ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 23 : Management of Patients with Chest and Lower Respiratory Tract Disorders Questions
Question 1 of 5
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
Correct Answer: A
Rationale: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.
Question 2 of 5
The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology?
Correct Answer: B
Rationale: Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.
Question 3 of 5
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?
Correct Answer: A
Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPP
B), or bronchoscopy may be used.
Question 4 of 5
While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care?
Correct Answer: A
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. A soft diet is not necessarily indicated and there is no need for the patient to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.
Question 5 of 5
The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)?
Correct Answer: A
Rationale: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patients risk for bleeding.