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Detailed Answer Key Complex Oyxgenation ATI Practice with rationale.

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Detailed Answer Key Complex Oyxgenation ATI Practice 1.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequ... ence 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. 2.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. 3.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: Created on:08/03/2018 Page 1 Detailed Answer Key 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. 4.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. 5.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 Created on:08/03/2018 Page 2 Detailed Answer Key Complex Oyxgenation ATI Practice and poor lung compliance. C. Induce sedation Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and have no sedative effect at all. A sedative or analgesic should be prescribed as an adjunct to the pancuronium. D. Decrease respiratory secretions Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis. An adverse effect of this medication is increased production of respiratory secretions. 6.A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection Rationale:Although the spleen plays a role in immunity against bacterial infections, the nurse would be more concerned about the risk of an upper respiratory infection in a client who has undergone splenectomy, or removal of the spleen. B. Pulmonary edema Rationale:Pulmonary edema may develop in a client who is on bedrest following trauma, but this is not the most likely cause of decreased breath sounds in this client. C. Atelectasis Rationale:Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis. D. Delayed gastric emptying Rationale:Although delayed gastric emptying may result in ineffective coughing, this is not the most likely cause of decreased breath sounds in this client. 7.A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. Rationale: This action is used to determine why a water seal chamber has continuous bubbling, not slow, steady bubbling. B. Check the suction control outlet on the wall. Rationale: This action is used to determine why a suction control chamber that is hooked to wall suction has little or no bubbling. Created on:08/03/2018 Page 3 Detailed Answer Key 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. 8.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. 9.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 Created on:08/03/2018 Page 4 Detailed Answer Key Complex Oyxgenation ATI Practice are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death). D. Stridor 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 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 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: Created on:08/03/2018 Page 5 Detailed Answer Key Complex Oyxgenation ATI Practice Emptying the collection chamber prior to transport is unnecessary. 12.A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client’s recovery? A. It decreases the client's level of anxiety. Rationale: The nurse should assess for and manage the client’s anxiety, as this can result in postoperative delirium. Following the administration of an opioid medication, the nurse should assess the client for relief of pain and apprehension. Even though opioid analgesics may decrease the client's level of anxiety (partially from pain reduction alone), there is another effect that is more important. B. It facilitates the client's deep breathing. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client’s has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain. C. It enhances the client's ability to sleep. Rationale: The nurse should take measures to facilitate sleep in the postoperative client such as providing quiet time that is undisturbed, dimming lights, and ensuring the client is comfortable and not in pain. Even though opioid analgesics may increase the client’s ability to relax and sleep, another effect is more important. D. It reduces the client's blood pressure. Rationale: The nurse should closely monitor the cardiac status of the client who is postoperative. The client who is experiencing pain releases catecholamines which produce vasoconstriction and increase blood pressure. Even though opioid analgesics may assist in reducing a client’s blood pressure, another effect is more important. 13.A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side Rationale:A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately. B. Bubbling of the water in the water seal chamber with exhalation Rationale: The water seal chamber prevents air from re-entering the pleural space. Bubbling in this Created on:08/03/2018 Page 6 Detailed Answer Key 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 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 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. Created on:08/03/2018 Page 7 Detailed Answer Key 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 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. 17.