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
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Nursing Elites

ATI RN

Medical Surgical ATI Proctored Exam

1. A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?

Correct answer: B

Rationale: Tidal volume is the amount of air delivered with each breath during mechanical ventilation. A common formula used to calculate tidal volume is 6-8 mL/kg of ideal body weight. For a client with an ideal weight of 60 kg, the expected tidal volume would be 60 kg x 6-8 mL/kg = 360-480 mL. Therefore, the most appropriate choice is 480 mL (Option B), which falls within the expected range based on the client's weight.

2. A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?

Correct answer: C

Rationale: After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.

3. A client is unconscious with 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?

Correct answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

4. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Correct answer: D

Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.

5. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

Correct answer: C

Rationale:

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