Nokea
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
- A. A resident who suffered a severe stroke several weeks ago
- B. A resident with mid-stage Alzheimers disease
- C. A 92-year-old resident who needs extensive help with ADLs
- D. A resident with severe and deforming rheumatoid arthritis
Correct Answer: A
Rationale: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.
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The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?
- A. Pulmonary hypotension due to decreased cardiac output
- B. Severe and progressive pulmonary hypertension
- C. Hypovolemia secondary to leakage of fluid into the interstitial spaces
- D. Increased cardiac output from high levels of PEEP therapy
Correct Answer: C
Rationale: Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.
A client presents to the walk-in clinic complaining of a dry, irritating cough and production of a minute amount of mucus-like sputum. The patient complains of soreness in her chest in the sternal area. The nurse should suspect that the primary care provider will assess the patient for what health problem?
- A. Pleural effusion
- B. Pulmonary embolism
- C. Tracheobronchitis
- D. Tuberculosis
Correct Answer: C
Rationale: Initially, the patient with tracheobronchitis has a dry, irritating cough and expectorates a scant amount of mucoid sputum. The patient may report sternal soreness from coughing and have fever or chills, night sweats, headache, and general malaise. Pleural effusion and pulmonary embolism do not normally cause sputum production and would likely cause acute shortness of breath. Hemoptysis is characteristic of TB.
An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care?
- A. Nasogastric intubation
- B. Administration of probiotic supplements
- C. Bedrest
- D. Cautious hydration
Correct Answer: D
Rationale: Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the patient.
A patient who was involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care?
- A. Facilitation of long-term intubation
- B. Restoration of adequate gas exchange
- C. Attainment of effective coping
- D. Self-management of oxygen therapy
Correct Answer: B
Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.
When assessing for substances that are known to harm workers lungs, the occupational health nurse should assess their potential exposure to which of the following?
- A. Organic acids
- B. Propane
- C. Asbestos
- D. Gypsum
Correct Answer: C
Rationale: Asbestos is among the more common causes of pneumoconiosis. Organic acids, propane, and gypsum do not have this effect.