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. What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct answer: B
Rationale: The correct answer is B. A nurse should ask the client if they have any chronic breathing problems when the anteroposterior (AP) chest diameter is the same as the lateral chest diameter. This finding indicates a barrel chest, which can be associated with chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) or emphysema. Assessing for chronic breathing problems can help the nurse further evaluate the client's respiratory status and provide appropriate care.
3. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct answer: C
Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.
4. When caring for a client with Alzheimer's disease, what is the most appropriate communication technique for a nurse to use?
- A. Providing detailed explanations
- B. Speaking in a loud and clear voice
- C. Using simple and direct statements
- D. Offering multiple choices to the client
Correct answer: C
Rationale: When communicating with clients with Alzheimer's disease, using simple and direct statements is the most appropriate technique. This approach helps to minimize confusion, enhance understanding, and facilitate effective communication with individuals who may have difficulty processing complex information due to their condition.
5. A healthcare professional 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 healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct answer: A
Rationale: Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.
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