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Ati lpn level 3 med surg resp test
Ati lpn level 3 med surg resp test
Total Questions : 17
Showing 10 questions Sign up for moreA nurse in an emergency department is assisting with admitting a client.
A nurse is caring for a client who has pneumonia. Select the 4 findings in the client's medical record that places them at risk for pneumonia.
Explanation
A. Age: The client is 70 years old, which places them at a higher risk for pneumonia. Age is a significant risk factor because the immune system weakens as people get older, making it more difficult to fight off infections like pneumonia.
B. Fluid intake: The client reports decreased fluid intake due to throat pain. Inadequate hydration can result in thicker respiratory secretions, making it harder to clear the lungs and increasing the risk of developing or worsening pneumonia.
C. Influenza vaccine: The client has not received an annual influenza vaccination, which is a risk factor. Influenza can lead to secondary bacterial pneumonia or worsen respiratory conditions, particularly in older adults. Vaccination against influenza helps reduce this risk.
D. Level of consciousness: The client is lethargic and has difficulty answering questions due to shortness of breath. Altered level of consciousness can lead to reduced ability to protect the airway, increasing the risk of aspiration, which can lead to pneumonia.
E. Health history: The client has no significant medical history aside from the primary concern of pneumonia. While a lack of chronic conditions is generally a good sign, it does not contribute to an increased risk of pneumonia.
F. Smoking history: The client has never smoked, which reduces their risk for pneumonia. Smoking damages the respiratory tract and impairs the lung’s defense mechanisms, but this client does not have this risk factor.
G. Pneumococcal vaccine: The client has not received the pneumococcal vaccine, which is recommended for older adults to protect against pneumococcal pneumonia. Lack of vaccination increases the risk of acquiring pneumonia caused by Streptococcus pneumoniae.
A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?
Explanation
A. Continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber indicates a possible air leak in the system, which needs to be assessed and potentially reported to the charge nurse for further evaluation.
B. Patient respiratory status is stable and denies pain to chest tube site: This is a normal finding and does not require reporting.
C. Tidalling, fluctuations in the fluid level in the water-seal chamber: This is a normal finding, indicating that the chest tube is functioning properly and that the lungs are expanding.
D. Occasional bubbling in the water-seal chamber: This may be acceptable, especially with respiratory movements, as it could indicate that the patient is exhaling, but continuous bubbling is concerning.
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
Explanation
A. Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
B. Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
C. Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
D. Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.
A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?
Explanation
A. Decreasing respiratory rate: This is not expected; respiratory rate may increase as the body attempts to compensate for reduced oxygenation.
B. Facial flushing: This is not a common symptom of atelectasis and may indicate other issues such as anxiety or fever.
C. Dry cough: While a cough may be present, it is more likely to be productive due to retained secretions.
D. Increasing dyspnea: Atelectasis often leads to decreased lung volume, which can cause increasing dyspnea as the lung tissue collapses.
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
Explanation
A. Plan to administer insulin to the client: Insulin is not indicated for respiratory alkalosis; it is used for managing hyperglycemia in diabetic patients.
B. Plan to administer sodium bicarbonate to the client: Sodium bicarbonate is not appropriate for respiratory alkalosis and could worsen the condition.
C. Have the client breathe into a paper bag: Breathing into a paper bag can help increase carbon dioxide levels in the blood, which is often helpful in treating respiratory alkalosis due to hyperventilation.
D. Have the client place their head between their knees: This position does not directly address hyperventilation or help regulate breathing.
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
Explanation
A. "It delivers the highest concentration of oxygen possible." This is inaccurate; other methods (like non-rebreather masks) deliver higher concentrations.
B. "It delivers a specific concentration of oxygen constantly." While it does provide a specific concentration, it is not as constant as other devices because it can vary based on the client's breathing patterns.
C. "It delivers the low concentration of oxygen you need." A nasal cannula typically delivers a low concentration of oxygen (approximately 24-44% oxygen depending on the flow rate), which is appropriate for clients who need supplemental oxygen but do not require a high concentration.
D. "It allows you to remove it for a while when it gets uncomfortable." This is misleading; while the client can remove it temporarily, it is essential to maintain oxygen therapy as prescribed for adequate oxygenation.
A nurse is collecting data on a client who has respiratory alkalosis. Which of the following findings should the nurse expect?
Explanation
A. Abdominal pain: This is not typically associated with respiratory alkalosis, which primarily affects respiratory and neurologic systems.
B. Hyperventilation: Respiratory alkalosis occurs when a person exhales too much carbon dioxide, typically from hyperventilation, which can result from anxiety, pain, or other conditions.
C. Constipation: This is not a symptom of respiratory alkalosis; it might be seen in other metabolic disorders but not this one.
D. Dry skin: Dry skin is not a common manifestation of respiratory alkalosis; symptoms are usually respiratory and neurological (e.g., lightheadedness, tingling).
A nurse is reinforcing teaching with a client who has a new prescription for nebulizer treatments. Which of the following client statements indicates to the nurse a need for further teaching?
Explanation
A. "I will seal my lips around the mouthpiece and take slow, deep breaths.": This is a correct technique for nebulizer use, ensuring proper delivery of the medication.
B. "I should wash the mouthpiece with warm, soapy water each day.": Proper cleaning of the mouthpiece daily is recommended to prevent infection and maintain hygiene.
C. "I will store my nebulizer at room temperature.": Storing the nebulizer at room temperature is appropriate to ensure its functionality.
D. "I should keep medication in my nebulizer at all times." Nebulizer medication should not be left in the device when it is not in use. Leaving medication in the nebulizer can lead to contamination or improper dosing. The medication should be added only before each treatment.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?
Explanation
A. Perform chest physiotherapy prior to suctioning: While chest physiotherapy helps mobilize secretions, it does not thin them, which is the main concern in this situation.
B. Provide humidified oxygen. Humidified oxygen helps to moisten secretions, making them easier to expectorate or suction, which is especially important for tracheostomy care.
C. Pre-lubricate the suction catheter tip with sterile saline when suctioning the airway: This is not a method to thin secretions, but rather to lubricate the catheter.
D. Hyperventilate the client with 100% oxygen before suctioning the airway: This is done to prevent hypoxia during suctioning but does not help with thinning secretions.
A nurse is assisting discharge planning for a client who has a new prescription for bi-level positive airway pressure (BIPAP). The nurse should plan to contact which of the following healthcare team members to educate the client?
Explanation
A. Case manager: A case manager can help coordinate care but is not responsible for the specific education on BiPAP use.
B. Occupational therapist: Occupational therapists focus on daily living activities, not respiratory therapy.
C. Physical therapist: Physical therapists work on mobility and musculoskeletal issues, not respiratory support or BiPAP education.
D. Respiratory therapist: A respiratory therapist is responsible for providing education on the use of BiPAP, as they are specialists in respiratory equipment and therapy. They ensure that the client knows how to use the machine properly at home.
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