or strength of the bases. In cases of respiratory alkalosis, this occurs because of an excessive loss of carbon dioxide through hyperventilation. It can occur in clients as a response to fear, anxiety or pain, from a fever or salicylate (aspirin) overdose. C. Metabolic acidosis Rationale: Metabolic acidosis results due to an increase in the amount of acid or a decrease in the amount of base available. It is seen in starvation, diabetic ketoacidosis, renal failure, dehydration, and diarrhea. D. Metabolic alkalosis Rationale: Metabolic alkalosis results from an increase in the amount of bases seen in massive blood transfusion, or the administration of sodium bicarbonate, or a bicarbonate containing antacid. It can also occur related to an acid deficit, seen with prolonged vomiting, the use of thiazide diuretics, or prolonged gastric suctioning. 38.A 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? A. Administer low-flow oxygen continuously via nasal cannula. Rationale: ARDS is an acute respiratory failure in which the client remains hypoxic despite the administration of 100% oxygen. Clients who have ARDS require high concentrations of oxygen, usually by mask or ventilator. B. Encourage oral intake of at least 3,000 mL of fluids per day. Rationale: Diuretics and fluid restrictions help minimize pulmonary edema, which is part of ARDS. C. Offer high-protein and high-carbohydrate foods frequently. Rationale: Clients who have ARDS are at high risk for malnutrition. The client is often sedated and paralyzed to provide mechanical ventilation and decrease oxygen needs. The nutritional needs of the client will be met through enteral or parenteral means. D. Place in a prone position. Rationale: Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds. 39.A A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing Rationale:
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Complex Oyxgenation ATI Practice
Atelectasis refers to the closure or collapse of the alveoli resulting in hypoxia. A client may develop cyanosis as a result. B. Increasing dyspnea Rationale: The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain. C. Decreasing respiratory rate Rationale: Because of the decreased oxygen exchange caused by the atelectasis, the client will be tachypneic in an effort to meet the body's oxygen needs. D. Friction rub Rationale: A friction rub is a grating or creaking sound heard when a client has inflammation of the pleura. For the client who has atelectasis, auscultation may reveal decreased breath sounds and crackles. 40.A A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide Rationale: Furosemide, a diuretic, is often used in the treatment of pulmonary edema; however, it is not used for the client who has a pulmonary embolism. B. Dexamethasone Rationale: Glucocorticoids such as dexamethasone decrease inflammation and is used to treat a wide variety of disorders, including inflammatory bowel disease and cerebral edema. It is not, however, useful in treating a pulmonary emboli. C. Heparin Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots. D. Atropine Rationale: Atropine, an anticholinergic, is used in the treatment of bradycardia. The client who has a pulmonary embolism will be tachycardic. 41.A A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. Rationale: It is important to manage the client's pain because this can reduce oxygen consumption and
