ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
Correct Answer: A
Rationale: The correct answer is A: Withhold food and liquids until the client's gag reflex returns. After a flexible bronchoscopy, the client may have a decreased gag reflex due to topical anesthesia used during the procedure, which increases the risk of aspiration. Withholding food and liquids helps prevent aspiration until the gag reflex returns, usually within 1-2 hours. B: Irrigating the client's throat every 4 hours is unnecessary and may not be indicated post-bronchoscopy. C: Having the client refrain from talking for 24 hours is not necessary after a flexible bronchoscopy unless specifically instructed by the healthcare provider. D: Suctioning the client's oropharynx frequently is not indicated unless there is a clinical indication for it, such as excessive secretions or respiratory distress. Frequent suctioning can increase the risk of trauma to the airway.
Question 2 of 5
A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis. In this case, the low pH indicates acidosis, and the elevated PaCO2 indicates respiratory involvement. In respiratory acidosis, the lungs cannot eliminate enough CO2, leading to an increase in carbonic acid and a decrease in pH. Metabolic acidosis (choice A) would involve a primary decrease in bicarbonate levels, not seen in this scenario. Metabolic alkalosis (choice B) would involve an increase in bicarbonate levels, which is not indicated by the given information. Respiratory alkalosis (choice D) would have a low PaCO2 and an elevated pH, opposite of what is seen here.
Question 3 of 5
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
Question 4 of 5
A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
Correct Answer: D
Rationale: The correct answer is D: Reposition the client. This action should be taken because chest burning could indicate that the chest tube is irritating the pleura. Repositioning the client may help alleviate the pressure on the pleura, reducing discomfort. Increasing wall suction (A) could worsen the irritation. Stripping the chest tube (B) is outdated and can cause damage. Clamping the chest tube (C) can lead to tension pneumothorax.
Question 5 of 5
During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?
Correct Answer: C
Rationale: The correct answer is C: Agitation. During an asthma attack, hypoxemia can lead to increased respiratory effort and decreased oxygen delivery to tissues, causing agitation. Nausea (A) is not a typical manifestation of hypoxemia in asthma. Dysphagia (B) refers to difficulty swallowing and is not directly related to hypoxemia. Hypotension (D) is unlikely in asthma as it is more commonly associated with shock or severe systemic conditions.