Management of Patients With Chest and Lower Respiratory Tract Disorders
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? a) "The tube will drain air from the space around the lung." b) "The tube will drain secretions from the lung." c) "Chest tube will allow air to be restored to the lung." d) "Chest tubes provide a route for medication instillation to the lung."
a) "The tube will drain air from the space around the lung. Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Acute respiratory distress syndrome b) Lung cancer c) Tracheobronchitis d) Bronchitis
a) Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.
What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
a) Draining secretions, air, and blood from the thoracic cavity is necessary.
A mediastinal shift occurs in which type of chest disorder? a) Tension pneumothorax b) Traumatic pneumothorax c) Cardiac tamponade d) Simple pneumothorax
a) Tension pneumothorax A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) empyema. b) lobar pneumonia. c) infected chest tube wound site. d) Pneumocystis carinii pneumonia.
a) empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis
b) Acute respiratory distress syndrome
The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Risk for Infection b) Ineffective Airway Clearance c) Impaired Gas Exchange d) Ineffective Breathing Pattern
b) Ineffective Airway Clearance Explanation: The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.
The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Inspiratory crackles b) Rapid onset of severe dyspnea c) Bilateral wheezing d) Cyanosis
b) Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event
Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall? a) Elevate the head of the bed b) Turn onto the affected side c) Use a prescribed analgesic d) Use a heat application
b) Turn onto the affected side The nurse teaches the patient to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain.
The nurse is caring for a patient with suspected ARDS with a pO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? a) Increased PaO2 b) Unresponsive arterial hypoxemia c) Diminished alveolar dilation d) Tachypnea
b) Unresponsive arterial hypoxemia Explanation: Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure ( Dushianthan, Grott, Postle, et al., 2011).
Nursing instruction during postural drainage should include telling the patient to: a) Lie supine to rest the lungs. b) Remain in each position for 30 to 45 minutes for best results. c) Change positions frequently and cough up secretions. d) Sit upright to promote ventilation.
c) Change positions frequently and cough up secretions. Patients who lie supine will have secretions accumulate in the posterior lung sections, whereas upright patients will pool secretions in their lower lobes. By changing positions (see Fig. 10-2 in the text), secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperoxemia, hypocapnia, and hyperventilation b) Hyperventilation, hypertension, and hypocapnia c) Hypotension, hyperoxemia, and hypercapnia d) Hypercapnia, hypoventilation, and hypoxemia
d) Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Chest pain on inspiration b) Clubbing of fingers and toes c) Respiratory acidosis d) Paradoxical chest movement
d) Paradoxical chest movement Explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.46, PaO2 80 mm Hg b) pH 7.36, PaCO2 32 mm Hg c) pH 7.35, PaCO2 48 mm Hg d) pH 7.28, PaO2 50 mm Hg
d) pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Anxiety b) Impaired gas exchange c) Ineffective tissue perfusion (cardiopulmonary) d) Decreased cardiac output
b) Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? a) Inability to dorsiflex b) Pain in the calf c) Pain in the feet d) Negative Homan's sign
b) Pain in the calf Explanation: When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) See if the wall suction unit has malfunctioned. b) See if there are leaks in the system. c) See if a kink has developed in the tubing. d) See if the chest tube is clogged.
b) See if there are leaks in the system. Explanation: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.
A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Bloody, productive cough b) Sucking sound at the site of injury c) Diminished breath sounds d) Decreased respiratory rate
b) Sucking sound at the site of injury
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Myocardial infarction (MI) b) Heart failure c) Pneumothorax d) Pulmonary embolism
c) Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? a) Auscultate breath sounds bilaterally every 4 hours. b) Instruct the client to breathe into a paper bag. c) Encourage the client to deep-breathe and cough every 2 hours. d) Administer oxygen by nasal cannula as ordered.
d) Administer oxygen by nasal cannula as ordered. When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.
A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Schedule the patient for pulmonary surgery c) Increase oxygen administration d) Intubate the patient and control breathing with mechanical ventilation
d) Intubate the patient and control breathing with mechanical ventilation A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate