ATI LPN
Critical Care Respiratory Questions Questions
Question 1 of 5
During an admission assessment a client responds with rhyming statements such as 'tip, rip, dip and hip'. The nurse recognizes this speech pattern is associated with which mental health disorder?
Correct Answer: D
Rationale: This speech pattern is associated with psychotic disorders and schizophrenia. The client is exhibiting a type of speech called Clang association which is the meaningless rhyming of words, often in a forceful manner.
Question 2 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 3 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 4 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 5 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.