ATI LPN
Critical Care Respiratory Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?
Correct Answer: D
Rationale: The tracheostomy obturator is used to reinsert the tube if dislodged so taping it to the head of the bed (D) ensures immediate availability. Deflating the cuff (A) is not routine and risks aspiration. Elastic bandages (B) are unsafe for securing ties as they lack stability. Removing the inner cannula (C) is part of cleaning but not the priority here making D the correct action for safety.
Question 5 of 5
The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurses next action?
Correct Answer: B
Rationale: Padding the tubing at the ears (B) prevents pressure irritation enhancing comfort and compliance. Filling the humidifier (A) is important but not the immediate next step. Setting to 5 liters (C) risks CO2 retention in COPD and requires physician guidance. Ties (D) are not standard for nasal cannulas making B the correct next action for client comfort.