Nokea
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
- A. Getting the flu can complicate pneumonia
- B. Influenza vaccine will prevent typical pneumonias
- C. Influenza is the major cause of death in the United States
- D. Viruses like influenza are the most common cause of pneumonia
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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Which entry by the nurse into the medical record is appropriate for a client who presents with symptoms indicative of acute bronchitis?
- A. Physical activity seems to increase incidence of paroxysmal coughing
- B. Frequent cough with sputum production noted
- C. Dry, irritating, nonproductive cough noted
- D. Fewer crackles today. No cough or mucus noted
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.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
- A. Pain in the feet
- B. Coolness to lower extremities
- C. Decreased urinary output
- D. LocalizedFixed calf tenderness
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.
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?
- A. Respiratory acidosis
- B. Paradoxical chest movement
- C. Chest pain on inspiration
- D. Clubbing of fingers and toes
Correct Answer: B
Rationale: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.
The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?
- A. Skin around tube is pink
- B. Bloody drainage is observed in the collection chamber
- C. Absence of bloody drainage in the anterior/upper tube
- D. The tissues give a crackling sensation when palpated
Correct Answer: D
Rationale: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?
- A. The tube will allow air to be restored to the lung
- B. The tube will drain secretions from the lung
- C. The tube will provide a route for medication instillation to the lung
- D. The tube will drain air from the space around the lung
Correct Answer: D
Rationale: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.