Nokea
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.
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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.
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.
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.
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.
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.