Ch 23
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? a) 5 - 15 ml b) No fluid normally is present c) 20 - 30 ml d) 15 - 25 ml
5 - 15 ml Under normal conditions, approximately 5 to 15 mL of fluid between the pleurae prevent friction during pleural surface movement.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 6 to 12 months b) 3 to 5 days c) 1 to 3 weeks d) 2 to 4 months
6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? a) Bradypnea b) Respiratory alkalosis c) Productive cough d) Blood-tinged sputum
Blood-tinged sputum The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.
An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion? a) Resonance upon percussion b) Decreased chest wall excursion upon palpation c) Mottling of the skin upon inspection d) Wheezing upon auscultation
Decreased chest wall excursion upon palpation Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area.
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a) Pulmonary contusion b) Flail chest c) Tension pneumothorax d) Cardiac tamponade
Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
A Class 1 with regards to TB indicates a) exposure and no evidence of infection. b) no exposure and no infection. c) disease that is not clinically active. d) latent infection with no disease.
exposure and no evidence of infection. Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active.
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) presence of a wheal at the injection site in 2 days indicates active tuberculosis. c) test stimulates a reddened response in some clients and requires a second test in 3 months. d) skin test doesn't differentiate between active and dormant tuberculosis infection.
skin test doesn't differentiate between active and dormant tuberculosis infection. The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis
Acute respiratory distress syndrome 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. Options A, C and D are incorrect.
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Acute respiratory distress syndrome b) Tracheobronchitis c) Lung cancer d) Bronchitis
Acute respiratory distress syndrome 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.
You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a) Direct lung damage b) Chemical irritation c) Aspiration d) Drug ingestion
Chemical irritation 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.
What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
Draining secretions, air, and blood from the thoracic cavity is necessary. After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.
Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions b) Encourage breathing exercises c) Do not allow visitors with respiratory infection d) Place suspected patients together
Encourage breathing exercises The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions and isolate suspected and confirmed influenza patients in private rooms or place suspected and confirmed patients together. The nurse does not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? a) Turning the client every 2 hours b) Maintaining a cool room temperature c) Encouraging increased fluid intake d) Elevating the head of the bed 30 degrees
Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperventilation, hypertension, and hypocapnia b) Hypercapnia, hypoventilation, and hypoxemia c) Hyperoxemia, hypocapnia, and hyperventilation d) Hypotension, hyperoxemia, and hypercapnia
Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Increase oxygen administration c) Intubate the patient and control breathing with mechanical ventilation d) Schedule the patient for pulmonary surgery
Intubate the patient and control breathing with mechanical ventilation A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate.
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Report the finding to the physician immediately b) Record the observation c) Measure the patient's pulse oximetry d) Apply a compression dressing to the area
Record the observation Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes.
The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? a) Headache b) Shortness of breath c) Fever d) Weight loss
Shortness of breath Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.
The most diagnostic clinical symptom of pleurisy is: a) Stabbing pain during respiratory movements. b) Dullness or flatness on percussion over areas of collected fluid. c) Fever and chills. d) Dyspnea and coughing.
Stabbing pain during respiratory movements. The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.
The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin D b) Vitamin C c) Vitamin B6 d) Vitamin E
Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient? a) "Only wear your contact lenses during the day and take them out in the evening before bed." b) "The physician can give you eye drops to prevent any problems." c) "You should switch to wearing your glasses while taking this medication." d) "There are no significant problems with wearing contact lenses."
"You should switch to wearing your glasses while taking this medication." The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client with a nasogastric tube b) A client who ambulates in the hallway every 4 hours c) A client who is receiving acetaminophen (Tylenol) for pain d) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago
A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Sore throat and abdominal pain b) Dyspnea and wheezing c) Hemoptysis and dysuria d) Nonproductive cough and normal temperature
Dyspnea and wheezing In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? a) Lung contusion b) Damage to surrounding tissues c) Hemorrhage d) Fibrotic changes in lungs
Fibrotic changes in lungs 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.
You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? a) Insist on adequate breaks for each employee. b) Fit all employees with protective masks. c) Give workshops on disease prevention. d) Provide employees with smoking cessation materials.
Fit all employees with protective masks. The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Impaired gas exchange b) Anxiety c) Ineffective tissue perfusion (cardiopulmonary) d) Decreased cardiac output
Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? a) Hypothermia will occur b) It is spread by fecal contamination c) It is the most contagious during the second week of illness d) Constipation usually develops
It is the most contagious during the second week of illness Based on available information, SARS is most likely to be contagious only when symptoms are present, and patients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.
The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Large cell carcinoma b) Squamous cell carcinoma c) Adenocarcinoma d) Bronchoalveolar carcinoma
Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Respiratory acidosis b) Clubbing of fingers and toes c) Chest pain on inspiration d) Paradoxical chest movement
Paradoxical chest movement Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall 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.
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? a) Progressive loss of lung function associated with chronic disease b) Sudden loss of lung function associated with chronic disease c) Progressive loss of lung function with history of normal lung function d) Sudden loss of lung function with history of normal lung function
Progressive loss of lung function associated with chronic disease In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.
The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Inspiratory crackles b) Rapid onset of severe dyspnea c) Cyanosis d) Bilateral wheezing
Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. b) The client exhibits restlessness and confusion. c) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. d) The client exhibits bronchial breath sounds over the affected area.
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.36, PaCO2 32 mm Hg b) pH 7.46, PaO2 80 mm Hg c) pH 7.35, PaCO2 48 mm Hg d) pH 7.28, PaO2 50 mm Hg
pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.
A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? a) Silica b) Pollen c) Coal dust d) Asbestos
Asbestos Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? a) Ascites b) Syncope c) Hypertension d) Dyspnea
Dyspnea Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of rightsided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Impaired tissue integrity. b) Risk for falls. c) Ineffective airway clearance. d) Ineffective breathing pattern.
Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pulmonary embolism b) Heart failure c) Myocardial infarction (MI) d) Pneumothorax
Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." b) "You must consume a diet low in fat by limiting dairy products and concentrated sweets." c) "You must consume a diet rich in protein, such as chicken, fish, and beans." d) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables."
"You must consume a diet rich in protein, such as chicken, fish, and beans." For a patient with a lung abscess the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer b) Administering pain medications, frequent repositioning, and limiting fluid intake c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer d) Administering oxygen, coughing, breathing deeply, and maintaining bed rest
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.
A mediastinal shift occurs in which type of chest disorder? a) Traumatic pneumothorax b) Tension pneumothorax c) Simple pneumothorax d) Cardiac tamponade
Tension pneumothorax A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.
Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall? a) Use a prescribed analgesic. b) Use a heat or cold application. c) Turn onto affected side. d) Avoid using a pillow while splinting.
Turn onto affected side. Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.
What are the conditions that make up Virchow's triad? Select all that apply. a) Hypocoagulability b) Hypercoagulability c) Edema d) Venostasis e) Disruption of the vessel lining
• Hypercoagulability • Disruption of the vessel lining • Venostasis 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.