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
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?
Correct Answer: C
Rationale: The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Infection Risk 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.
Question 2 of 5
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
Correct Answer: D
Rationale: Influenza type A is a 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.
Question 3 of 5
The nurse is caring for a client diagnosed with bronchiectasis. Which is a primary nursing intervention in caring for this client?
Correct Answer: A
Rationale: 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.
Question 4 of 5
Upon assessing a client with emphysema, the nurse notes increased difficulty with inspiration. What is the likely cause of this finding?
Correct Answer: B
Rationale: 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.
Question 5 of 5
Which action should the nurse take first when providing care for a client during an acute asthma attack?
Correct Answer: C
Rationale: Administering a short-acting bronchodilator will dilate the airway and enable oxygen to reach the lungs. Although ABGs and a chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute asthma attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.