Nokea
The nurse identifies which finding to be most consistent prior to the onset of acute respiratory failure?
- A. Normal lung function
- B. Loss of lung function
- C. Chronic lung disease
- D. Slow onset of symptoms
Correct Answer: A
Rationale: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.
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What are the condition(s) that make up Virchow's triad? Select all that apply.
- A. Hypercoagulability
- B. Disruption of the vessel lining
- C. Hypocoagulability
- D. Edema
- E. Venostasis
Correct Answer: A,B,E
Rationale: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad.
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.
What might be revealed by a chest radiograph for a client with occupational lung diseases?
- A. Fibrotic changes in lungs
- B. Hemorrhage
- C. Lung contusion
- D. Damage to surrounding tissues
Correct Answer: A
Rationale: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
- A. Getting the flu can complicate pneumonia
- B. Influenza vaccine will prevent typical pneumonias
- C. Influenza is the major cause of death in the United States
- D. Viruses like influenza are the most common cause of pneumonia
Correct Answer: D
Rationale: Influenza type A is a common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.
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.