Lower respiratory

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. DIF: Cognitive Level: Apply (application)

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age b. Blood pressure c. Respiratory rate d. O2 saturation f. Blood urea nitrogen (BUN) level

ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess, but are not used for CURB-65 scoring. DIF: Cognitive Level: Apply (application)

To what was the resurgence in tuberculosis (TB) resulting from the emergence of multidrugresistant (MDR) strains of Mycobacterium tuberculosis related? a. A lack of effective means to diagnose TB b. Poor compliance with drug therapy in patients with TB c. Indiscriminate use of antitubercular drugs in treatment of other infections d. Increased population of immunosuppressed individuals with acquired immunodeficiency syndrome (AIDS)

. b. Drug-resistant strains of TB have developed because TB patients' compliance with drug therapy has been poor, and there has been general decreased vigilance in monitoring and followup of TB treatment. TB can be diagnosed effectively with sputum cultures. Antitubercular drugs are almost exclusively used for TB infections. The incidence of TB is at epidemic proportions in patients with HIV, but this does not account for multidrug-resistant strains of TB.

While caring for a patient with idiopathic pulmonary arterial hypertension (IPAH), the nurse observes that the patient has exertional dyspnea and chest pain in addition to fatigue. To what are these symptoms related? a. Decreased left ventricular output b. Right ventricular hypertrophy and failure c. Increased systemic arterial blood pressure d. Development of alveolar interstitial edema

. b. High pressure in the pulmonary arteries increases the workload of the right ventricle and eventually causes right ventricular hypertrophy, known as cor pulmonale, and eventual heart failure. Eventually, decreased left ventricular output may occur because of decreased return to the left atrium, but it is not the primary effect of pulmonary hypertension. Alveolar interstitial edema is pulmonary edema associated with left ventricular failure. Pulmonary hypertension does not cause systemic hypertension.

When obtaining a health history from a patient suspected of having early TB, the nurse should ask the patient about what manifestations? a. Chest pain, hemoptysis, and weight loss b. Fatigue, low-grade fever, and night sweats c. Cough with purulent mucus and fever with chills d. Pleuritic pain, nonproductive cough, and temperature elevation at night

. b. TB usually develops insidiously with fatigue, malaise, anorexia, low-grade fevers, and night sweats, a dry cough, and unexplained weight loss. Pleuritic pain, flu-like symptoms, and a productive cough may occur with an acute sudden presentation; but dyspnea and hemoptysis are late symptoms.

Priority Decision: To reduce the risk for many occupational lung diseases, what is the most important measure the occupational nurse should promote? a. Maintaining smoke-free work environments for all employees b. Using masks and effective ventilation systems to reduce exposure to irritants c. Inspection and monitoring of workplaces by national occupational safety agencies d. Requiring periodic chest x-rays and pulmonary function tests for exposed employees

. b. Although all of the precautions identified in this question are appropriate in decreasing the risk of occupational lung diseases, using masks and effective ventilation systems to reduce exposure is the most efficient and affects the greatest number of employees. The safety inspections are required.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. 1.Dyspnea 2.Headache 3.Night sweats 4.A bloody, productive cough 5.A cough with the expectoration of mucoid sputum

1.Dyspnea 3.Night sweats 4.A bloody, productive cough 5.A cough with the expectoration of mucoid sputum Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Teach pursed-lip breathing technique. c. Assist the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

ANS: C Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance. DIF: Cognitive Level: Apply (application)

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? 1.Hypercalcemia 2.Peripheral neuritis 3.Small blood vessel spasm 4.Impaired peripheral circulation

Peripheral neuritis Isoniazid is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1.Positive 2.Negative 3.Inconclusive 4.Need for repeat testing

Positive The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

How do microorganisms reach the lungs and cause pneumonia (select all that apply)? a. Aspiration b. Lymphatic spread c. Inhalation of microbes in the air d. Touch contact with the infectious microbes e. Hematogenous spread from infections elsewhere in the body

a, c, e. Microorganisms that cause pneumonia reach the lungs by aspiration from the nasopharynx or oropharynx, inhalation of microbes in the air, and hematogenous spread from infections elsewhere in the body. The other causes of infection do not contribute to pneumonia.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.

