ATI LPN
Critical Care Respiratory Questions Questions
Question 1 of 5
A client who has endometrial cancer is receiving sealed internal radiation therapy. Which actions should the nurse implement? Select one that doesn't apply.
Correct Answer: C
Rationale: 1. Wearing a lead apron when providing care is recommended to protect the caregiver from radiation exposure. Always keep the front of the apron facing the client and do not turn so that the back of the caregiver is facing the client. 5. Women who are pregnant (including caregivers) should not enter the room. In addition, if the caregiver is attempting to conceive, whether they are male or female, they should not perform direct client care. Children younger than 16 should not be allowed to visit either. A 'Caution: Radioactive Material' sign should be placed on the door to the client’s room.
Question 2 of 5
A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?
Correct Answer: A
Rationale: An ICP reading of $12 \mathrm{~mm} \mathrm{Hg}$ is within the normal range (10 to $15 \mathrm{~mm} \mathrm{Hg}$ ). The nurse would continue with ongoing neurological assessment including vital signs, pupillary function, cranial nerve function, Glasgow Coma Scale, and sensory and motor response.
Question 3 of 5
The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation?
Correct Answer: B
Rationale: Documentation for SRDs must include objective patient-centered information. The nurse's feelings (A) are subjective and inappropriate for documentation. The specific type of SRD and patient assessment (B) are essential to ensure continuity of care and monitor for complications. Confirmation of a PRN order (C) is necessary to validate the use of SRDs. Assessing every 8 hours (D) is insufficient; SRDs require more frequent checks (e.g. every 1-2 hours) to ensure safety making B and C correct.
Question 4 of 5
The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?
Correct Answer: B
Rationale: A tracheostomy bypasses the nasal passages which normally filter humidify and warm inspired air (B). This protective mechanism is lost increasing the risk of respiratory infections and dryness requiring monitoring. The ability to cough (A) is not directly affected by the tracheostomy. The sneeze reflex (C) is irrelevant as it involves nasal passages. Decreased oxygen-carrying capacity (D) is not a protective mechanism and is unrelated to tracheostomy effects making B correct.
Question 5 of 5
A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?
Correct Answer: D
Rationale: Metabolic acidosis triggers compensatory hyperventilation to reduce CO2 a process known as Kussmaul respirations (D) characterized by rapid deep breathing. Cheyne-Stokes (A) involves cycles of increasing and decreasing breathing seen in brain injury or heart failure. Biot's (B) features irregular shallow breaths associated with CNS disorders. Cluster (C) breathing involves bursts with pauses linked to brainstem issues. Thus D is correct for metabolic acidosis compensation.