Chapter 47: Respiratory Problems
The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? 1. Lateral position 2. Low Fowler's position 3. Semi-Fowler's position 4. Head of the bed elevation at 40 degrees
1 Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed needs to be elevated. Test-Taking Strategy: Focus on the subject, the position that is contraindicated. Think about what is involved in this surgical procedure. Eliminate options 2, 3, and 4 because they are comparable or alike and all indicate head elevation.
The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is the priority? 1. Report the findings. 2. Document the finding in the client's record. 3. Call the employee health service department. 4. Call the radiology department for a chest x-ray.
1 Rationale: The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client. Test-Taking Strategy: Note the strategic word, priority. Because the nurse may not prescribe diagnostic tests, eliminate option 4 first. Option 3 can be eliminated because calling the employee health service is of no benefit to the client. From the remaining options, notifying the PHCP has a higher priority than the documentation, even though both may be done in the same narrow time period.
The client is diagnosed with pleurisy. The nurse would expect to see which signs/symptoms? Select all that apply. 1. Pleural friction rub 2. Sharp, knife-like pain 3. Cyanosis of lips and nailbeds 4. Pain that occurs on both sides of the chest 5. Pain occurs most often during inspiration
1, 2, 5 Rationale: Pleurisy is inflammation of the pleura. The most characteristic symptom of pleurisy is abrupt and severe pain. The pain almost always occurs on one side of the chest. Pleurisy pain is sharp, knife-like, and abrupt in onset and is most evident during inspiration. This causes shallow breathing. A pleural friction rub may be heard. Test-Taking Strategy: Note the subject, signs/symptoms of pleurisy. Eliminate option 3 first because it is unrelated to pleurisy. Next, eliminate option 4 because the pain almost always occurs on one side of the chest and clients usually can point to the exact location of the pain.
The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse reinforce? Select all that apply. 1. Activities need to be resumed gradually. 2. Avoid contact with other individuals except family members for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.
1, 3, 4, 5 Rationale: The nurse would provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities need to be resumed gradually. The client and family are informed that respiratory isolation is not necessary because family members have already been exposed. The client is instructed about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment. Test-Taking Strategy: Note the subject, homecare instructions for the client with tuberculosis. Knowledge regarding the pathophysiology, transmission, and treatment of tuberculosis is needed to answer this question. Using this knowledge will assist you with directing you to the correct options.
The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action would the nurse take? 1. Administer oxygen. 2. Ventilate the client manually. 3. Check the client's vital signs. 4. Start cardiopulmonary resuscitation (CPR).
2 Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR. Test-Taking Strategy: Use the concept of ABCs—airway breathing, circulation—and note the strategic word, initial. Read the question carefully to note that the subject relates to adequate ventilation of the client. Focusing on this subject will direct you to the correct option.
The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? 1. Hypothermia 2. Respiratory distress 3. Hematoma in the left groin 4. Discomfort in the left groin
2 Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. Discomfort is expected. Test-Taking Strategy: Focus on the subject, an allergic reaction, and use the ABCs—airway, breathing, and circulation. This will direct you to the correct option.
The nurse is caring for a client with emphysema receiving oxygen. The nurse would consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen? 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min
2 Rationale: The concentration of oxygen administered is always prescribed by the primary health care provider and is based on ABG values and oxygen saturation by pulse oximetry. Between 1 and 3 L/min of oxygen by nasal cannula may be prescribed and required to raise the PaO2 level to 60 to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and would not exceed 2 L/min unless specifically prescribed. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system. Test-Taking Strategy: Focus on the subject, oxygen administration with emphysema. Recalling the physiology associated with emphysema is required to answer this question. Remember that oxygen is used cautiously in the client with emphysema and would not exceed 2 L/min unless specifically prescribed.
The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse would review the results of which diagnostic test to confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test
3 Rationale: A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy. Test-Taking Strategy: Focus on the subject, by noting the word confirm in the question. Confirmation is made by identifying the bacteria, M. tuberculosis, which causes the infection. This will direct you to the correct option.
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding needs to be reported immediately to the primary health care provider (PHCP)? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-tinged sputum
3 Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client needs to be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. Test-Taking Strategy: Note the strategic word, immediately. Eliminate option 2 first because it is unrelated to the procedure. Next, eliminate option 1 because a dry cough may be expected. Noting that a biopsy has been performed will assist you with eliminating option 4, because blood-streaked sputum would be expected. Note that the correct option relates to the airway.
The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? 1. An uninsured man who is homeless 2. A woman newly immigrated from another country 3. A man who is an inspector for the U.S. Postal Service 4. An older woman admitted from a long-term care facility
3 Rationale: People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users. Test-Taking Strategy: Note the subject, the client at least risk for developing a tuberculosis infection. Begin to answer this question by eliminating options 1 and 2 because immigrants and the medically underserved are more frequently affected by this infection. From the remaining options, note that the postal inspector may or may not come in contact with many people depending on job description. The client from the long-term care facility, however, lives in a group setting, where a large number of people share a common environment 24 hours a day.
A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information would reassure the client that contaminating family members and others is not likely? 1. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy. 4. The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
4 Rationale: Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client needs to take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis. Test-Taking Strategy: Focus on the subject, treatment of those exposed to tuberculosis and reassuring the client. Recalling that the family requires prophylactic therapy allows you to eliminate options 1 and 2. From the remaining options, it is necessary to know that the client is not contagious after 2 to 3 weeks of therapy.
The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position would the nurse instruct the client to assume? 1. Side-lying in bed 2. Sitting in a recliner chair 3. Sitting up in bed at a 90-degree angle 4. Sitting on the side of the bed leaning on an overbed table
4 Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. The positions in options 1, 2, and 3 will not enhance the effectiveness of breathing. Test-Taking Strategy: Focus on the subject, positioning for a client with emphysema. Eliminate option 1 because side-lying will not promote appropriate lung expansion. Next, eliminate options 2 and 3 because they are comparable or alike and will restrict lung expansion.
The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse would tell the client that the primary purpose of pursed lip breathing is which? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination
4 Rationale: Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. Test-Taking Strategy: Focus on the subject, pursed lip breathing, and note the strategic word, primary. Visualize the use of this breathing technique to assist with answering correctly. Recalling the respiratory conditions in which this type of breathing is helpful will also assist in directing you to the correct option.
The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath
4 Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs/symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss. Test-Taking Strategy: Note the strategic word, early, in the question. Because sarcoidosis is a pulmonary problem, eliminate options 1 and 3 first. Choose option 4 over option 2 because the shortness of breath (and impaired ventilation) appears first and would cause the fatigue as a secondary symptom.
The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1 1/2 weeks. The nurse knows that the client has understood the information if which statement is made? 1. "I can't shop at the mall for the next 6 months." 2. "I need to continue medication therapy for 2 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy."
4 Rationale: The client continues medication therapy for 6 to 12 months depending on the situation. The client is generally considered to not be contagious after 2 to 3 weeks of medication. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative. Test-Taking Strategy: Focus on the subject, client understanding of discharge teaching regarding treatment of tuberculosis. Knowing that the medication regimen lasts for at least 6 months helps you eliminate option 2 first. Knowing that three sputum cultures needs to be negative helps you eliminate option 3 next. From the remaining options, recalling that the client is not contagious after 2 to 3 weeks of therapy helps you choose option 4.
