ATI LPN
Critical Care Respiratory Questions Questions
Question 1 of 5
The nurse is caring for a client with a tracheostomy receiving oxygen therapy. Which intervention should the nurse prioritize to prevent infection and ensure proper oxygen delivery?
Correct Answer: C
Rationale: Applying a sterile dressing over the tracheostomy site helps prevent infection by providing a barrier against microorganisms. It also ensures a clean environment for optimal oxygen delivery and promotes wound healing.
Question 2 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 3 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 4 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 5 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.