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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.
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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.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
- A. Pain in the feet
- B. Coolness to lower extremities
- C. Decreased urinary output
- D. LocalizedFixed calf tenderness
Correct Answer: D
Rationale: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
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 action should the nurse take first when providing care for a client during an acute asthma attack?
- A. Send for STAT chest x-ray
- B. Obtain arterial blood gases (ABGs)
- C. Administer prescribed short-acting bronchodilator
- D. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes
Correct Answer: C
Rationale: Administering a short-acting bronchodilator will dilate the airway and enable oxygen to reach the lungs. Although ABGs and a chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute asthma attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.
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.