ATI RN Targeted Medical Surgical: Respiratory 2019
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Questions and Answers

What do arterial blood gases evaluate?

  • Blood pressure
  • Serum oxygen saturation (correct)
  • Cap refill
  • Heart rate
  • Which finding should the nurse report to the provider for a client with emphysema?

  • Rhonchi on inspiration
  • Barrel-shaped chest
  • Diminished breath sounds
  • Elevated temperature (correct)
  • What is the nurse's priority intervention for a client with pulmonary embolism?

  • Provide a quiet environment
  • Obtain blood sample for electrolyte study
  • Administer heparin via continuous IV infusion (correct)
  • Encourage use of incentive spirometer every 1-2 hrs
  • Expect your urine and other secretions to be ______ while taking rifampin.

    <p>orange</p> Signup and view all the answers

    Which situation should the nurse recognize as a possible cause of the low-pressure alarm in a client receiving mechanical ventilation?

    <p>Artificial airway cuff leak</p> Signup and view all the answers

    Which of the following clients is at greatest risk for a pulmonary embolism?

    <p>A client who is 48 hr postoperative following a total hip arthroplasty</p> Signup and view all the answers

    In which position should the nurse place a client with emphysema to promote effective breathing?

    <p>High-Fowler's position with the arms supported on the overbed table</p> Signup and view all the answers

    For which of the following adverse effects should the nurse monitor a client receiving albuterol?

    <p>Tachycardia</p> Signup and view all the answers

    Which assessment should the nurse identify as the priority after a client undergoes bronchoscopy with moderate sedation?

    <p>Presence of gag reflex</p> Signup and view all the answers

    Which manifestation should the nurse expect in a client who has lung cancer?

    <p>Blood-tinged sputum</p> Signup and view all the answers

    Which finding indicates that the client may be experiencing a tension pneumothorax following acute chest trauma?

    <p>Tracheal deviation to the unaffected side</p> Signup and view all the answers

    Which isolation precautions should the nurse include in the plan of care for a client with active TB?

    <p>Airborne</p> Signup and view all the answers

    What lab finding should the nurse expect in a client experiencing acute respiratory failure?

    <p>PaO2 58 mm Hg</p> Signup and view all the answers

    Which of the following actions should the nurse take first for a client experiencing a pulmonary embolism?

    <p>Apply supplemental oxygen.</p> Signup and view all the answers

    Which statement by a staff nurse shows understanding of endotracheal suctioning?

    <p>I will use a rotating motion when removing the suction catheter.</p> Signup and view all the answers

    What finding should the nurse prioritize reporting for a client who is 4 hr postoperative following a total laryngectomy?

    <p>Decreased oxygen saturation</p> Signup and view all the answers

    Which actions should the nurse take when assisting with a thoracentesis?

    <p>Apply pressure to the site after the procedure.</p> Signup and view all the answers

    What is the priority assessment finding for a client who is 1 hr postoperative following a thoracentesis?

    <p>Persistent cough</p> Signup and view all the answers

    Which manifestation should the nurse expect in a client with bacterial pneumonia?

    <p>Temperature 38.8° C (101.8° F)</p> Signup and view all the answers

    For which client should the nurse clarify the provider's prescription for nasopharyngeal suctioning?

    <p>Client with epistaxis</p> Signup and view all the answers

    What item should the nurse keep easily accessible for a client with a chest tube following a lobectomy?

    <p>Container of sterile water</p> Signup and view all the answers

    Which intervention should be included in the care plan for a client with COPD?

    <p>Provide a diet that is high in calories and protein.</p> Signup and view all the answers

    Which statement indicates a client understands teaching about montelukast for chronic asthma?

    <p>I will take this medication every night even if I don't have symptoms.</p> Signup and view all the answers

    Which ABG values indicate that a client is experiencing respiratory acidosis?

    <p>pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L</p> Signup and view all the answers

    Which finding should the nurse report for a client with acute respiratory distress syndrome (ARDS)?

    <p>Intercostal retractions</p> Signup and view all the answers

    Which finding is the priority for the nurse to report for a client with COPD?

    <p>Productive cough with green sputum</p> Signup and view all the answers

    Which statement by a newly licensed nurse indicates understanding of when to notify the provider for a client with a chest tube?

    <p>I will notify the provider if there is continuous bubbling in the water seal chamber.</p> Signup and view all the answers

    Which low-flow delivery device should the nurse use to provide the highest level of oxygen for a client in respiratory distress?

    <p>Nonrebreather mask</p> Signup and view all the answers

    Which medication should the nurse plan to administer during an acute asthma attack?