ANS: B Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system. DIF: Cognitive Level: Apply (application)

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Increasing the O2 flow rate to keep the O2 saturation over 90%

ANS: B Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate. DIF: Cognitive Level: Apply (application)

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository

ANS: B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last. DIF: Cognitive Level: Analyze (analysis)

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? a. Patient's chest x-ray indicates clear lung fields. b. Heart rate is between 60 and 100 beats/minute. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.

ANS: C Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective. DIF: Cognitive Level: Analyze (analysis)

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy

ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis. DIF: Cognitive Level: Apply (application)

Which medications would be used in four-drug treatment for the initial phase of TB (select all that apply)? a. Isoniazid b. Pyrazinamide c. Rifampin (Rifadin) d. Rifabutin (Mycobutin) e. Levofloxacin (Levaquin) f. Ethambutol (Myambutol)

. a, b, c, f. For the first 2 months, a four-drug regimen consists of isoniazid, pyrazinamide, rifampin (Rifadin), and ethambutol (Myambutol). Rifabutin (Mycobutin) and levofloxacin (Levaquin) may be used if the patient develops toxicity to the primary drugs. Rifabutin may be used as first-line treatment for patients receiving medications that interact with rifampin (e.g., antiretrovirals, estradiol, warfarin).

Which condition contributes to secondary pulmonary arterial hypertension by causing pulmonary capillary and alveolar damage? a. COPD b. Sarcoidosis c. Pulmonary fibrosis d. Pulmonary embolism

. a. Chronic obstructive pulmonary disease (COPD) causes pulmonary capillary and alveolar damage increasing pressure, as does scleroderma. Sarcoidosis is a granulomatous disease, pulmonary fibrosis stiffens the pulmonary vasculature, and pulmonary embolism obstructs pulmonary blood flow, but alone, these would not cause secondary pulmonary arterial hypertension.

Patient-Centered Care: A patient with active TB continues to have positive sputum cultures after 6 months of treatment. She says she cannot remember to take the medication all the time. What is the best action for the nurse to take? a. Arrange for directly observed therapy (DOT) by a public health nurse. b. Schedule the patient to come to the clinic every day to take the medication. c. Have a patient who has recovered from TB tell the patient about his successful treatment. d. Schedule more teaching sessions so that the patient will understand the risks of noncompliance.

. a. Notification of the public health department is required. If drug compliance is questionable, follow-up of patients can be made by directly observed therapy by a public health nurse. A patient who cannot remember to take the medication usually will not remember to come to the clinic daily or will find it too inconvenient. Additional teaching or support from others is not usually effective for this type of patient.

Priority Decision: A patient diagnosed with class 3 TB 1 week ago is admitted to the hospital with symptoms of chest pain and coughing. What nursing action has the highest priority? a. Administering the patient's antitubercular drugs b. Admitting the patient to an airborne infection isolation room c. Preparing the patient's room with suction equipment and extra linens d. Placing the patient in an intensive care unit, where he can be closely monitored

. b. A patient with class 3 TB has clinically active disease, and airborne infection isolation is required for active disease until the patient is noninfectious, indicated by negative sputum smears. Cardiac monitoring and observation will be done with the patient in isolation. The nurse will administer the antitubercular drugs after the patient is in isolation. There should be no need for suction or extra linens after the TB patient is receiving drug therapy.

During a health promotion program, why should the nurse plan to target women in a discussion of lung cancer prevention (select all that apply)? a. Women develop lung cancer at a younger age than men. b. More women die of lung cancer than die from breast cancer. c. Women have a worse prognosis from lung cancer than do men. d. Nonsmoking women are at greater risk for developing lung cancer than nonsmoking men. e. African American women have a higher rate of lung cancer than other ethnic groups.

9. a, b, d. Smoking by women is taking a great toll, as reflected by the increasing incidence and deaths from lung cancer in women, who develop lung cancer at a younger age than men. Nonsmoking women are at greater risk of developing lung cancer than nonsmoking men. Men still have a worse prognosis than women from lung cancer. White women have a higher rate of lung cancer than other ethnic groups.

The nurse determines that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." Rationale: The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

Priority Decision: An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed. b. securing the drainage container in an upright position. c. stripping or milking the chest tube to promote drainage. d. reminding the patient to cough and deep breathe every 2 hours.

