Sem 2 Lower Respiratory conditions

32. A client with pulmonary hypertension asks the nurse to explain the heart changes that can occur with this disorder. Which is the best response?

"The right side of the heart enlarges as pressure backs from the lungs."

30. The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax Which is the best response by the nurse?

"The tube will drain air from the space around the lung."

33. A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?

"Viruses, like influenza, are the most common cause of pneumonia."

13. The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Acute respiratory distress syndrome

17. The nurse caring for a 2-year-old near-drowning victim monitors for what possible

Acute respiratory distress syndrome

15. Which action should the nurse take first in caring for a client during an acute asthma attack?

Administer bronchodilator as ordered.

7. A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?

Apply airtight dressing.

19. The client admitted with a deep vein thrombosis (DVT) is now complaining of chest pain and dyspnea. Which is the primary intervention for the nurse to take?

Apply oxygen via face mask.

24. The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and assist in the diagnosis of an occupational lung disease?

Black-streaked sputum

6. Following a femur fracture surgical repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?

Bone marrow

5. The nurse is caring for a client with a closed chest drainage system. While repositioning the client, the chest tube dislodges. What is the immediate nursing intervention?

Cover the exit site.

4. The client has been self-medicating with antitussives. Which assessment finding would alert the nurse to an adverse effect of this medication?

Crackles in the bases

21. While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

Crackling is heard when skin around tube is touched.

3. What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity is necessary.

31. Which of the following provides the best example of documentation for a client who is presenting with acute bronchitis?

Expectorating moderate amounts of thick, green mucus.

18. The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms

23. The occupational nurse is completing routine assessments on the employees. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

1. When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly?

Fluid rises and falls with respirations.

29. The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?

General sfatement of the client's condition

14. The client, with a lower respiratory airway infection, is presenting with symptoms such as fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse?

Ineffective Airway Clearance

8. The client with acute respiratory distress syndrome (ARDS) presents with severe hypoxemia, in spite of oxygen administration via face mask. Which intervention would the nurse anticipate.and prepare for?

Insertion of endotracheal tube

28. The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Localized calf tenderness

26. The nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Mucopurulent sputum

2. The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress?

Normal lung function

11. A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest?

Paradoxical chest movement

27. Which is a primary nursing intervention in caring for a client with the diagnosis of bronchiectasis?

Postural drainage

10. When managing the postoperative pain after a pneumonectomy, the nurse is most concerned about which assessment data?

Respirations 10 breaths/minute /

12. Upon assessing a client with emphysema, the nurse notes increased difficulty with inspiration. What is the likely cause of this finding?

Rigid chest cage

9. Which nursing assessment would alert a nurse to the development of a mediastinal shift, in a client with tension pneumothorax?

Shift of trachea, esophagus, heart, and areat vessels

16. Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?

The mucus-secreting glands are abnormal."

25. The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

chemical irritation

20. In the prevention of occupational lung diseases, the nurse would direct preventative teaching to which high-risk occupations? Select all that apply.

💊rock quarry worker 💊Z miner

22. What are the conditions that make up Virchow's triad? Select all that apply.

💊venostasis 💊hypercoagulability 💊disruption of the vessel lining