CH. 21-23

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? a) Chemical irritation b) Direct lung damage c) Drug ingestion d) Aspiration

a) Chemical irritation Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? a) Obtain a sputum specimen for enzyme immunoassay testing. b) Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. c) Institute isolation precautions. d) Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour.

c) Institute isolation precautions. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Apply a dressing over the wound and tape it on three sides. b) Prepare to start an I.V. line. c) Draw blood for a hematocrit and hemoglobin level. d) Prepare a chest tube insertion tray.

a) Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Ineffective Airway Clearance b) Ineffective Breathing Pattern c) Impaired Gas Exchange d) Risk for Infection

a) Ineffective Airway Clearance The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis

b) Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect.

Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction? a) Apply a warm pack postoperatively b) Provide a splint postoperatively c) Ensure mouth breathing d) Apply pressure to the convex portion of the nose

c) Ensure mouth breathing For a patient who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating mouth breathing. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? a) Syncope b) Hemoptysis c) Tachypnea d) Cough

c) Tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? a) Keeping the head of the bed at 15 degrees or less b) Providing oral hygiene daily c) Using strict hand hygiene d) Turning the client every 4 hours to prevent fatigue

c) Using strict hand hygiene The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.