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 Created on:08/03/2018 Page 8 Detailed Answer Key Complex Oyxgenation ATI Practice priority. C. Chest tube drainage Rationale: The nurse should monitor the amount and characteristics of chest tube drainage because drainage in excess of 70 mL/hr may indicate acute bleeding or require that administration of blood products. While this is an appropriate intervention, there is another intervention that would take priority. D. Pain level Rationale: The nurse should monitor for and treat pain in the client who is postoperative following a thoracotomy to provide comfort and to enhance the client’s ability to deep breathe. However, there is another assessment that would take priority. 18.A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis Rationale: Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45) and a CO2 level that is higher than the normal reference range (35 – 45 mm Hg). B. Metabolic acidosis Rationale: Metabolic acidosis occurs when there is an alteration in the level of hydrogen ions or a reduction in the amount of bicarbonate available. It can be the result of diabetic ketoacidosis, starvation, hypoxia, renal or liver failure, dehydration, or diarrhea. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45) and a bicarbonate (HCO3) level that is lower than the normal reference range (21 – 28 mEq/mL). C. Metabolic alkalosis Rationale: Metabolic alkalosis occurs when there is an alteration in the level of HCO3 along with an increase in the pH of the blood. It can be the result when a client ingests too much antacid from blood transfusions or total parenteral nutrition. It can also occur if the client has prolonged vomiting or NG suction, takes thiazide diuretics, or has a metabolic disorder such as hypercortisolism or hyper aldosteronism. Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45) and an HCO3 level that is higher than the normal reference range (35 – 45 mm Hg). D. Respiratory alkalosis Rationale: Respiratory alkalosis occurs when there is an excessive loss of CO2 through hyperventilation, mechanical ventilation, fever, overdose of salicylates, or lesions to the central nervous system. Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45) and a CO2 level that is lower than the normal reference range (35 – 45 mm Hg). Created on:08/03/2018 Page 9 Detailed Answer Key Complex Oyxgenation ATI Practice 19.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. 20.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 (103 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: Created on:08/03/2018 Page 10 Detailed Answer Key Complex Oyxgenation ATI Practice This change in heart rate is not significant, as both values are within the expected reference range. 21.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 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. Created on:08/03/2018 Page 11 Detailed Answer Key Complex Oyxgenation ATI Practice 23.A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation. Rationale:If the client cannot compensate for this acid-base imbalance and conservative treatment does not help, mechanical ventilation might become necessary; however, it is not the first step in managing this client’s imbalance. B. Administer oxygen via face mask. Rationale: The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client’s oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation. C. Prepare to administer a sedative. Rationale:In many cases, the cause of this acid-base disorder is extreme anxiety with hyperventilation and loss of CO2, as evidenced by the client’s respiratory rate of 40/min and her PaCO2 of 29. A sedative will help relieve anxiety and slow her breathing enough to correct the acid-base imbalance. However, the greatest risk to the client is hypoxia, so administering a sedative is not the priority action. D. Assess for indications of pulmonary embolism. Rationale:Pulmonary embolism is a possible cause of this type of acid-base imbalance, particularly with the client’s history of birth control pills and smoking, so the nurse should be alert for manifestations of this disorder. However, this is part of ongoing client monitoring and not the first step in managing the imbalance. 24.A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site Rationale:A small amount of serosanguineous drainage at the puncture site is expected after a thoracentesis. B. Discomfort at the puncture site Rationale: Mild discomfort at the puncture site is expected after a thoracentesis. C. Increased heart rate Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require Created on:08/03/2018 Page 12 Detailed Answer Key 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 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 PaCO2 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 PaCO2 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 PaCO2 is greater than 45 mm Hg. D. Respiratory alkalosis Rationale: With uncompensated respiratory alkalosis, the pH is greater than 7.45 and the PaCO2 is less than 45 mm Hg. 26.