chapter 21

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

"The mucus-secreting glands are abnormal."

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."

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."

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."

What is the reason for chest tube's after thoracic surgery?

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

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.

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?

Respiratory acidosis

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 great vessels

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?

adolescents who regularly take aspirin

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

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

baker rock-quarry worker welder

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

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

bone marrow

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?

chemical irritation

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

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

few early symptoms

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

hypercoagulability disruption of vessel lining edema

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?

ineffective airway clearance

You are caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

mucopurulent sputum

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

normal lung function

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

pain in the calf

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

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

acute respiratory distress sydrome

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?

acute respiratory distress syndrome

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

administer bronchodilater as ordered

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

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

respirations 10 breaths/minute

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

rigid chest cage

. 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 base

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

fluid rises and falls with respiration

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?

fibrotic changes in lungs

. You are preparing a client for emergency thoracic surgery. What would you document in your assessment?

general statement of clients condition

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

cracking is heard when skin around tube is touched

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

postural drainage

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?

insertion of endotracheal tube