Nokea
The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?
- A. Skin around tube is pink
- B. Bloody drainage is observed in the collection chamber
- C. Absence of bloody drainage in the anterior/upper tube
- D. The tissues give a crackling sensation when palpated
Correct Answer: D
Rationale: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.
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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.
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.
The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?
- A. Emergency contacts
- B. IV fluids ordered
- C. General statement of the client's condition
- D. Detailed physical assessment
Correct Answer: C
Rationale: If the surgery is an emergency, physical assessment may be limited to a general statement of the client's condition, a list of emergency measures and treatments done, and vital signs. The nurse would not document emergency contacts or a detailed physical assessment. The nurse would document the IV fluids running and not any that are ordered.
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.
Upon assessing a client with emphysema, the nurse notes increased difficulty with inspiration. What is the likely cause of this finding?
- A. Prolonged tobacco use
- B. Rigid chest cage
- C. Saccular dilatation
- D. Inflammation of the bronchioles
Correct Answer: B
Rationale: Fibrous scarring in the alveolar walls occurs with progressive emphysema and results in a rigid chest cage and inspiration difficulty. Smoking can contribute to the destruction of lung function but is not significant for the difficulty in inspiration. Saccular dilation is a symptom of bronchiectasis. Emphysema is a chronic disease not an inflammatory condition.