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: Created on:08/03/2018 Page 13 Detailed Answer Key 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 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 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. Created on:08/03/2018 Page 14 Detailed Answer Key Complex Oyxgenation ATI Practice 29.A nurse is preparing to measure a client’s level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger Rationale:Edema of the hands and fingers interferes with blood circulation in the capillary bed. The oximeter probe may not be able to adequately detect hemoglobin molecules to provide an accurate oxygen saturation reading. B. Earlobe Rationale: The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation. C. Toe Rationale: Thickening of nails interferes with blood circulation in the capillary bed. The oximeter probe may not be able to adequately detect hemoglobin molecules to provide an accurate oxygen saturation reading. D. Skin fold Rationale:A skin fold may not have adequate capillary circulation of hemoglobin molecules to provide an accurate oxygen saturation reading. 30.A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently. Rationale:Ambulation prevents the accumulation of respiratory secretions, but not their thinning. B. Encourage coughing and deep breathing. Rationale: Coughing and deep breathing promotes expectoration, not thinning of respiratory secretions. C. Encourage the client to increase fluid intake. Rationale:Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client’s ability to cough and remove the secretions. D. Encourage regular use of the incentive spirometer. Rationale: Using an incentive spirometer promotes expectoration, not thinning of respiratory secretions. 31.A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? A. Clamp the catheter. Rationale: Created on:08/03/2018 Page 15 Detailed Answer Key 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. 32.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 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: Created on:08/03/2018 Page 16 Detailed Answer Key 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 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. 35.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 Created on:08/03/2018 Page 17 Detailed Answer Key Complex Oyxgenation ATI Practice in the level of arterial oxygen, and the client can require mechanical ventilation. B. Check the client for a positive Chvostek's sign. Rationale: The nurse should check the client for a positive Chvostek's sign to monitor for hypocalcemia secondary to fat embolism syndrome; however, there is another action the nurse should take first. C. Administer an IV vasopressor medication. Rationale: The nurse should administer an IV vasopressor medication to prevent hypotension secondary to fat embolism syndrome; however, there is another action the nurse should take first. D. Monitor the client for headache. Rationale: The nurse should monitor the client for headache secondary to fat embolism syndrome to provide appropriate pain relief; however, there is another action the nurse should take first. 36.A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue Rationale: The ET tube is positioned over the client's tongue, so the tongue cannot obstruct it. The nurse should expect decreased SaO2 if the ET tube is obstructed. B. Passage of the ET tube into the esophagus Rationale: The nurse should suspect passage of the ET tube into the esophagus if the client's breath sounds are heard over the abdomen and the abdomen becomes distended. C. Movement of the ET tube into the right main bronchus Rationale: During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single side as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube. D. Infection of the vocal cords Rationale: The nurse should suspect infection if the client exhibits findings such as hyperthermia and increased WBC. 37.A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? A. Respiratory acidosis Rationale: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or Created on:08/03/2018 Page 18 Detailed Answer Key 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 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 nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing Rationale: Created on:08/03/2018 Page 19 Detailed Answer Key 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 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 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 Created on:08/03/2018 Page 20 Detailed Answer Key Complex Oyxgenation ATI Practice limit the harmful effects of catecholamines, which are released when the client experiences pain; however, another intervention should be implemented by the nurse first. B. Administer oxygen therapy. Rationale: The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation. C. Start an IV infusion of lactated Ringer's. Rationale: Crystalloids are administered via continuous IV bolus to maintain cardiac output and prevent shock; however, another intervention is the priority action for the nurse to take. D. Initiate cardiac monitoring. Rationale: The client who develops a pulmonary embolism is likely to have cardiac manifestation as a result of decreased tissue perfusion. It will be important to monitor the client's cardiac rhythm for T-wave and ST-segment changes as well as right ventricular failure or myocardial infarction. There is, however, another intervention that is the priority. 