ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
- A. Blockage of the ET tube by the client's tongue
- B. Passage of the ET tube into the esophagus
- C. Movement of the ET tube into the right main bronchus
- D. Infection of the vocal cords
Correct answer: C
Rationale: When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.
2. A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: A
Rationale: The client's shallow respirations at 9/min indicate hypoventilation, leading to an accumulation of carbon dioxide in the blood, causing respiratory acidosis. In this scenario, the client is at risk for developing respiratory acidosis due to inadequate ventilation and subsequent CO2 retention.
3. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client's response to questions about place and time.
Correct answer: A
Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.
4. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
- A. Withhold food and liquids until the client's gag reflex returns.
- B. Irrigate the client's throat every 4 hours.
- C. Have the client refrain from talking for 24 hours.
- D. Suction the client's oropharynx frequently.
Correct answer: A
Rationale: After a flexible bronchoscopy, it is crucial to withhold food and liquids until the client's gag reflex returns to prevent aspiration. Irrigating the client's throat every 4 hours, having the client refrain from talking for 24 hours, and frequent suctioning of the oropharynx are not indicated post-bronchoscopy and may even pose risks to the client's recovery.
5. A client who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?
- A. A flexed position
- B. An extended position
- C. A neutral position
- D. A hyperextended position
Correct answer: D
Rationale: During a bronchoscopy with a rigid scope and general anesthesia, the provider will typically place the client's neck in a hyperextended position to allow better visualization and access to the airways. This position helps to align the trachea for easier insertion of the scope.
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