CHAPTER 21

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? A)Apply oxygen via face mask. B)Assess and rate the chest pain. C)Apply compression stockings. D)Prepare for ventilation-perfusion scan

A

The client has been self-medicating with antitussives. Which assessment finding would alert the nurse to an adverse effect of this medication? A)Crackles in the bases B)Increased coughing C)Temperature 101° F D)Nausea and vomiting

A

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress? A)Normal lung function B)Loss of lung function C)Chronic lung disease D)Slow onset of symptoms

A

Which is a primary nursing intervention in caring for a client with the diagnosis of bronchiectasis? A)Postural drainage B)Droplet precautions C)Preventative antibiotic use D)Administration of antitussives

A

What are the conditions that make up Virchow's triad? Select all that apply. A)Hypercoagulability B)Disruption of the vessel lining C)Hypocoagulability D)Edema E)Venostasis

A,B,E

In the prevention of silicosis, the nurse would direct preventative teaching to which high-risk occupations? Select all that apply. A)Baker B)Banker C)Rock quarry worker D)Nurse E)Welder F)Mechanic

A,C,E

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? A)Respiratory acidosis B)Paradoxical chest movement C)Chest pain on inspiration D)Clubbing of fingers and toes

B

Following a hip repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site? A)Deep veins of the legs B)Bone marrow C)Myocardial tissue D)Superior vena cava

B

The client with acute respiratory distress syndrome (ARDS) presents with severe hypoxemia, in spite of oxygen administration via face mask. The nurse would anticipate and prepare for which intervention? A)Intermittent positive pressure breathing B)Insertion of endotracheal tube C)Increasing oxygen to 12 to 15 L flow D)Insertion of chest tube

B

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? A)Clean the wound and leave open to the air. B)Apply vented dressing. C)Apply airtight dressing. D)Apply direct pressure to the wound

C

A client with chronic respiratory failure presents with a pH 7.28, PCO2 54 mm Hg, and HCO3- 25 mEq/L. The nurse recognizes this to indicate which finding? A)Respiratory alkalosis B)Metabolic alkalosis C)Respiratory acidosis D)Metabolic acidosis

C

A client with pulmonary hypertension asks the nurse to explain the heart changes that can occur with this disorder. Which is the best response? A)"I will ask your physician to discuss this with you." B)"Blood pressure is high as it leaves the heart." C)"The right side of the heart enlarges as pressure backs from the lungs." D)"The left side of the heart is not pumping well and blood backs into the lungs

C

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)Risk for Infection B)Impaired Gas Exchange C)Ineffective Airway Clearance D)Ineffective Breathing Pattern

C

The local public health department is holding a flu vaccine clinic. The health department recommends flu vaccinations for healthcare workers and people at high risk for complications or for those exposed daily to many different people. When using FluMist (live, attenuated influenza vaccine), what group is not approved? A)Children between 6 and 12 years of age B)People with hypersensitivity to milk products C)Adolescents who regularly take aspirin D)Adults 30 to 40 years of age

C

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? A)Reinsert the chest tube. B)Notify the physician. C)Cover the exit site. D)Apply oxygen via face mask

C

Which action should the nurse take first in caring for a client during an acute asthma attack? A)Obtain arterial blood gases. B)Send for STAT chest x-ray. C)Administer bronchodilator as ordered. D)Initiate oxygen therapy and reassess pulse oximetry in 10 minutes

C

You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? A)Aspiration B)Drug ingestion C)Chemical irritation D)Direct lung damage

C

You are preparing a client for emergency thoracic surgery. What would you document in your assessment? A)Emergency contacts B)IV fluids ordered C)General statement of the client's condition D)Detailed physical assessment

C

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? A)"Getting the flu can complicate pneumonia." B)"Influenza vaccine will prevent typical pneumonias." C)"Influenza is the major cause of death in the United States." D)"Viruses, like influenza, are the most common cause of pneumonia

D

The nurse knows the mortality rate is high in lung cancer clients due to which factor? A)Increase in women smokers B)Increased incidence among the elderly C)Increased exposure to industrial pollutants D)Few early symptoms

D

What is the reason for chest tubes after thoracic surgery? A)Draining secretions, air, and blood from the thoracic cavity is necessary. B)Chest tubes allow air into the pleural space. C)Chest tubes indicate when the lungs have reexpanded by ceasing to bubble. D)Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

A

When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly? A)Fluid rises and falls with respirations. B)Level of fluid is lowered in suction chamber. C)Fluid is bubbling vigorously. D)Fluid appears white and frothy

A

You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? A)Acute respiratory distress syndrome B)Lung cancer C)Bronchitis D)Tracheobronchitis

A

You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? A)Fibrotic changes in lungs B)Hemorrhage C)Lung contusion D)Damage to surrounding tissues

A

Upon assessing a client with emphysema, the nurse notes increased difficulty with inspiration. What is the likely cause of this finding? A)Prolonged tobacco use B)Rigid chest cage C)Saccular dilatation D)Inflammation of the bronchioles

B

Which of the following provides the best example of documentation for a client who is presenting with acute bronchitis? A)Physical activity seems to increase incidence of paroxysmal coughing. B)Expectorating moderate amounts of thick, green mucus. C)Dry, frequent cough with occasional production of sputum. D)Less crackles today. No cough or mucus noted.

B

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? A)"Early treatment can stop the progression of the disease." B)"The mucus-secreting glands are abnormal." C)"There are fibrous cysts in the lungs." D)"Allergic reactions cause inflammation in the lungs

B

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? A)"Chest tube will allow air to be restored to the lung." B)"The tube will drain secretions from the lung." C)"Chest tubes provide a route for medication instillation to the lung." D)"The tube will drain air from the space around the lung

D

When managing the postoperative pain after a pneumonectomy, the nurse is most concerned about which assessment data? A)Blood pressure 100/60 mm Hg B)Temperature 97.8° F C)Heart rate 100 beats/minute D)Respirations 10 breaths/minute

D

Which nursing assessment would alert a nurse to the development of a mediastinal shift, in a client with tension pneumothorax? A)Fluctuation of the fluid in the water-seal chamber B)Shift of rib cage toward affected side C)Sucking sound heard on inspiration and expiration D)Shift of trachea, esophagus, heart, and great vessels

D

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? A)Pain in the feet B)Inability to dorsiflex C)Negative Homan's sign D)Pain in the calf

D

You are caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? A)Mucopurulent sputum B)Pain on inspiration C)Obvious trauma D)Shortness of breath

A

The 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

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? A)Cough and dyspnea B)Black-streaked sputum C)Tenacious secretions D)Barrel chest

B

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? A)Skin around tube is pink. B)Bloody drainage is seemed in the collection chamber. C)Absence of bloody drainage in the anterior/upper tube D)Crackling is heard when skin around tube is touched

D