42.A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia Rationale:A client who is hypoxic is more likely to have tachycardia than bradycardia. B. Bradypnea Rationale: Clients who have hypoxia generally have rapid, shallow respirations and are dyspneic. C. Lethargy Rationale: The client who is hypoxic is increasingly restless and may state feeling light-headed. D. Intercostal retractions Rationale: Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs. 43.A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? A. Stridor Rationale:Stridor, or a high-pitched crowing sound heard during inspiration, is a result of laryngeal edema. This finding indicates possible obstruction of the client's airway. Therefore, the nurse should report it to the provider immediately. Created on:08/03/2018 Page 21 Detailed Answer Key Complex Oyxgenation ATI Practice B. Copious oral secretions Rationale: Copious oral secretions following extubation is an expected finding. The nurse should remind the client to cough to facilitate removal of secretions in the throat. C. Hoarseness Rationale: Hoarseness is an expected finding following extubation. D. Sore throat Rationale:Sore throat is an expected finding following extubation. 44.A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A. Atelectasis Rationale:Atelectasis is a collapse of the alveoli. With atelectasis, the exchange of oxygen and carbon dioxide is diminished. Crackles, fever and productive cough are manifestations of atelectasis. B. Flail chest Rationale: Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out. C. Hemothorax Rationale: Hemothorax is blood in the pleural space and involves decreased movement of the involved chest wall. Manifestations of a large hemothorax include diminished breath sounds and dull percussion sounds. D. Pneumothorax Rationale:Pneumothorax is air in the pleural space and involves decreased movement of the involved chest wall. Manifestations of pneumothorax include diminished breath sounds and hyperresonance upon percussion. 45.A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds Rationale:Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy. B. Squeaky, musical sounds Rationale:Squeaky, musical sounds caused by air whoosh through narrowed airways are a manifestation of bronchospasms. Created on:08/03/2018 Page 22 Detailed Answer Key Complex Oyxgenation ATI Practice C. Popping sounds Rationale:Popping sounds caused by moving into deflated airways are a manifestation of atelectasis and pneumonia. D. Snoring sounds Rationale:Snoring sounds, known as rhonchi, are heard when a client has thick, tenacious secretions. 46.A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A. Administer high-flow oxygen at 5 L/min by facemask to the client. Rationale:A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen at 5 L/min by facemask to the client. B. Place the client in high-Fowler's position with legs dependent. Rationale: The nurse should place the client in high-Fowler's position with legs dependent to decrease venous return to the heart. However, there is another intervention that is the nurse's priority. C. Give the client sublingual nitroglycerin. Rationale: The nurse should administer sublingual nitroglycerin to decrease preload and afterload. However, there is another intervention that is the nurse's priority. D. Reassure the client. Rationale: The nurse should reassure the client that his dyspnea will diminish with treatment. However, there is another intervention that is the nurse's priority. 47.A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion Rationale: Following a bronchoscopy, an older adult client is at risk for confusion due to medications use for sedation. However, there is another assessment that is the nurse's priority. B. Auscultating breath sounds Rationale: The client is at risk for hypoxia following a bronchoscopy and the nurse should auscultate the client's breath sounds. However, there is another assessment that is the nurse's priority. C. Confirming the gag reflex Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway. Created on:08/03/2018 Page 23 Detailed Answer Key Complex Oyxgenation ATI Practice D. Measuring blood pressure Rationale: The client is at risk for hypotension due to the medications used for sedation during the procedure. However, there is another assessment that is the nurse's priority. 48.A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils Rationale: Unequal pupils are an expected finding for a client who has increased intracranial pressure. B. Hypertension Rationale: Hypotension is an expected finding for a client who has pneumonia. C. Tympany upon chest percussion Rationale: Dull sounds upon chest percussion is an expected finding for a client who has pneumonia. D. Confusion Rationale: Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia. 49.A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A. "Rest in a side-lying position after the tube is removed." Rationale: To promote ventilation, the client should sit upright in a semi-Fowler's position after the tube is removed. B. "Use the incentive spirometer every 4 hr after the tube is removed." Rationale: To promote ventilation the client should use the incentive spirometer every 2 hr after the tube is removed. C. "Avoid speaking for long periods." Rationale: The client should avoid speaking for long periods to promote gas exchange. D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed." Rationale: To reduce the risk of respiratory distress after the tube is removed, the nurse will monitor the client's vital signs every 5 min after the tube is removed. 