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 with pulmonary hypertension asks the nurse to explain the heart changes that can occur with this disorder. Which is the best response by the nurse?
Correct Answer: C
Rationale: 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.
Question 2 of 5
Following a hip repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?
Correct Answer: B
Rationale: 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.
Question 3 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 4 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 5 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.