. c. If chest tubes are to be milked or stripped, this procedure should be done only by the professional nurse. This procedure is no longer recommended, as it may dangerously increase pleural pressure, but there is no indication to milk the tubes when there is no bloody drainage, as in a pneumothorax. The UAP can loop the chest tubing on the bed to promote drainage and secure the drainage container in an upright position. A UAP can remind patients to cough and deep breathe at least every 2 hours to aid in lung reexpansion.

Following a thoracotomy, the patient has a nursing diagnosis of ineffective breathing pattern related to inability to cough as a result of pain and positioning. What is the best nursing intervention for this patient? a. Have the patient drink 16 oz of water before attempting to deep breathe. b. Auscultate the lungs before and after deep-breathing and coughing regimens. c. Place the patient in the Trendelenburg position for 30 minutes before the coughing exercises. d. Medicate the patient with analgesics 20 to 30 minutes before assisting to cough and deep breathe.

. d. A thoracotomy incision is large and involves cutting into muscle, cartilage, and possibly the sternum, resulting in significant postoperative pain, interfering with deep-breathing and coughing. The patient should be provided analgesics before attempting these activities. Water intake is important to liquefy secretions but is not indicated in this case, nor should a patient with chest trauma or surgery be placed in Trendelenburg position, because it increases intrathoracic pressure. Auscultating before and after coughing evaluates effectiveness of airway clearance but does not facilitate it.

How should the nurse explain to the patient and family what the purpose of video-assisted thoracic surgery (VATS) is? a. Removal of a lung b. Removal of one or more lung segments c. Removal of lung tissue by multiple wedge excisions d. Inspection, diagnosis, and management of intrathoracic injuries

. d. During video-assisted thoracic surgery (VATS), a video scope is inserted into the thorax to assess, diagnose, and treat intrathoracic injuries. A pneumonectomy is the removal of an entire lung. A wedge resection is the removal of a lung segment with localized lesions. Lung volume reduction surgery is the removal of lung tissue by excising multiple wedges.

A patient with a 40 pack-year smoking history has recently stopped smoking because of the fear of developing lung cancer. The patient asks the nurse what he can do to learn about whether he develops lung cancer. What is the best response from the nurse? a. "You should get a chest x-ray every 6 months to screen for any new growths." b. "It would be very rare for you to develop lung cancer now that you have stopped smoking." c. "You should monitor for any persistent cough, wheezing, or difficulty breathing, which could indicate tumor growth." d. "Adults aged 55 to 80 with a history of heavy smoking who quit in the past 15 years should be screened yearly with low-dose computed tomography."

. d. In December 2013, the U.S. Preventive Services Task Force recommended yearly low-dose CT scan screening for 30 pack-year smokers. The use of x-ray has also been shown to detect lung cancer at earlier stages when it is suspected. Sputum cytology may be used, but malignant cells are seldom present in sputum. A patient who has a smoking history always has an increased risk for lung cancer compared with an individual who has never smoked, but the risk decreases to that of a nonsmoker after 15 years of nonsmoking.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1.Activities should 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 already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

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 already have been exposed. 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary, because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1."I need to continue medication therapy for 1 month." 2."I can't shop at the mall for the next 6 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."I should not be contagious after 2 to 3 weeks of medication therapy." The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. 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 work when the results of 3 sputum cultures are negative.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done. DIF: Cognitive Level: Analyze (analysis)

Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking? a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer

ANS: A Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Sputum cytology is a diagnostic test, but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer. DIF: Cognitive Level: Apply (application)

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale. DIF: Cognitive Level: Apply (application)

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia. DIF: Cognitive Level: Apply (application)

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. DIF: Cognitive Level: Apply (application)

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Pain level is 5 (on 0 to 10 scale) with a deep breath. d. Respiratory rate is 24 breaths/minute when lying flat.

ANS: A O2 saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority. DIF: Cognitive Level: Analyze (analysis)

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxical chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

ANS: A Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange. DIF: Cognitive Level: Analyze (analysis)

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine

ANS: A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection. DIF: Cognitive Level: Apply (application)

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. DIF: Cognitive Level: Analyze (analysis)

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. DIF: Cognitive Level: Analyze (analysis)

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel. DIF: Cognitive Level: Apply (application)

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes d. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. DIF: Cognitive Level: Analyze (analysis)

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."

ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia. DIF: Cognitive Level: Apply (application)

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed. DIF: Cognitive Level: Analyze (analysis)

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.

ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax. DIF: Cognitive Level: Apply (application)

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer sedatives. b. Position the patient sitting up on the side of the bed. c. Obtain a collection device to hold 3 liters of pleural fluid. d. Remind the patient not to eat or drink anything for 6 hours.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema. DIF: Cognitive Level: Apply (application)

Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

ANS: B With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. DIF: Cognitive Level: Apply (application)

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance, but should be done after the morphine is given. DIF: Cognitive Level: Analyze (analysis)

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.

ANS: C Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation. DIF: Cognitive Level: Analyze (analysis)

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space. DIF: Cognitive Level: Apply (application)

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."

ANS: C More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery. DIF: Cognitive Level: Analyze (analysis)

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol, which is a different tuberculosis medication. DIF: Cognitive Level: Apply (application)

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

ANS: C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation. DIF: Cognitive Level: Apply (application)

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.

ANS: C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB. DIF: Cognitive Level: Apply (application)

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."

ANS: C Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation. DIF: Cognitive Level: Apply (application)

After change-of-shift report, which patient should the nurse assess first? a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia. DIF: Cognitive Level: Analyze (analysis)

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.

ANS: C The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed. DIF: Cognitive Level: Analyze (analysis)

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged.

ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. DIF: Cognitive Level: Analyze (analysis)

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

ANS: C The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made. DIF: Cognitive Level: Analyze (analysis)

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. DIF: Cognitive Level: Apply (application)

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? a. "Are you ready to talk with your family members about dying now?" b. "Would you like to talk to the hospital chaplain about your feelings?" c. "Can you tell me what it is that makes you think you will die so soon?" d. "Do you think that taking an antidepressant medication would be helpful?"

ANS: C The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate. DIF: Cognitive Level: Analyze (analysis)

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority? a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion

ANS: D All of these nursing diagnoses are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. DIF: Cognitive Level: Analyze (analysis)

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.

ANS: D Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB. DIF: Cognitive Level: Analyze (analysis)

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

ANS: D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. DIF: Cognitive Level: Analyze (analysis)

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Teach the patient to avoid the use of over-the-counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough. DIF: Cognitive Level: Apply (application)

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection. DIF: Cognitive Level: Apply (application)

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. DIF: Cognitive Level: Analyze (analysis)

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP assist the patient to ambulate to the bathroom. b. UAP help splint the patient's chest during coughing. c. UAP transfer the patient to a bedside chair for meals. d. UAP lower the head of the patient's bed to 15 degrees.

ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. DIF: Cognitive Level: Apply (application)

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis. DIF: Cognitive Level: Apply (application)

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.

ANS: D Repeated negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment. DIF: Cognitive Level: Apply (application)

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.

ANS: D The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing. DIF: Cognitive Level: Apply (application)

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE. DIF: Cognitive Level: Analyze (analysis)

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems. DIF: Cognitive Level: Apply (application)

A patient with a persistent cough is diagnosed with pertussis. What medication does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant Incorrect

Antibiotic Rationale: Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

The nurse is caring for a patient with a fever due to pneumonia. What assessment data does the nurse obtain that correlates with the patient having a fever? (Select all that apply.) A temperature of 101.4° F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days

Correct Answer: A temperature of 101.4° F Heart rate of 120 beats/min A productive cough with yellow sputum Rationale: A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

Correct Answer: Basilar crackles Rationale: The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with impaired airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with other lower respiratory problems.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. Which risk factors are a priority for the nurse to assess? (Select all that apply.) Cancer Obesity Pneumonia Cigarette smoking Prolonged air travel

Correct Answer: Cancer Obesity Cigarette smoking Prolonged air travel Rationale: An increased risk of pulmonary embolism is associated with obesity, cancer, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) Maintain adequate fluid intake. Maintain a 15-degree elevation. Splint the chest when coughing. Have the patient use incentive spirometry. Teach the patient to cough at end of exhalation.

