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 ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
Correct Answer: A
Rationale: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.
Question 2 of 5
The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?
Correct Answer: C
Rationale: Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.
Question 3 of 5
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Correct Answer: D
Rationale: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
Question 4 of 5
The nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Correct Answer: A
Rationale: For a client with lung cancer, a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders but are not considered indicative of lung cancer.
Question 5 of 5
The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?
Correct Answer: C
Rationale: If the surgery is an emergency, physical assessment may be limited to a general statement of the client's condition, a list of emergency measures and treatments done, and vital signs. The nurse would not document emergency contacts or a detailed physical assessment. The nurse would document the IV fluids running and not any that are ordered.