Nokea
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.
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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.
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.
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.
What is the reason for chest tubes after thoracic surgery?
- A. Draining secretions, air, and blood from the thoracic cavity
- B. Allowing air into the pleural space
- C. Indicating when the lungs have re-expanded by ceasing to bubble
- D. Draining secretions and blood while allowing air to remain in the thoracic cavity
Correct Answer: A
Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. Allowing air into the pleural space, indicating when lungs have re-expanded, and draining secretions and blood while air remains in the thoracic cavity are not the reasons for chest tubes after thoracic surgery.
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.