Correct Answer: Maintain adequate fluid intake. Splint the chest when coughing. Teach the patient to cough at end of exhalation. Rationale: Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should teach the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. Incentive spirometry promotes lung expansion. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.

Correct Answer: Sit the patient up in bed as tolerated and apply oxygen. Rationale: The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the health care provider. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? Sudden onset of confusion Oral temperature of 102.3° F Coarse crackles in lung bases Clutching chest on inspiration

Correct Answer: Sudden onset of confusion Rationale: Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist this patient to expectorate thick lung secretions? Humidify the oxygen as able. Administer a cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

Increase fluid intake to 3 L/day if tolerated. Rationale: Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which provider orders must the nurse verify have been completed before administering a dose of cefuroxime? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM

Sputum culture and sensitivity Rationale: The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

Which microorganisms are associated with both CAP and HAP (select all that apply)? a. Klebsiella b. Acinetobacter c. Staphylococcus aureus d. Mycoplasma pneumoniae e. Pseudomonas aeruginosa f. Streptococcus pneumoniae

a, c, e, f. CAP and HAP are both associated with Klebsiella, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pneumoniae. Acinetobacter is only associated with HAP. Mycoplasma pneumoniae is only associated with CAP.

Priority Decision: Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. What is the first action that the nurse should take? a. Raise the head of the bed. b. Notify the health care provider. c. Take the patient's pulse and blood pressure. d. Determine the patient's SpO2 with an oximeter

a. All of the activities are correct, but the first thing to do is to raise the head of the bed to facilitate breathing in the patient who is dyspneic. The HCP would not be called until the nurse has assessment data relating to vital signs, pulse oximetry, and any other patient complaints.

A patient with a lung mass found on chest x-ray is undergoing further testing. The nurse explains that a definitive diagnosis of lung cancer can be confirmed using which diagnostic test? a. Lung biopsy b. Lung tomograms c. Pulmonary angiography d. Computed tomography (CT) scans

a. Although chest x-rays, lung tomograms, CT scans, MRI, and positron emission tomography (PET) can identify tumors and masses, a definitive diagnosis of a lung cancer requires identification of malignant cells in a biopsy or cytologic study of bronchial washings.

When obtaining a health history from a 76-yr-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report? a. Confusion b. A recent loss of consciousness c. An abrupt onset of fever and chills d. A gradual onset of headache and sore throat

a. Confusion possibly related to hypoxia may be the only finding in older adults. Although CAP is most commonly caused by Staphylococcus aureus and is associated with an acute onset with fever, chills, productive cough with purulent or bloody sputum, and pleuritic chest pain, the older patient may not have classic symptoms. A recent loss of consciousness or altered consciousness is common in those pneumonias associated with aspiration, such as anaerobic 536 bacterial pneumonias. Other causes of pneumonia have a more gradual onset with dry, hacking cough; headache; and sore throat

. During an annual health assessment of a 66-yr-old patient at the clinic, the patient tells the nurse he has not had the pneumonia vaccine. What should the nurse advise him about the best way for him to prevent pneumonia? a. Obtain a pneumococcal vaccine now and get a booster 12 months later. b. Seek medical care and antibiotic therapy for all upper respiratory infections. c. Obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia. d. Obtain only the influenza vaccine every year because he should have immunity to the pneumococcus because of his age.

a. He should receive his first dose of PCV13, followed at least 1 year later by a dose of PPSV23. Influenza vaccine should be taken each year. Antibiotic therapy is not appropriate for all upper respiratory infections unless secondary bacterial infections develop.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding? a. SpO2 of 86% b. Crackles in both lower lobes c. Temperature of 101.4° F (38.6° C) d. Production of greenish purulent sputum

a. Oxygen saturation obtained by pulse oximetry should be between 90% and 100%. An SpO2 lower than 90% indicates hypoxemia and impaired gas exchange. Crackles, fever, and purulent sputum are all manifestations of pneumonia but do not necessarily relate to impaired gas exchange.

Priority Decision: When should the nurse check for leaks in the chest tube and pleural drainage system? a. There is continuous bubbling in the water-seal chamber. b. There is constant bubbling of water in the suction control chamber. c. Fluid in the water-seal chamber fluctuates with the patient's breathing. d. The water levels in the water-seal and suction control chambers are decreased

a. The water-seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing patient. Continuous bubbling indicates a leak. The water in the suction control chamber will bubble continuously and the fluid in the water-seal chamber fluctuates (tidaling) with the patient's breathing. Water in the suction control chamber, and perhaps in the water-seal chamber, evaporates and may have to be replaced periodically.

