ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 30 Questions
Question 1 of 5
A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
Correct Answer: D
Rationale: Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 91% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.
Question 2 of 5
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
Correct Answer: C,E
Rationale: Sudden shortness of breath and tracheal deviation indicate a pneumothorax, requiring immediate intervention. Pink sputum, pain at the insertion site, and drainage of 75 ml/hr are not immediately life-threatening.
Question 3 of 5
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
Correct Answer: B
Rationale: Covering the insertion site with sterile gauze prevents air from entering the pleural space, which could cause a pneumothorax. Assessing drainage, contacting the provider, or reinserting the tube are secondary actions after securing the site to prevent complications.
Question 4 of 5
A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
Correct Answer: D
Rationale: Keeping padded clamps at the bedside ensures safety if the drainage system is interrupted. Stripping the tubing can cause harm, junctions should be taped not clamped, and suction levels are set per the device manufacturer, not the provider.
Question 5 of 5
A nurse auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip)
Correct Answer: A
Rationale: A pleural friction rub, heard when the pleura is inflamed, is associated with inflammation of the pleura rubbing against the lung wall. Upper airway obstruction causes stridor, pulmonary edema causes crackles, and bronchospasm causes wheezing.