ATI LPN
Critical Care Respiratory Questions Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to
Correct Answer: C
Rationale: Coughing removes irritants from the trachea and bronchi (C) where mucus traps particles and cilia sweep them upward. It does not primarily improve oxygenation (A) or involve nasal passages (B). Closing the glottis (D) is unrelated to cough function making C the correct purpose especially relevant after smoke inhalation.