Nokea
Which entry by the nurse into the medical record is appropriate for a client who presents with symptoms indicative of acute bronchitis?
- A. Physical activity seems to increase incidence of paroxysmal coughing
- B. Frequent cough with sputum production noted
- C. Dry, irritating, nonproductive cough noted
- D. Fewer crackles today. No cough or mucus noted
Correct Answer: C
Rationale: Clinical manifestations indicative of acute bronchitis include fever, chills, malaise, headache, and a dry, irritating, nonproductive cough; therefore, the entry made into the client's medical record that is indicative of this respiratory disorder is as follows: Dry, irritating, nonproductive cough noted. 'Physical activity seems to increase incidence of paroxysmal coughing' is a judgment and not an observation. A frequent cough with sputum production is not anticipated for a client who is suspected of experiencing acute bronchitis; additionally, there is no description of the client's sputum, which is required when documenting objective client data. Documenting fewer crackles today does not provide enough detail and is not measurable.
You may also like to solve these questions
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.
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.
The nurse is caring for a client diagnosed with bronchiectasis. Which is a primary nursing intervention in caring for this client?
- A. Postural drainage
- B. Droplet precautions
- C. Preventative antibiotic use
- D. Administration of antitussives
Correct Answer: A
Rationale: Management of bronchiectasis focuses on postural drainage and the movement of secretions out of the dilated sacs of the bronchioles. Bronchiectasis is not contagious or spread through droplets. The presence of infection is treated with selective antibiotics, but long-term preventative treatment with antibiotics is not protocol. Suppressing the cough mechanism with use of antitussives would be counterproductive in the management of bronchiectasis.
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?
- A. Early treatment can stop the progression of the disease
- B. The mucus-secreting glands are abnormal
- C. There are fibrous cysts in the lungs
- D. Allergic reactions cause inflammation in the lungs
Correct Answer: B
Rationale: Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.
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.