ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 19 : Introduction to the Respiratory System Questions
Question 1 of 5
A client presents to the emergency department in respiratory compromise. The client's temperature is 102.4?°F, heart rate 88 beats/minute and regular, and blood pressure 138/76 mm Hg. The client is dyspneic, pale, and expectorating green-tinged sputum. The physician orders medications including antibiotics, antipyretics, nebulizer treatments, and IV fluids. A chest x-ray and sputum culture are to be completed. Which physician order would the nurse complete before beginning antibiotic therapy?
Correct Answer: B
Rationale: The nurse would obtain a sputum culture for sensitivity before beginning antibiotic therapy. Obtaining a sputum culture after beginning antibiotics can skew results. Once the sputum culture results are returned, the antibiotic can be closely aligned to kill the organism, if present. The other orders can be prioritized according to client needs.
Question 2 of 5
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
Correct Answer: A
Rationale: Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.
Question 3 of 5
A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?
Correct Answer: D
Rationale: During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
Question 4 of 5
The nurse is caring for a client who states, 'I am really worried about the thoracentesis. I know I won't be able to sleep tonight.' Which statement is most helpful to the client at this time?
Correct Answer: A
Rationale: A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client expresses being worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the client makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.
Question 5 of 5
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
Correct Answer: B
Rationale: Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.