ATI LPN
Critical Care Respiratory Questions Questions
Question 1 of 5
The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment?
Correct Answer: A
Rationale: E (Decreased cough reflex Dry mucous membranes Increased risk of aspiration) Aging reduces cough reflex (A) increasing aspiration risk (E) and dries mucous membranes (D) impairing airway clearance. Stiffening of blood vessels (B) affects cardiovascular health not respiratory. Altered protein synthesis (C) is nonspecific and unrelated making A
Question 2 of 5
The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this clients plan of care?
Correct Answer: A
Rationale: E (Insert oropharyngeal airway Nasal care Oral hygiene Move tube every 8 hours) Care includes an oropharyngeal airway (A) to prevent biting nasal care (B) and oral hygiene (C) every 2-4 hours for cleanliness and moving the tube (E) every 8 hours to prevent mucosal irritation. Non-humidified airflow (D) is incorrect as humidification is necessary
Question 3 of 5
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
Correct Answer: C
Rationale: The client should hold the cane on the stronger side of her body to increase support and maintain alignment. The top of the cane should be parallel to the greater trochanter, the client should only advance the cane 14-30 cm at a time, the client should move the weak leg with the cane for support.
Question 4 of 5
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Reassure the client that this is an expected response to grief. The client might perceive the discussion of risk factors as challenging or argumentative, the nurse should focus the teaching on the present psychosocial adaptation and not the future management, unless the client requests material this is not a good time, this is when the client needs to express their feelings.
Question 5 of 5
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Make sure two fingers can fit under the sleeve to prevent inhibition of circulation. The client should be in dorsal recumbent or semi-Fowler's. The nurse should place the sleeve under each leg with an opening. The pressure should be between 35-65.