50.A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following? Created on:08/03/2018 Page 24 Detailed Answer Key Complex Oyxgenation ATI Practice A. 300 mL Rationale: The average tidal volume is 7 to 9 mL/kg of body weight. Therefore, this setting is below the average range. B. 480 mL Rationale: The average tidal volume is 7 to 9 mL/kg. 60 kg x 8 mL/kg = 480. Therefore, this setting is within the average range. C. 800 mL Rationale: The average tidal volume is 7 to 9 mL/kg of body weight. Therefore, this setting exceeds the average range. D. 950 mL Rationale: The average tidal volume is 7 to 9 mL/kg of body weight. Therefore, this setting exceeds the average range. 51.A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.) A. Severe dyspnea B. Nausea C. Decreased level of consciousness D. Headache E. Hypotension Rationale:Severe dyspnea is correct. Severe dyspnea is a manifestation of ARF that occurs as a result of hypoxemia.Nausea is incorrect. Gastrointestinal manifestations are not manifestations of ARF.Decreased level of consciousness is correct. Decreased level of consciousness is a manifestation of ARF that occurs due to hypercapnia.Headache is correct. Headache is a manifestation of ARF that occurs due to hypercapnia.Hypotension is correct. Hypotension is a manifestation of ARF that occurs due to acidosis. 52.A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take? A. Start CPR. Rationale: Clients in need of CPR are not immediately treated when multiple victims are present. Furthermore, CPR will not be effective if the client is trapped under a vehicle. B. Place a red tag on the client's upper body and obtain immediate help from other personnel. Rationale: Created on:08/03/2018 Page 25 Detailed Answer Key Complex Oyxgenation ATI Practice A red triage tag is not appropriate for a client who has apnea. This client's condition is imminently terminal. Therefore, the client should place a black tag on the client. C. Place a black tag on the client's upper body and attempt to help the next client in need. Rationale: When assessing an apneic adult casualty in a disaster situation, a nurse should attempt to reposition the upper airway on time. If the client still does not breathe, a black tag should be placed on the upper body and the nurse should move on to the next client in need. D. Reposition the client's upper airway a second time before assessing his respirations. Rationale:After attempting to reposition the airway one time, the nurse should triage the client and move on to the next client in need. 53.A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies Rationale:A client who has scabies requires contact precautions. B. A client who has pertussis Rationale:A client who has pertussis requires droplet precautions. C. A client who has streptococcal pharyngitis Rationale:A client who has streptococcal pharyngitis requires droplet precautions. D. A client who has measles Rationale:A client who has measles requires airborne precautions as well as a negative pressure room. 54.A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine? A. Respirations are unlabored. Rationale:Losartan is an angiotensin receptor blocker (ARB). Both ARBs and angiotensin converting enzyme (ACE) inhibitors have the adverse effect of angioedema. The primary symptom of angioedema is swelling of the tongue, glottis, and pharynx. This results in limitation or blockage of the airway. Angioedema causes the capillaries to become more permeable, resulting in fluid shifting into the subcutaneous tissues. Although the mouth and throat are most often affected, any area may be involved in the process. Untreated, angioedema can result in death. Improvement of respiratory effort following the administration of epinephrine is the most important therapeutic indicator. B. Client reports decreased groin pain of 3 on a 1 to 10 scale. Rationale:Although edema can occur in any area, the groin is not affected specifically by the disorder. Angioplasty and angiograms most often utilize the femoral vessels, but the prefix "angio" is a Created on:08/03/2018 Page 26 Detailed Answer Key Complex Oyxgenation ATI Practice general term for blood vessel rather than a reference to the femoral area. C. The client's blood pressure when arising from resting position is at premedication levels. Rationale: Hypotension is a common side effect of angiotensin II receptor blockers (ARBs) such as losartan. For this side effect, the nurse should monitor blood pressure when the client changes position. However, angioedema is an adverse reaction that can result in swelling of the lips, tongue, and glottis. The client experiences extreme respiratory distress. D. The client tolerates a second dose of medication with no greater than 1+ peripheral edema. Rationale:Peripheral edema is not usually associated with angioedema. The edema that is significant in this client occurs in the lips, mouth, and throat, causing airway obstruction. Once the client has this response, the client must know to never take any medication in the angiotensin II receptor blocker classification. 