ATI RN
Medical Surgical Respiratory 3
1. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?
- A. Night sweats
- B. Low-grade fever
- C. Weight gain
- D. Blood in the sputum
Correct answer: C
Rationale:
2. A healthcare professional is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
- A. Increased temperature
- B. Absent breath sounds
- C. Productive cough
- D. Incisional discomfort
Correct answer: B
Rationale: Absent breath sounds may indicate a pneumothorax, a serious complication post lung biopsy. This condition requires immediate attention to prevent respiratory distress.
3. When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct answer: C
Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.
4. A nursing student asks what essential hypertension is. What response by the registered nurse is best?
- A. It means it is caused by another disease.
- B. It means it is essential that it be treated.
- C. It is hypertension with no specific cause.
- D. It refers to severe and life-threatening hypertension.
Correct answer: C
Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.
5. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
- A. Do you have a strong support system?
- B. What do you understand about your disease?
- C. Do you experience shortness of breath with basic activities?
- D. What medications are you prescribed to take each day?
Correct answer: C
Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.
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