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ATI Skills Module 3.0: Closed-Chest ...

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kel A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity?

• Hypertension
• ringing in the ears
• fever
• dilated pupils

B

• The nurse should identify that ringing in the ears, as well as headache, disorientation, and muscle twitching can indicate oxygen toxicity.

A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding?

• Jugular vein distension
• Clubbing of the fingers
• Heart murmur
• Paradoxical breathing

B

• The nurse should identify that clubbing of the fingers is an expected finding for a client who has chronic pulmonary disease, such as COPD

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect?

• Regurgitation
• Stenosis
• Muscle atrophy
• Hypotension

B

• The nurse should expect a client who has heart disease and a narrowed valve to have stenosis. Stenosis is a narrowing or stiffening of the heart

valve that causes backflow of the blood.

A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use?

• Nasal cannula
• Nonrebreather mask
• Partial rebreather mask
• Simple face mask

A

• The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be delivered at low concentrations of 1 to 4 L/min.

A nurse is auscultating a clients heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following ?

• Tachycardia
• Murmur
• Gallop
• Stroke volume

B

• A whooshing or blowing sound indicates a murmur and can be low, medium, or high pitched

(BRUIT)

A nurse is assessing a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following?

• Normal breathing
• Kussmaul breathing
• Cheyne-stokes breathing
• Apnea

A

• A normal breathing pattern is regular, quiet, and shows no manifestations of discomfort

A nurse is providing teaching for a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include?

• "Exhale into the incentive spirometer"
• "Use the incentive spirometer every hour while awake"
• :"Hold your breath for 10 seconds when using the incentive spirometer"
• "Use the incentive spirometer two times each session."

B

• The nurse should instruct the patient to use the incentive spirometer every hour while awake to promote lung expansion and mobilize

secretions (Prevents atelectasis) A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

• Monitor the client for subcutaneous emphysema
• Expect continuous bubbling in the water seal chamber
• Keep the drainage system above the level of the clients chest
• Clamp the chest tube tubing when the client ambulates.

A

• The nurse should monitor the client for subcutaneous emphysema, which can indicate a leak or blockage of the system

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output?

• Respiratory rate
• Blood pressure
• Stroke volume
• Vital capacity

C

• The nurse should use stroke volume to calculate the client's cardiac output. CO is a measurement of the volume of blood pumped by the left

ventricle in 1 min. CO is calculated by multiplying the client's heart rate by the client's stroke volume.A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take?

• Use clean technique to perform the procedure
• Apply suction when inserting the catheter
• Administer 100% oxygen before the procedure
• Suction the tracheostomy for 20 seconds each time

C

• The nurse should administer 100% oxygen to the client before the procedure to reduce the risk of hypoxia

(Hyperoxygenate) A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis?

• Lymphatic fluid
• Oxygenated blood
• Synovial fluid
• Surfactant

D

• Surfactant is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. A lack of surfactant can result in atelectasis.

A nurse is planning care for a group of patients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first?

• A patient who requires teaching about a new cholesterol- lowering medication
• A patient who reports dyspnea when walking to the bathroom
• A patient who has a new diagnosis of aortic valve stenosis and needs a referral to a cardiologist
• A patient who has asthma and is being discharged to home

B

• When using the urgent VS nonurgent approach to a client care, the nurse determines that the first client the nurse should see is the client who

reports dyspnea. The client might be experiencing hypoxia due to inadequate oxygenation, which requires further intervention by the nurse.A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take?

• Perform chest percussion therapy six times per day
• Listen for a hollow sound when performing chest percussion therapy
• Use flat hands to perform chest percussion therapy
• Apply chest percussion therapy over the clients ribs.

B

• Should hear a hollow sound when performing chest percussion therapy. This indicates proper technique is being used to loosen the secretions

A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations?

• Trachea
• Alveoli
• Diaphragm
• Bronchial tubes

B

• Alveoli are air-filled sacs where the exchange of oxygen and carbon dioxide occurs

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as risk factors for heart disease?(select all that apply)

• A diet high in saturated fats
• A history of an overactive bladder
• A history of smoking for 25 years
• A sedentary lifestyle
• A waist circumference of 84 cm (33 in)

A, C, D

• High saturated fats can increase blood pressure and cholesterol. This increases the risk for heart disease
• History of smoking increases blood pressure and the risk for heart disease
• Sedentary lifestyle increases the risk for heart disease

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• Crackles in the lungs
• Edema of the lower extremities
• A rapid, irregular heart rate
• A systolic murmur

A

• Left sided heart failure causes the blood to back up into the pulmonary circulation, causing crackles in the lungs

**** Right side failure = body Left side failure= LUNGS **** A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include?

• "Use the CPAP mask during the daytime"
• "Cover your nose with the CPAP mask"
• "Medications to assist with breathing can be administered through the CPAP machine"
• " You will need supplemental oxygen to use the CPAP machine"

B

• Cover nose to create a seal to treat obstructive sleep apnea