55.A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect? A. Widened QRS complexes Rationale:A client who has respiratory acidosis is likely to cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block. B. Hyperactive deep tendon reflexes Rationale:A client who has respiratory acidosis is more likely to have reduced muscle tone and hypoactive deep tendon reflexes due to hyperkalemia. C. Bounding peripheral pulses Rationale:A client who has respiratory acidosis is more likely to have thready peripheral pulses which are difficult to palpate. D. Warm, flushed skin Rationale:A client who has respiratory acidosis is more likely to have pale to cyanotic, dry skin. A client who has metabolic acidosis is likely to have warm, flushed dry skin. 56.A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. Rationale: The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube. B. Immediately notify the provider. Rationale: Created on:08/03/2018 Page 27 Detailed Answer Key Complex Oyxgenation ATI Practice The nurse does not need to contact the provider at this time. The fluid in the water seal chamber is expected to rise during inhalation and fall during exhalation. C. Reposition the client toward the left side. Rationale: Repositioning the client can aid in comfort and prevention of pressure ulcers; however, repositioning is not indicated in this situation. D. Clamp the chest tube near the water seal. Rationale: Chest tube manipulation should be kept at a minimum. Clamping the chest tube is not recommended. It should be clamped only for brief periods to check for an air leak or change the drainage system. 57.A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.) A. Elevate the head of the bed to at least 30&deg. B. Verify the prescribed ventilator settings daily. C. Apply restraints if the client becomes agitated. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth daily. Rationale:Elevate the head of the bed to at least 30&deg is correct. A client who is intubated is at risk for aspiration and ventilator-associated pneumonia. To minimize these risks, the nurse should maintain the head of the bed at 30&deg or higher.Verify the prescribed ventilator settings daily is incorrect. The nurse should perform and document ventilator checks at least every 8 hr to ensure the ventilator settings are as prescribed.Apply restraints if the client becomes agitated is incorrect. A client who becomes agitated or restless might be experiencing air hunger. The nurse should assess the flow settings. If the client continues to be restless or agitated, a chemical restraint, such as midazolam, may be administered. Physical restraints are a last resort and only applied to prevent accidental dislodgement of the endotracheal tube.Administer pantoprazole as prescribed is correct. Stress ulcers occur in many patients receiving mechanical ventilation. Antacids, histamine blockers, or proton-pump inhibitors are often prescribed as soon as a client is intubated.Reposition the endotracheal tube to the opposite side of the mouth daily is correct. The nurse should assess the area around the endotracheal tube frequently for color, tenderness, skin irritation, and drainage. The nurse should perform oral care every 2 hr. To prevent skin breakdown, the oral endotracheal tube should be moved to the opposite side on the mouth once daily. 58.A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? A. Chest tube eyelets not visible Rationale:Eyelets allow for drainage from the pleural space. The eyelets should not be visible when inspecting the insertion site. Created on:08/03/2018 Page 28 Detailed Answer Key Complex Oyxgenation ATI Practice B. Continuous bubbling in the suction control chamber Rationale: The suction control chamber regulates the amount of negative pressure being applied to the pleural space. When suction is applied, the water in this chamber should bubble continuously. C. Presence of tidal fluctuation in the water seal chamber Rationale: The water contained in the water seal chamber prevents air from re-entering the pleural space. The water level in this chamber rises with inhalation and falls with exhalation, which referred to as tidaling and is an expected finding D. Development of subcutaneous emphysema Rationale:Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider. 59.A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. HCO3- 30 mEq/L Rationale: This laboratory value is expected for a client who has metabolic alkalosis. B. PaCO2 50 mm Hg Rationale: This laboratory value is an expected finding for a client who has respiratory acidosis. C. pH 7.45 Rationale: This laboratory value is within the expected reference range. D. Potassium 3.3 mEq/L Rationale: This laboratory value is expected for a client who has metabolic alkalosis. 