ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 32 Questions
Question 1 of 5
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes, PCO2: 28 mm Hg, Respiratory rate: 34, Feels frightened, PO2: 88 mm Hg, Can't catch my breath, SPO2: 88%, Blood pressure 158/92 mm Hg, Lungs have crackles. What action by the nurse is most appropriate?
Correct Answer: B
Rationale: The client's symptoms and data (tachypnea, hypoxia, low PCO2, crackles, and anxiety) suggest a pulmonary embolism. STAT pulmonary angiography is the most appropriate action to confirm the diagnosis.
Question 2 of 5
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?
Correct Answer: D
Rationale: The upper peak airway pressure limit alarm must be on to prevent lung injury from excessive pressure. This is the priority to ensure client safety.
Question 3 of 5
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
Correct Answer: A
Rationale: Determining the cause of agitation (e.g., pain, hypoxia, or anxiety) is the first step to address the underlying issue. Restraints or sedation may be needed but are not the initial action.
Question 4 of 5
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
Correct Answer: C
Rationale: Frequent oral care is within the UAP's scope of practice and is essential for ventilated clients to prevent ventilator-associated pneumonia. The other tasks require nursing judgment and cannot be delegated.
Question 5 of 5
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client does not appear to be moving normally with respirations, oxygen saturation is 92%. What action by the nurse is best?
Correct Answer: A
Rationale: The client's abnormal respiratory movement and low oxygen saturation suggest a traumatic chest injury, possibly pneumothorax or hemothorax. Administering oxygen via a non-rebreather mask is the priority to address hypoxia while further assessment is conducted.