To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. Dull percussion sounds on the injured side b. Severe respiratory distress and tracheal deviation c. Muffled and distant heart sounds with decreasing blood pressure d. Decreased movement and diminished breath sounds on the affected side

b. A tension pneumothorax causes many of the same manifestations as other types of pneumothoraxes, but severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures and trachea to the unaffected side is present in a tension pneumothorax. Percussion dullness on the injured site indicates the presence of blood or fluid, and decreased movement and diminished breath sounds are characteristic of a pneumothorax. Muffled and distant heart sounds indicate a cardiac tamponade.

. A patient with advanced lung cancer refuses pain medication, saying, "I deserve everything this cancer can give me." What is the nurse's best response to this patient? a. "Would talking to a counselor help you?" b. "Can you tell me what the pain means to you?" c. "Are you using the pain as a punishment for your smoking?" d. "Pain control will help you to deal more effectively with your feelings."

b. Before making any judgments about the patient's statement, it is important to explore what meaning he or she finds in the pain. It may be that the patient feels the pain is deserved punishment for smoking, but further information must be obtained from the patient. Immediate referral to a counselor negates the nurse's responsibility in helping the patient, and there is no indication that the patient is not dealing effectively with his or her feelings.

A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. What is an expected outcome for this patient? a. SpO2 is 90% b. Lungs clear to auscultation c. Patient tolerates walking in hallway d. Patient takes three or four shallow breaths before coughing to minimize pain

b. Clear lung sounds indicate that the airways are clear. SpO2 of 90% to 100% indicates appropriate gas exchange. Tolerating walking in the hallway indicates appropriate gas exchange and activity tolerance, not improved airway clearance. Deep breaths are necessary to move mucus from distal airways, but this is not an outcome for this nursing diagnosis.

Which chest surgery is used for the stripping of a fibrous membrane? a. Lobectomy b. Decortication c. Thoracotomy d. Wedge resection

b. Decortication is the stripping of a thick fibrous membrane. A lobectomy is the removal of one lung lobe. A thoracotomy is the incision into the thorax. A wedge resection is used to remove a small localized lesion.

. The microorganisms Pneumocystis jiroveci (PJP) and cytomegalovirus (CMV) are associated with which type of pneumonia? a. Necrotizing pneumonia b. Opportunistic pneumonia c. Hospital-associated pneumonia d. Community-acquired pneumonia

b. People at risk for opportunistic pneumonia include those with altered immune responses. Pneumocystis jiroveci rarely causes pneumonia in healthy individuals but is the most common cause of pneumonia in persons with HIV disease. Cytomegalovirus (CMV) occurs in people with an impaired immune response. Necrotizing pneumonia is caused by Staphylococcus, Klebsiella, and Streptococcus. Hospital-acquired pneumonia (HAP) is frequently caused by Pseudomonas aeruginosa, Escherichia coli, Klebsiella, and Acinetobacter. Community-acquired pneumonia (CAP) is most commonly caused by Streptococcus pneumonia.

A pulmonary embolus is suspected in a patient with a deep vein thrombosis who develops dyspnea, tachycardia, and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? a. D-dimer b. Chest x-ray c. Spiral (helical) CT scan d. Ventilation-perfusion lung scan

c. A spiral (helical) CT scan is the most frequently used test to diagnose pulmonary emboli (PE) because it allows illumination of all anatomic structures and produces a 3-D picture. If a patient cannot have contrast media, a ventilation-perfusion scan is done. Although pulmonary angiography is most sensitive, it is invasive, expensive, and carries more risk for complications. D-dimer is neither specific nor sensitive for small PE, especially in this patient with deep vein thrombosis. Chest x-rays do not detect pulmonary emboli until necrosis or abscesses occur.

