ATI LPN
Acute Respiratory Care Nursing Questions Questions
Question 1 of 5
Upon assessment,the nurse notes that a client has dyspnea crackles in both lung bases and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?
Correct Answer: C
Rationale: Crackles in both lung bases (C) indicate fluid or mucus in the airways supporting Ineffective Airway Clearance where the client struggles to clear secretions leading to dyspnea and fatigue. Ineffective Breathing Pattern (A) focuses on altered rhythm or depth not crackles. Anxiety (B) lacks specific respiratory findings. Impaired Gas Exchange (D) relates to oxygenation deficits not primarily airway clearance making C the best-supported diagnosis.
Question 2 of 5
The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties?
Correct Answer: C
Rationale: Changing tracheostomy ties risks dislodgement requiring an assistant to hold the tube (C) while removing soiled ties and replacing them ensuring safety. Removing ties without assistance (A) is unsafe. Tying with a square knot (B) is correct but incomplete without assistance. Removing the outer cannula (D) is unnecessary and risky making C the best method for secure tie replacement.
Question 3 of 5
A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in
Correct Answer: A
Rationale: Atelectasis (collapsed alveoli) reduces lung compliance impairing ventilation (A) the movement of air into and out of the lungs. Alveolar gas exchange (B) is affected secondarily. Transportation (C) and systemic diffusion (D) are downstream processes not directly altered by atelectasis making A the primary alteration to anticipate.
Question 4 of 5
A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this clients respiratory function?
Correct Answer: B
Rationale: Congestive heart failure (CHF) reduces cardiac output impairing oxygen transport (B) from lungs to tissues and $\mathrm{CO} 2$ return affecting respiratory function. Airway conditions (A) air movement (C) and diffusion (D) are less directly impacted by CHF making B the primary concern for assessing respiratory alterations.
Question 5 of 5
The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity?
Correct Answer: B
Rationale: Yankauer suctioning (oral) is nonsterile and delegable to UAP. Not applying suction during insertion (B) prevents mucosal trauma a key point for UAP training. Applying suction during insertion (A) is incorrect. Sterile technique (C) is unnecessary for oral suctioning. Listening for lung sounds (D) is beyond UAP scope making B essential for safe delegation.