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 entry by the nurse into the medical record is appropriate for a client who presents with symptoms indicative of acute bronchitis?
Correct Answer: C
Rationale: Clinical manifestations indicative of acute bronchitis include fever, chills, malaise, headache, and a dry, irritating, nonproductive cough; therefore, the entry made into the client's medical record that is indicative of this respiratory disorder is as follows: Dry, irritating, nonproductive cough noted. 'Physical activity seems to increase incidence of paroxysmal coughing' is a judgment and not an observation. A frequent cough with sputum production is not anticipated for a client who is suspected of experiencing acute bronchitis; additionally, there is no description of the client's sputum, which is required when documenting objective client data. Documenting fewer crackles today does not provide enough detail and is not measurable.
Question 2 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 3 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 4 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 5 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.