Chapter 23: Management of Patients with Chest and Lower Respiratory Tract Disorders

The most diagnostic clinical symptom of pleurisy is: A.) Dullness or flatness on percussion over areas of collected fluid. B.) Dyspnea and coughing. C.) Fever and chills. D.) Stabbing pain during respiratory movements.

ANswer: D.) Stabbing pain during respiratory movements. Rationale: 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.

A nurse assesses a client with pneumonia. Which assessments are diagnostic for pneumonia? Select all that apply. - Presence of crackles - Egophony - Friction rubs - Wheezes - Whispered pectoriloquy - Percussion dullness

Answer: - Presence of crackles - Egophony - Wheezes - Whispered pectoriloquy - Percussion dullness Rationale: Physical examination findings may reveal bronchial breath sounds over consolidated lung areas: soft, high-pitched crackles, inspiratory vesicular sounds that are longer than expired normal breath sounds, increased tactile fremitus (vocal vibration detected on palpation), percussion dullness, egophony, wheezing, and whispered pectoriloquy (whispered sounds are easily auscultated through the chest wall). Friction rubs are not common assessment findings for clients with pneumonia.

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? A.) "You must consume a diet rich in protein, such as chicken, fish, and beans." B.) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." C.) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." D.) "You must consume a diet low in fat by limiting dairy products and concentrated sweets."

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

Which of the following is a potential complication of a low pressure in the endotracheal cuff? A.) Aspiration pneumonia B.) Tracheal bleeding C.) Tracheal ischemia D.) Pressure necrosis

Answer: A.) Aspiration pneumonia Rationale: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? A.) Crackles in the lung bases B.) Low-pitched rhonchi during expiration C.) Pleural friction rub D.) Sibilant wheezes

Answer: A.) Crackles in the lung bases Rationale: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

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.

Answer: A.) Draining secretions, air, and blood from the thoracic cavity is necessary. Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? A.) Impaired gas exchange B.) Anxiety C.) Decreased cardiac output D.) Ineffective tissue perfusion (cardiopulmonary)

Answer: A.) Impaired gas exchange

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? A.) Initiate oxygen therapy. B.) Administer a heparin bolus and begin an infusion at 500 units/hour. C.) Administer analgesics as ordered. D.) Perform nasopharyngeal suctioning.

Answer: A.) Initiate oxygen therapy. Rationale: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

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? A.) Intubate the client and control breathing with mechanical ventilation B.) Increase oxygen administration C.) Administer a large dose of furosemide (Lasix) IVP stat D.) Schedule the client for pulmonary surgery

Answer: A.) Intubate the client and control breathing with mechanical ventilation Rationale: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? A.) Negative B.) Positive C.) Borderline D.) Uncertain

Answer: A.) Negative Rationale: The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? A.) Rapid onset of severe dyspnea B.) Inspiratory crackles C.) Bilateral wheezing D.) Cyanosis

Answer: A.) Rapid onset of severe dyspnea Rationale: 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.

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? A.) Shortness of breath B.) Weight loss C.) Fever D.) Headache

Answer: A.) Shortness of breath Rationale: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? A.) Vitamin B6 B.) Vitamin C C.) Vitamin D D.) Vitamin E

Answer: A.) Vitamin B6

Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as A.) primary drug resistance. B.) secondary drug resistance. C.) tertiary drug resistance. D.) multidrug resistance.

Answer: A.) primary drug resistance. Rationale: Primary drug resistance refers to resistance to one of the first-line antituberculotic agents in people who have not received previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in clients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.

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.) "You should switch to wearing your glasses while taking this medication." C.) "The physician can give you eye drops to prevent any problems." D.) "There are no significant problems with wearing contact lenses."

Answer: B.) "You should switch to wearing your glasses while taking this medication." Rationale: The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.

What dietary recommendations should a nurse provide a client with a lung abscess? A.) A diet low in calories B.) A diet rich in protein C.) A carbohydrate-dense diet D.) A diet with limited fat

Answer: B.) A diet rich in protein Rationale: For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.

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.) Dyspnea C.) Hypertension D.) Syncope

Answer: B.) Dyspnea Rationale: 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 right-sided 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 patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? A.) Pneumothorax B.) Flail chest C.) ARDS D.) Tension pneumothorax

Answer: B.) Flail chest

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

Answer: B.) Paradoxical chest movement 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.

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? A.) Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes B.) Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays C.) Classes at community centers to teach about smoking cessation strategies D.) Legislation that requires homes and apartments be checked for asbestos leakage

Answer: C.) Classes at community centers to teach about smoking cessation strategies Rationale: Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.

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.) Elevating the head of the bed 30 degrees C.) Encouraging increased fluid intake D.) Maintaining a cool room temperature

Answer: C.) Encouraging increased fluid intake Rationale: 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 atelectasis, but will not adequately mobilize thick 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.

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? A.) Mobilizing early B.) Using incentive spirometry C.) Receiving vaccinations D.) Using prescribed opioids

Answer: C.) Receiving vaccinations

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? A.) "I will come back in 1 week to have the test read." B.) "If the test area turns red that means I have tuberculosis." C.) "I will avoid contact with my family until I am done with the test." D.) "Because I had a previous reaction to the test, this time I need to get a chest X-ray."

Answer: D.) "Because I had a previous reaction to the test, this time I need to get a chest X-ray." Rationale: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.

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.) 3 to 5 days B.) 1 to 3 weeks C.) 2 to 4 months D.) 6 to 12 months

Answer: D.) 6 to 12 months Rationale: 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.

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

Answer: D.) Few early symptoms 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.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? A.) Hypotension, hyperoxemia, and hypercapnia B.) Hyperventilation, hypertension, and hypocapnia C.) Hyperoxemia, hypocapnia, and hyperventilation D.) Hypercapnia, hypoventilation, and hypoxemia

Answer: D.) Hypercapnia, hypoventilation, and hypoxemia

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? A.) Apply a compression dressing to the area B.) Measure the patient's pulse oximetry C.) Report the finding to the physician immediately D.) Record the observation

Answer: D.) Record the observation Rationale: The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. 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 absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? A.) See if the chest tube is clogged. B.) See if the wall suction unit has malfunctioned. C.) See if a kink has developed in the tubing. D.) See if there are leaks in the system.

Answer: D.) See if there are leaks in the system. Rationale: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: A.) Not significant B.) Negative C.) Nonreactive D.) Significant

Answer: D.) Significant Rationale: An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? A.) Administering oxygen, coughing, breathing deeply, and maintaining bed rest B.) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer C.) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer D.) Administering pain medications, frequent repositioning, and limiting fluid intake

Answer; C.) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer