Lower Respiratory Conditions(Exam 3)
Bone marrow
Following a femur fracture surgical repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?
"The tube will drain air from the space around the lung."
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?
Rigid chest cage
Upon assessing a client with emphysema, the nurse notes increased difficulty with inspiration. What is the likely cause of this finding?
Shift of trachea, esophagus, heart, and great vessels
Which nursing assessment would alert a nurse to the development of a mediastinal shift, in a client with tension pneumothorax?
Apply airtight dressing.
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?
Paradoxical chest movement
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?
rock quarry worker miner
In the prevention of occupational lung diseases, the nurse would direct preventative teaching to which high-risk occupations? Select all that apply. A. rock quarry worker B. miner C. mechanic D. banker E. nurse
Acute respiratory distress syndrome
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?
Crackles in the bases
The client has been self-medicating with antitussives. Which assessment finding would alert the nurse to an adverse effect of this medication?
chemical irritation
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?
Acute respiratory distress syndrome
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Normal lung function
The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress?
venostasis hypercoagulability disruption of the vessel lining
What are the conditions that make up Virchow's triad? Select all that apply. A. venostasis B. hypercoagulability C. hypocoagulability D. disruption of the vessel lining E. edema
Draining secretions, air, and blood from the thoracic cavity is necessary.
What is the reason for chest tubes after thoracic surgery?
Fibrotic changes in lungs
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?
Respirations 10 breaths/minute
When managing the postoperative pain after a pneumonectomy, the nurse is most concerned about which assessment data?
"The right side of the heart enlarges as pressure backs from the lungs."
A client with pulmonary hypertension asks the nurse to explain the heart changes that can occur with this disorder. Which is the best response?
"Viruses, like influenza, are the most common cause of pneumonia."
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?
Apply oxygen via face mask.
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?
Insertion of endotracheal tube
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?
Ineffective Airway Clearance
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?
Localized calf tenderness
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Mucopurulent sputum
The nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Cover the exit site.
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?
Black-streaked sputum
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?
General statement of the client's condition
The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?
Few early symptoms
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
Fluid rises and falls with respirations.
When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly?
Administer bronchodilator as ordered.
Which action should the nurse take first in caring for a client during an acute asthma attack?
Postural drainage
Which is a primary nursing intervention in caring for a client with the diagnosis of bronchiectasis?
Expectorating moderate amounts of thick, green mucus.
Which of the following provides the best example of documentation for a client who is presenting with acute bronchitis?
"The mucus-secreting glands are abnormal."
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?
Crackling is heard when skin around tube is touched.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?
