ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 21 : Caring for Clients With Lower Respiratory Disorders Questions
Question 1 of 5
A client admitted for the treatment of venous thromboembolism reports chest pain and dyspnea. Which of the following is the primary intervention for the nurse to implement?
Correct Answer: A
Rationale: Based on the client's symptoms, the nurse suspects pulmonary embolism (PE). Emergency intervention is required to decrease the client's risk for death; therefore, the priority intervention is the application of oxygen. Although managing the client's pain is important this is not the priority intervention. The client may be prescribed a ventilation-perfusion scan and pulmonary angiography but these actions are not the priority interventions by the nurse. Application of compression stockings is ideal for preventing pulmonary emboli in high-risk clients but not an appropriate intervention after occurrence.
Question 2 of 5
The nurse identifies which finding to be most consistent prior to the onset of acute respiratory failure?
Correct Answer: A
Rationale: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.
Question 3 of 5
The client diagnosed with acute respiratory distress syndrome (ARDS) presents with severe hypoxemia, despite oxygen administration via face mask. The nurse anticipates and prepares for which prescription from the health care provider (HCP)?
Correct Answer: C
Rationale:
To maintain the client's airway, an ET tube or tracheostomy tube will be inserted for administration of mechanical ventilation. Mechanical ventilation uses positive end-expiratory pressure (PEEP), not IPPB. The use of IPPB is appropriate for respiratory failure, not ARDS. Because the client is not experiencing a pneumothorax based on the clinical manifestations, a chest tube is not indicated for reinflation. Increasing the oxygen flow rate via mask does not maintain patency of the airway; however, the use of mechanical ventilation is supported for this purpose.
Question 4 of 5
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
Correct Answer: D
Rationale: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.
Question 5 of 5
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?
Correct Answer: B
Rationale: 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.