Chapter 21: Caring for Clients with Lower Respiratory Disorders

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care.

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema

Encourage breathing exercises.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?

Encourage breathing exercises.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

Pulmonary hypertension

A client is brought to the ED after aspirating large amounts of water and nearly drowning. This client is at risk for which complication as a result of this recent trauma?

acute respiratory distress syndrome (ARDS)

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

acute respiratory distress syndrome (ARDS).

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

pleural effusion.

When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of hypoxemia?

PaO2 < 60 mm Hg

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

Tense and relax muscles in the lower extremities.

What dietary recommendations should a nurse provide a client with a lung abscess?

A diet rich in protein

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:

asbestos.

A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside?

Monitor pulse oximetry readings.

The most diagnostic clinical symptom of pleurisy is:

Stabbing pain during respiratory movements.

The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement by the client should prompt the nurse to refer the client for further assessment?

"Lately, I have this cough that just never seems to go away.

A client has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the client asks the nurse how the treatment is decided upon. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the client's health status."

A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?

"The younger you are when you start smoking, the higher your risk of lung cancer."

A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend?

"Wear protective attire and devices when working with a toxic substance."

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?

6 to 12 months

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem?

Acute respiratory failure

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?

Administer intradermal injections into each child's inner forearm.

Which of the following would be inconsistent with the respiratory system mechanisms leading to acute respiratory failure (ARF)?

Decreased dead space

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax

Diminished or absent breath sounds on the affected side

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?

Early ambulation and the use of compression stockings

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate?

Fluid has built up between your lungs and the lining that surrounds your lungs."

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange

A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized?

Impaired gas exchange

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?

Increase oral fluids unless contraindicated.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client'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 help the client breathe more easily?

Intubate the client and control breathing with mechanical ventilation

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?

You must consume a diet rich in protein, such as chicken, fish, and beans."

A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply.

evel of consciousness Arterial blood gases Vital signs

Preventing falls in older adults directly correlates to preventing bone fractures. If an older adult falls and fractures one or more ribs, what is a possible complication that could develop after the fracture?

pneumonia