60.A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk for ventilator-associated pneumonia? A. Position the head of the client's bed in the flat position. Rationale: The nurse should elevate the head of the client’s bed 30&deg to reduce the risk for aspiration and pneumonia. B. Turn the client every 4 hr. Rationale: The nurse should turn the client every 2 hr to promote lung expansion and reduce the risk for pneumonia. C. Rinse the client's mouth with an antimicrobial solution every 4 hr. Rationale: The nurse should brush the client’s teeth every 8 hr and rinse the client’s mouth with an Created on:08/03/2018 Page 29 Detailed Answer Key Complex Oyxgenation ATI Practice antimicrobial rinse every 2 hr to reduce the growth of bacteria. D. Perform hand hygiene prior to suctioning the client's endotracheal tube. Rationale: The nurse should perform hand hygiene prior to suctioning the client’s endotracheal tube to reduce the risk of introducing bacteria. 61.A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first? A. Prepare the client for reintubation. Rationale: The nurse should prepare the client for reintubation to promote ventilation and improve oxygenation; however, there is another action the nurse should take first. B. Assess the client’s airway. Rationale: The first action the nurse should take using the nursing process is to assess the client’s airway for obstruction, listen to the client’s lungs for air movement, and provide mechanical ventilation with a bag-valve-mask device to reduce the risk for hypoxia. C. Suction the client’s mouth. Rationale: The nurse should suction the client’s oral airway as needed to remove secretions and improve oxygenation; however, there is another action the nurse should take first. D. Elevate the client’s head of bed. Rationale: The nurse should elevate the client’s head of bed to promote ventilation; however, there is another action the nurse should take first. 62.A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? A. Administer a short-acting ß2 –agonist (SABA). Rationale: When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation. B. Obtain a peak flow reading. Rationale: Obtaining a peak flow reading is non-urgent while the client is in distress. Although a peak flow reading will assist with determining the severity of the bronchospasms and assist with management of medications to prevent further exacerbations, there is another action that is the priority. C. Administer an inhaled glucocorticoid. Rationale:Administering an inhaled glucocorticoid is non-urgent while the client is in distress. Although an inhaled glucocorticoid should be used for long-term therapy to prevent future exacerbations, Created on:08/03/2018 Page 30 Detailed Answer Key Complex Oyxgenation ATI Practice there is another action that is the priority. The nurse should administer a systemic glucocorticoid for immediate relief of airway inflammation. D. Determine the cause of the acute exacerbation. Rationale: Determining the cause of the acute exacerbation is non-urgent while the client is in distress. Although the nurse should determine the trigger for the asthma exacerbation to prevent future attacks, there is another action that is the priority. 63.A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea Rationale: The nurse would not expect the client to be nauseated during an asthma attack. B. Dysphagia Rationale: The nurse should expect the client to display dyspnea, not dysphagia, during an asthma attack. C. Agitation Rationale: The nurse should expect agitation due to neurological changes from poor oxygen exchange. D. Hypotension Rationale: The nurse should expect hypertension due to increased work load of the heart from decreased oxygenation. 64.A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? A. Sedation Rationale: Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia. B. Constipation Rationale: Diphenhydramine can cause diarrhea. C. Hypertension Rationale: Diphenhydramine can cause hypotension. D. Bradycardia. Rationale: Diphenhydramine can cause palpitations. Created on:08/03/2018 Page 31 Detailed Answer Key Complex Oyxgenation ATI Practice 65.A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity and turbulence of the air the client exhales, which of the following techniques should the nurse use? A. Postural drainage Rationale:Postural drainage allows secretions to drain by gravity. It does not increase air turbulence. B. Nebulization Rationale: Nebulizer therapy can help loosen secretions prior to chest physiotherapy, but it does not increase air turbulence. C. Percussion Rationale: To perform percussion, the nurse strikes the skin over congested lung fields to loosen secretions. It does not increase air turbulence. D. Vibration Rationale:Vibration after percussion, or alternately with percussion, increases the velocity and turbulence of the air the client exhales, while loosening secretions and triggering coughing. Created on:08/03/2018 Page 32 [Show More]

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