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
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.
Question 2 of 5
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?
Correct Answer: B
Rationale: Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.
Question 3 of 5
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?
Correct Answer: B
Rationale: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time.
Question 4 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 5 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.