ATI RN
ATI Med Surg Nurs 300 Day Exam 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?
Correct Answer: C
Rationale: Tachypnea is a hallmark of ARDS due to impaired gas exchange from pulmonary edema, as the body compensates for decreased oxygenation by increasing respiratory rate.
Question 2 of 5
The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?
Correct Answer: B
Rationale: Increasing fluid intake thins mucus, antibiotics treat the infection, and coughing clears secretions, addressing pneumonia symptoms.
Question 3 of 5
The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?
Correct Answer: C
Rationale: Tachypnea is a hallmark of ARDS due to impaired gas exchange from pulmonary edema, as the body compensates for decreased oxygenation by increasing respiratory rate.
Question 4 of 5
The nurse would check for leaks in the chest tube and water seal system when:
Correct Answer: A
Rationale: Continuous bubbling in the water-seal chamber suggests a potential air leak in the system, which needs to be investigated. The water-seal chamber is designed to prevent backflow of air into the pleural space, and persistent bubbling typically indicates that air is escaping from the pleural cavity or there is a problem with the tubing or chest tube placement.
Question 5 of 5
The nurse is caring for a client three hours after percutaneous coronary intervention (PCI) with stent placement. The client now complains of 5/10 chest pain. The client is visibly diaphoretic and anxious. The ECG shows ST segment elevations. The vital signs are as follows: BP: 156/82, HR: 110, RR: 20, T: 98.6, and Sp02: 94% on 2L nasal canula. The nurse anticipates which intervention in this situation?
Correct Answer: D
Rationale: Chest pain with ST elevations post-PCI suggests reocclusion, requiring repeat PCI to restore coronary blood flow.