Test Bank NSG 210 Caring for Clients With Lower Respiratory Disorder with Rationale,100% CORRECT

Test Bank NSG 210 Caring for Clients With Lower Respiratory Disorder with Rationale 1. 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 Ans: C Feedback: Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. 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. 2. 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 Ans: A Feedback: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries. 3. 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 Ans: D Feedback: When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis. 4. 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 Ans: A Feedback: For a client with lung cancer, a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders but are not considered indicative of lung cancer. 5. 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 Ans: C Feedback: FluMist is a live and attenuated influenza vaccine administered intranasally. It is not approved for various categories of people, including adolescents who regularly take aspirin, children younger than 5 years of age, adults above 50 years of age, and people with a hypersensitivity to eggs. 6. 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 Ans: A Feedback: 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. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis. 7. 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 Ans: C Feedback: If the surgery is an emergency, physical assessment may be limited to a general statement of the client's condition, a list of emergency measures and treatments done, and vital signs. You would not document emergency contacts or a detailed physical assessment. You would document the IV fluids running and not any that are ordered. 8. 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. Ans: A Feedback: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D incorrect. 9. 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 Ans: A, B, E Feedback: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad. 10. 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 Ans: B Feedback: 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. 11. 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. Ans: B Feedback: Moderate amount of thick, green mucus provides amount of sputum and description. Physical activity seems to increase is a judgment not an observation. Dry, frequent cough is descriptive, but the sputum is not described. Less crackles today does not provide enough detail and is not measureable. 12. 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 Ans: C Feedback: 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. 13.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.” Ans: D Feedback: Influenza type A is the most common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States. 14. 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 Ans: A Feedback: The indiscriminate use of antitussives can cause more harm by suppressing the cough mechanism and allowing secretions to pool in the bases of the lungs. Antitussives decrease coughing and do not have antipyretic properties. Nausea and vomiting is a common adverse effect for many drugs but is not a finding that places the nurse on alert. 15. 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 Ans: A Feedback: Management of bronchiectasis focuses on postural drainage and the movement of secretions out of the dilated sacs of the bronchioles. Bronchiectasis is not contagious or spread through droplets. The presence of infection is treated with selective antibiotics, but long-term preventative treatment with antibiotics is not protocol. Suppressing the cough mechanism with use of antitussives would be counterproductive in the management of bronchiectasis. 16. 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 Ans: B Feedback: Fibrous scarring in the alveolar walls occurs with progressive emphysema and results in a rigid chest cage and inspiration difficulty. Smoking can contribute to the destruction of lung function but is not significant for the difficulty in inspiration. Saccular dilation is a symptom of bronchiectasis. Emphysema is a chronic disease not an inflammatory condition. 17. 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. Ans: C Feedback: Administering bronchodilator will dilate the airway and allow oxygen to reach the lungs. Although ABGs and chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack. 18. 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.” Ans: B Feedback: Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis. 19. 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 Ans: B Feedback: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time. 20. 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 Ans: A, C, E Feedback: A baker is exposed to dust from flour. A quarry worker is exposed to rock dust and silica. A welder is exposed to gases and fumes that can be inhaled and result in silicosis. A banker, nurse, and mechanic may have work hazards but not specific to the development of silicosis. 21.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.” Ans: C Feedback: In primary pulmonary hypertension, there is increased resistance and pressure in the pulmonary vascular bed, which places strain on the right ventricle and causes enlargement. To increase understanding of a disorder, the nurse should take time to answer questions presented. The blood pressure is highest in the pulmonary arteries and right ventricle of the heart, not on the left side of the heart or where the blood enters the general circulation. 22. 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 Ans: B Feedback: A fat embolus usually occurs after a fracture or repair to the long bones. Pulmonary emboli may arise from the endocardium of the right side of the heart, but a myocardial infarction has not been identified in this client. The deep veins of the legs are a common site for emboli formation especially with prolonged inactivity or thrombophlebitis, which does not apply to this client. 23. 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. Ans: A Feedback: Maintaining patency of the airway and promoting oxygen concentration to the tissues of the lung are paramount in the management of pulmonary embolus. Managing the pain is important but not the primary intervention. The client may be ordered a ventilation- perfusion scan and pulmonary angiography but not the priority intervention. Application of compression stockings is ideal for preventing pulmonary emboli in high-risk clients but not an intervention after occurrence. 24. 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 Ans: A Feedback: Acute respiratory failure occurs suddenly in clients who previously had normal lung function. 25.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 Ans: C Feedback: A pH of less than 7.35 indicates acidosis. With a high PCO2 and normal HCO3– indicates the lungs are the cause of the acidosis—respiratory acidosis. In metabolic acidosis, the PCO2 would be normal, but the HCO – would be low. 26. 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 Ans: B Feedback: To maintain airway, an endotracheal tube or tracheostomy tube will be inserted for administration of mechanical ventilation. Mechanical ventilation uses positive end- expiratory pressure (PEEP), not IPPB. Because the lungs are not collapsed, a chest tube is not indicated for reinflation. Increasing the oxygen flow rate via mask does not maintain patency of the airway and can place the client at risk for ocular damage. 27. 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 Ans: D Feedback: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to increase in number of women smokers, growing aging population, and exposure to pollutants but not indicative of mortality rates. 28.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 Ans: B Feedback: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia. 29.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. Ans: C Feedback: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted. 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? 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.” Ans: D Feedback: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity. 31. 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. Ans: C Feedback: Air entering the cavity will allow further collapse of the lung. Applying a dressing or covering the site will minimize the amount of air entering the cavity. The nurse would notify the physician for reinsertion of the tube but not the immediate action to take. Applying oxygen may be necessary to eliminate symptoms of hypoxia after wound is sealed. 32. 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 Ans: D Feedback: In a tension pneumothorax, the air is sucked into the pleural cavity and cannot escape. The air accumulates and pushes the trachea, esophagus, heart, and great vessels toward the unaffected side. Fluctuation of the fluid in the water-seal chamber is an expected finding. There may be a paradoxical movement of the ribs but not a shifting to the side. A sucking sound may be heard with a pneumothorax, but air moves in and cannot escape out. 33. 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. Ans: A Feedback: Fluctuation of fluid in the water-sealed chamber is initially present with each respiration. The level of fluid in the suction chamber should be maintained to initial level. Excessive or vigorous bubbling can indicate a leak in the system. The fluid in the chamber is clear. 34. 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. Ans: D Feedback: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers not serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal. 35. 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 Ans: D Feedback: The use of narcotics can further depress respirations. Respirations below 10 breaths/minute should be reported immediately to the physician, and the nurse would hold the medication for pain. Blood loss during surgery can result in symptoms of tachycardia and lower blood pressure, but these findings are not outside the range of what is expected outcome. A lower body temperature may be a result of anesthesia and environmental factors from the operating suite and are not outside the expected norm for this situation.