Questions 30

ATI LPN

ATI LPN TextBook-Based Test Bank

Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition

Chapter 21 Questions

Question 1 of 5

When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly?

Correct Answer: A

Rationale: Fluctuation of fluid in the water-sealed chamber is initially present with each respiration. The level of fluid in the suction chamber should be maintained to initial level. Excessive or vigorous bubbling can indicate a leak in the system. The fluid in the chamber is clear.

Question 2 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.

Question 3 of 5

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Correct Answer: D

Rationale: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

Question 4 of 5

The nurse is caring for a 2-year-old child who experienced near-drowning. The nurse will monitor for what possible complication?

Correct Answer: B

Rationale: Factors associated with the development of acute respiratory distress syndrome 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. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.

Question 5 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.

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