Nokea
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.
You may also like to solve these questions
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.
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.
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
- A. Acute respiratory distress syndrome
- B. Lung cancer
- C. Bronchitis
- D. Tracheobronchitis
Correct Answer: A
Rationale: Factors associated with the development of ARDS 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. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.
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 nurse is caring for a client diagnosed with bronchiectasis. Which is a primary nursing intervention in caring for this client?
- A. Postural drainage
- B. Droplet precautions
- C. Preventative antibiotic use
- D. Administration of antitussives
Correct Answer: A
Rationale: Management of bronchiectasis focuses on postural drainage and the movement of secretions out of the dilated sacs of the bronchioles. Bronchiectasis is not contagious or spread through droplets. The presence of infection is treated with selective antibiotics, but long-term preventative treatment with antibiotics is not protocol. Suppressing the cough mechanism with use of antitussives would be counterproductive in the management of bronchiectasis.