ATI LPN
ATI LPN LEVEL 3 Med Surg Resp Test Questions
Extract:
Question 1 of 5
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Breathing into a paper bag helps increase carbon dioxide levels, correcting respiratory alkalosis caused by hyperventilation.
Question 2 of 5
A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?
Correct Answer: A
Rationale: Continuous bubbling in the water-seal chamber indicates a possible air leak, which is abnormal and requires immediate reporting to ensure the chest tube system is functioning correctly.
Question 3 of 5
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Maintaining the drainage container below the client's chest prevents backflow of fluid or air into the pleural space, ensuring effective drainage and preventing complications.
Extract:
Nurses' Notes
Client presents to emergency department with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States went to a music concert recently "and probably picked up some kind of virus."
Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.
Client's face is flushed, sinus tachycardia, rate of 109/min. S1 and S2 heart sounds heard on auscultation. Pulses palpable.
Breath sounds with crackles to right lower lobe, tachypnea. rate of 28/min. Frequent productive cough with thick rusty sputum. Client denies hemoptysis. Unable to lie down, states "more comfortable to sit up."
Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."
Reports decreased urination over past 24 hr. "Haven't been drinking as much water as I should because my throat hurts."
Client reports they have not had a pneumococcal vaccine and do not get annual influenza vaccinations. States "I just hate needles.
Vital Signs
1200:
Temperature 38.6° C (101.5° F)
Heart rate 109/min
Respiratory rate 28/min
Blood pressure 106/54 mm Hg
Oxygen saturation 94% on room air
Medical History
1215:
70 years of age
No significant medical history other than primary concern
Well-nourished
Home Medications
Daily multivitamin
Vitamin D
Social History
Lives alone partner died 5 years ago
Drinks 1 to 2 glasses of red wine daily
Has never smoked
Walks 2 to 3 miles 6 days/week
Diagnostic Results
1230
Chest x-ray: Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia
Question 4 of 5
A nurse is caring for a client who has pneumonia. Select the 4 findings in the client's medical record that places them at risk for pneumonia.
Correct Answer: A,B,C,G
Rationale: A. Age: The client is 70 years old, which places them at a higher risk for pneumonia due to a weakened immune system. B. Fluid intake: Decreased fluid intake can lead to thicker respiratory secretions, increasing pneumonia risk. C. Influenza vaccine: Not receiving an influenza vaccine increases the risk of influenza-related pneumonia. G. Pneumococcal vaccine: Lack of pneumococcal vaccination increases the risk of pneumococcal pneumonia.
Extract:
Question 5 of 5
A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility. Which of the following interventions should the nurse include in the plan?
Correct Answer: C
Rationale: Restricting visitation reduces influenza spread in vulnerable populations, such as those in long-term care facilities.