Nokea
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?
- A. I will ask your physician to discuss this with you
- B. Blood pressure is high as it leaves the heart
- C. The right side of the heart enlarges as pressure backs up from the lungs
- D. The left side of the heart is not pumping well and blood backs into the lungs
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.
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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 nurse identifies which finding to be most consistent prior to the onset of acute respiratory failure?
- A. Normal lung function
- B. Loss of lung function
- C. Chronic lung disease
- D. Slow onset of symptoms
Correct Answer: A
Rationale: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.
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)?
- A. Intermittent positive pressure breathing (IPPB)
- B. Increasing oxygen to 12 to 15 L flow
- C. Insertion of endotracheal (ET) tube
- D. Insertion of chest tube
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.
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 caring for a 2-year-old child who experienced near-drowning. The nurse will monitor for what possible complication?
- A. Atelectasis
- B. Acute respiratory distress syndrome
- C. Metabolic alkalosis
- D. Respiratory acidosis
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.