a nurse in the pacu is assessing a client who has an endotracheal tube et tube in place and observes the absence of left sided chest wall expansion up
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Nursing Elites

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?

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 wearing a Venturi mask to receive oxygen, and the dinner tray has arrived. What action by the nurse is best?

Correct answer: B

Rationale: In this scenario, the nurse should determine if the client can safely switch to a nasal cannula during meals. It is crucial to ensure that the provider has approved this change. Oxygen is considered a medication and should be delivered continuously. Turning off the oxygen or lifting the mask while eating can lead to a decrease in the FiO2 delivered, potentially compromising the client's oxygenation status. Therefore, the best course of action is to ascertain if transitioning to a nasal cannula is appropriate for the client during the meal.

3. A client has an oxygen saturation of 88% on room air. Which action should the nurse take first?

Correct answer: A

Rationale: The priority action for a client with an oxygen saturation of 88% on room air is to initiate oxygen therapy to improve oxygen saturation levels. Oxygen therapy is crucial to address hypoxemia promptly. Placing the client in a high-Fowler's position can also aid in oxygenation, but administering oxygen takes precedence. While notifying the healthcare provider is important, it is a secondary action after ensuring the client's immediate need for oxygen is met. Documenting the finding in the client's medical record is necessary for continuity of care but is not the primary intervention when addressing hypoxemia.

4. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?

Correct answer: C

Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.

5. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

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