    <p>Albuterol</p> Signup and view all the answers

    Study Notes

    Mechanical Ventilation and Alarms

    • A low-pressure alarm in mechanical ventilation typically indicates potential issues, including an artificial airway cuff leak, which affects oxygen delivery.

    Tracheostomy Care

    • When managing a temporary tracheostomy, instruct clients to remove old twill ties only after securing new ones to prevent accidental decannulation.

    Risk for Pulmonary Embolism

    • Clients who have undergone total hip arthroplasty are at the highest risk for pulmonary embolism due to immobility, particularly within 48-72 hours post-surgery.

    Breathing Position for Emphysema

    • Position clients with emphysema in High-Fowler's position to facilitate optimal lung expansion and ease of breathing.

    Asthma and Albuterol

    • Monitor clients using albuterol for tachycardia, a common side effect, especially with frequent use.

    Post-Bronchoscopy Care

    • Post moderate sedation after bronchoscopy, the presence of a gag reflex is the top priority to prevent aspiration.

    Symptoms of Lung Cancer

    • Blood-tinged sputum is a significant expected symptom in clients with lung cancer, indicating potential bleeding from the tumor.

    Tension Pneumothorax Indicators

    • Tracheal deviation to the unaffected side suggests a tension pneumothorax, due to free air in the chest cavity causing the lung to collapse.

    Tuberculosis Isolation Protocol

    • Implement airborne precautions for clients with tuberculosis to minimize the risk of transmission through the air.

    Acute Respiratory Failure Labs

    • Anticipate a PaO2 of 58 mm Hg in clients experiencing acute respiratory failure, indicating significantly low oxygen levels.

    First Response to Pulmonary Embolism

    • The immediate action for clients with a pulmonary embolism should be to apply supplemental oxygen to address severe hypoxemia.

    Endotracheal Suctioning Technique

    • Appropriate suction technique includes using a rotating motion while withdrawing the catheter to maximize secretion removal.

    Postoperative Laryngectomy Monitoring

    • Following a total laryngectomy, decreased oxygen saturation is critical to monitor due to the high risk of airway obstruction.

    Thoracentesis Nursing Care

    • Use goggles and a mask, cleanse the procedure site, and apply pressure post-thoracentesis to minimize complications.

    Priority After Thoracentesis

    • Report a persistent cough in clients post-thoracentesis as it may indicate a tension pneumothorax—an emergency.

    Bacterial Pneumonia Indicators

    • An elevated temperature of 38.8° C (101.8° F) is a common symptom of bacterial pneumonia, reflecting infection.

    Contraindications for Nasopharyngeal Suctioning

    • Avoid nasopharyngeal suctioning in clients with epistaxis due to the risk of exacerbating bleeding.

    Chest Tube Maintenance

    • Keep a container of sterile water accessible for patients with chest tubes to use in the event of accidental disconnection.

    COPD Dietary Considerations

    • For clients with COPD, recommend a diet that is high in calories and protein, while low in carbohydrates.

    Montelukast Education

    • Clients prescribed montelukast for chronic asthma should understand the importance of taking the medication every night, regardless of symptoms.

    Detecting Respiratory Acidosis

    • ABG values showing pH 7.30 and PaCO2 55 mm Hg indicate respiratory acidosis, necessitating urgent clinical attention.

    ARDS Assessment Alerts

    • Report findings of intercostal retractions in ARDS clients as they signify worsening respiratory distress.

    Productivity of Cough in COPD

    • A productive cough with green sputum in COPD clients is a priority finding indicating potential infection that must be reported.

    Chest Tube Monitoring

    • Continuous bubbling in the water seal chamber of a chest tube indicates an air leak and should prompt immediate provider notification.

    Oxygen Delivery Devices

    • A nonrebreather mask provides the highest oxygen concentration for clients in respiratory distress, delivering over 90% FiO2.

    Medication for Acute Asthma Attack

    • Albuterol is the first-line treatment for acute asthma attacks due to its rapid bronchodilation properties.

    Monitoring Effectiveness in Acute Respiratory Failure

    • Use arterial blood gases (ABGs) to assess the efficacy of treatments in clients with acute respiratory failure.

    Emphysema Symptoms

    • An elevated temperature in clients with emphysema should be reported as it may suggest a respiratory infection.

    Management of Pulmonary Embolism

    • Administering heparin via continuous IV infusion is prioritized for clients with pulmonary embolism to prevent further clot development.

    Rifampin Patient Education

    • Inform clients taking rifampin that it will turn their urine and other secretions orange, a harmless but notable effect.

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    Description

    Test your knowledge on respiratory care in mechanical ventilation scenarios with this ATI RN flashcard quiz. Focus on identifying causes of low-pressure alarms and understanding their implications in clinical settings. Perfect for nursing students preparing for medical-surgical nursing exams.

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