Nokea
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.
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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.
The nurse is caring for a 2-year-old child who experienced near-drowning. The nurse will monitor for what possible complication?
- A. Atelectasis
- B. Acute respiratory distress syndrome
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Factors associated with the development of acute respiratory distress syndrome 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. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.
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.
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
- A. Increase in women smokers
- B. Increased incidence among the elderly
- C. Increased exposure to industrial pollutants
- D. Few early symptoms
Correct Answer: D
Rationale: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.