Question

ati fundamental test 2024 (nursing process)
52.a nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. when collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
a. cracks in oral mucous membranes
b. poor skin turgor
c. tachycardia
d. excessive pulmonary secretions
53.a nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. when collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
a. bradypnea
b. peripheral edema
c. cyanosis
d. hypertension
54.a nurse is collecting data from a client who has respiratory insufficiency. which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
a. diaphoresis
b. retractions
c. cyanosis
d. restlessness
55.a nurse is auscultating the breath sounds of a client who has asthma. when the client exhales, the nurse hears continuous high - pitched squeaking sounds. the nurse should document this as which of the following adventitious lung sounds?
a. crackles
b. rhonchi
c. stridor
d. wheezes

Explanation:

• Question 52: Oxygen therapy can dry out mucous membranes. Cracks in oral mucous membranes are an adverse effect. Poor skin turgor is related to dehydration (not specific to oxygen therapy). Tachycardia can be due to many causes (e.g., pneumonia itself). Excessive pulmonary secretions are not an adverse effect of oxygen therapy.
• Question 53: In early hypoxia, the body tries to compensate. Hypertension (increased blood pressure as a compensatory mechanism) can occur. Bradypnea (slow breathing) is not an early sign (tachypnea is more common early). Peripheral edema is more of a late - stage heart or kidney issue related to hypoxia. Cyanosis is a late sign as it requires significant desaturation.
• Question 54: Restlessness is an early sign as the brain is sensitive to low oxygen levels. Diaphoresis (sweating) can be a later sign. Retractions (pulling in of chest muscles) are more related to increased work of breathing (not the earliest). Cyanosis is a late sign.
• Question 55: Wheezes are continuous high - pitched squeaking sounds (especially on exhalation) in asthma due to narrowed airways. Crackles are discontinuous (like popping). Rhonchi are low - pitched (snoring - like). Stridor is a high - pitched sound (usually on inhalation) due to upper airway obstruction.

Answer:

• 52. A. Cracks in oral mucous membranes
• 53. D. Hypertension
• 54. D. Restlessness
• 55. D. Wheezes