Priority Decision: After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which order should the nurse implement first? a. Anterior/posterior and lateral chest x-rays b. Start IV levofloxacin (Levaquin) 500 mg every 24 hr c. Sputum specimen for Gram stain and culture and sensitivity d. Complete blood count (CBC) with white blood cell (WBC) count and differential

c. A sputum specimen for Gram stain and culture should be done before initiating antibiotic therapy and while waiting for the antibiotic to be delivered from the pharmacy in a hospitalized patient with suspected pneumonia. Then antibiotics should be started without delay. If the sputum specimen cannot be obtained rapidly, the chest x-ray will be done to assess the typical pattern characteristic of the infecting organism. Blood cell tests will not be altered significantly by delaying the tests until after the first dose of antibiotics.

Six days after a heart-lung transplant, the patient develops a low-grade fever, dyspnea, and decreased SpO2. What should the nurse recognize that this may indicate? a. A normal response to extensive surgery b. A frequently fatal cytomegalovirus infection c. Acute rejection that will be treated with corticosteroids d. Bronchiolitis obliterans, which plugs terminal bronchioles

c. Acute rejection may occur as early as 5 to 10 days after surgery and is manifested by lowgrade fever, fatigue, and oxygen desaturation with exertion. Complete remission of symptoms can be accomplished with high doses of IV corticosteroids followed by high doses of oral prednisone. Cytomegalovirus and other infections can be fatal but usually occur weeks after surgery and manifest with symptoms of pneumonia. Obliterative bro

Why is the classification of pneumonia as community-acquired pneumonia (CAP) or hospitalacquired pneumonia (HAP) clinically useful? a. Atypical pneumonia syndrome is more likely to occur in HAP. b. Diagnostic testing does not have to be used to identify causative agents. c. Causative agents can be predicted, and empiric treatment is often effective. d. IV antibiotic therapy is necessary for HAP, but oral therapy is adequate for CAP

c. Pneumonia that has its onset in the community is usually caused by different microorganisms than pneumonia that develops related to hospitalization and treatment can be empiric—based on observations and experience without knowing the exact causative organism. Frequently a causative organism cannot be identified from cultures, and treatment is based on experience.

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest? a. Severe hypotension b. Chest pain over ribs c. Absence of breath sounds d. Paradoxical chest movement

d. Flail chest may occur when two or more ribs are fractured, causing an unstable segment. The chest wall cannot provide the support for ventilation, and the injured segment will move paradoxically to the stable portion of the chest (in on expiration; out on inspiration). Hypotension occurs with a number of conditions that impair cardiac function, and chest pain occurs with a single fractured rib and will be important with flail chest. Absent breath sounds occur following pneumothorax or hemothorax.

What is a primary treatment goal for cor pulmonale? a. Controlling dysrhythmias b. Dilating the pulmonary arteries c. Strengthening the cardiac muscle d. Treating the underlying pulmonary condition

d. If possible, the primary management of cor pulmonale is treatment of the underlying pulmonary problem that caused the heart problem. Low-flow oxygen therapy will help to prevent hypoxemia and hypercapnia, which cause pulmonary vasoconstriction. The treatments used will be individualized for the patient.

What is the initial antibiotic treatment for pneumonia based on? a. The severity of symptoms b. The presence of characteristic leukocytes c. Gram stains and cultures of sputum specimens d. History and physical examination and characteristic chest x-ray findings

d. Prompt treatment of pneumonia with appropriate antibiotics is important in treating bacterial and mycoplasma pneumonia, and antibiotics are often administered on the basis of the history, physical examination, and a chest x-ray indicating a typical pattern characteristic of a particular organism without further testing. It is more significant if it is CAP or HAP than the severity of pneumonia symptoms. Blood and sputum cultures take 24 to 72 hours for results, and microorganisms often cannot be identified with either Gram stain or cultures.

A patient has chronic obstructive pulmonary disease (COPD) and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring? a. Tension pneumothorax b. Iatrogenic pneumothorax c. Traumatic pneumothorax d. Spontaneous pneumothorax

d. Spontaneous pneumothorax is seen from the rupture of small blebs on the surface of the lung in patients with lung disease or smoking, as well as in tall, thin males with a family history of or a previous spontaneous pneumothorax. Tension pneumothorax occurs with mechanical ventilation and with blocked chest tubes. Iatrogenic pneumothorax occurs due to the laceration or puncture of the lung during medical procedures. Traumatic pneumothorax can occur with penetrating or blunt chest trauma