ATI MED SURG FORM A EXAM
SOLUTIONS WITH EXPLANATION
A nurse is caring for an older client who has chronic
obstructive pulmonary disease with pneumonia. The
nurse should monitor the client for which of the
following acid-base imbalances?
a) respiratory alkalosis
b) respiratory acidosis
c) metabolic alkalosis
d) metabolic acidosis - ANSWER-b) respiratory acidosis
Respiratory acidosis is a common complication of COPD.
This complication occurs because clients who have
COPD are unable to exhale carbon dioxide due to a loss
of elastic recoil in the lungs.
A nurse is caring for a client who has a tracheostomy
with an inflated cuff in place. Which of the following
findings indicated that the nurse should suction the
client's airway secretions?
a) the client is unable to speak
b) the client's airway secretions were last suctioned 2 hr
ago
c) the client coughs and expectorates a large mucous
plug
d) the nurse auscultates coarse crackles in the lung field -
ANSWER-d) the nurse auscultates coarse crackles in the
lung field
The nurse should auscultate coarse crackles or rhonchi,
identify a moist cough, hear or see secretions in the
tracheostomy tube, and then suction the client's airway
secretions.
A nurse in a provider's office is assessing a client who
states he was recently exposed to tuberculosis. Which of
the following findings is a clinical manifestation of
pulmonary tuberculosis?
a) pericardia friction rub
b) weight gain
c) night sweats
d) cyanosis of the fingertips - ANSWER-c) night sweats
Night sweats and fevers are clinical manifestations of
tuberculosis.
A nurse in the ED is assessing a client for a closed
pneumothorax and significant bruising of the left chest
following a motor-vehicle crash. The client reports
severe left chest pain on inspiration. The nurse should
assess the client for which of the following
manifestations of pneumothorax?
a) absence of breath sounds
b) expiratory wheezing
c) inspiratory stridor
d) rhonchi - ANSWER-a) absence of breath sounds
A client who has pneumothorax experiences severely
diminished or absent breath sounds on the affected side.
A nurse is caring for a client who is postoperative
following vein ligation and stripping for varicose veins.
Which of the following actions should the nurse take?
a) position the client supine with his legs elevated when
in bed
b) encourage the client to ambulate for 15 minutes every
hour while awake for the first 24 hr
c) the client to sit with his legs dependent after
ambulating
d) instruct the client to wear knee-length socks for 2
weeks after surgery - ANSWER-a) position the client
supine with his legs elevated when in bed
should elevate the client's legs above his heart to
promote venous return by gravity. During discharge
teaching, the nurse should reinforce the importance of
periodic positioning of the legs above the heart
A nurse is reviewing a client's repeat lab results 4 hr
after administering fresh frozen plasma. Which of the
following lab results should the nurse review?
a) prothrombin time
b) WBC count
c) platelet count
d) hematrocrite - ANSWER-a) prothrombin time
A nurse is developing a teaching plan for a client about
preventing acute asthma attacks. Which of the following
points should the nurse plan to discuss first?
a) how to eliminate environmental triggers that
precipitate attacks
b) the client's perception of the disease process and what
might have triggered past attacks
c) the client's medication regimen
d) manifestations of respiratory infections - ANSWER-b)
the client's perception of the disease process and what
might have triggered past attacks
The nurse should apply the nursing process prioritysetting framework. The nurse can use the nursing
process to plan client care and prioritize nursing actions.
Each step of the nursing process builds on the previous
step, beginning with assessment. Before the nurse can
formulate a plan of action, implement a nursing
intervention, or notify a provider of a change in the
client's status, the nurse must first collect adequate data
from the client. Assessing the client will provide the
nurse with knowledge to make an appropriate decision.
Therefore, the first step the nurse should take is to assess
the client's current knowledge.
A client is admitted to the emergency department
following a motorcycle crash. The nurse notes a
crackling sensation upon palpation on the right side of
the client's chest. After notifying the provider, the nurse
should document this finding as which of the following?
a) friction rub
b) crackles
c) crepitus
d) tactile fremitus - ANSWER-c) crepitus
Crepitus, also called subcutaneous emphysema, is a
coarse crackling sensation that the nurse can feel when
palpating the skin surface over the client's chest.
Crepitus indicates an air leak into the subcutaneous
tissue, which is often a clinical manifestation of a
pneumothorax.