Nokea
A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?
- A. Clean the wound and leave open to the air
- B. Apply vented dressing
- C. Apply airtight dressing
- D. Apply direct pressure to the wound
Correct Answer: C
Rationale: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted.
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In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupation(s)? Select all that apply.
- A. Banker
- B. Rock quarry worker
- C. Nurse
- D. Miner
- E. Mechanic
- F. Stone cutter
Correct Answer: B,D,F
Rationale: A quarry worker and stone cutter are exposed to rock dust and silica. A miner can inhale dust, causing silicosis or pneumoconiosis. A banker, nurse, and mechanic may have work hazards, but none specific to the development of an occupational lung disease.
A client admitted for the treatment of venous thromboembolism reports chest pain and dyspnea. Which of the following is the primary intervention for the nurse to implement?
- A. Apply oxygen, as prescribed
- B. Assess and rate the chest pain
- C. Apply compression stockings
- D. Prepare for ventilation-perfusion scan
Correct Answer: A
Rationale: Based on the client's symptoms, the nurse suspects pulmonary embolism (PE). Emergency intervention is required to decrease the client's risk for death; therefore, the priority intervention is the application of oxygen. Although managing the client's pain is important this is not the priority intervention. The client may be prescribed a ventilation-perfusion scan and pulmonary angiography but these actions are not the priority interventions by the nurse. Application of compression stockings is ideal for preventing pulmonary emboli in high-risk clients but not an appropriate intervention after occurrence.
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.
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?
- A. Aspiration
- B. Drug ingestion
- C. Chemical irritation
- D. Direct lung damage
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.
When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly?
- A. Fluid rises and falls with respirations
- B. Level of fluid is lowered in suction chamber
- C. Fluid is bubbling vigorously
- D. Fluid appears white and frothy
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.