Nokea
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.
You may also like to solve these questions
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 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.
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?
- A. Early treatment can stop the progression of the disease
- B. The mucus-secreting glands are abnormal
- C. There are fibrous cysts in the lungs
- D. Allergic reactions cause inflammation in the lungs
Correct Answer: B
Rationale: Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.
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.
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?
- A. Infection Risk
- B. Impaired Gas Exchange
- C. Ineffective Airway Clearance
- D. Altered Breathing Pattern
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.