Med surg-study guid book/book

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).

While the nurse is feeding a patient, the patient appears to choke on the food. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? a. Stridor b. Cyanosis c. Wheezing d. Bradycardia e. Rapid respiratory rate

a, b, c. With partial airway obstruction, choking, stridor, use of accessory muscles, suprasternal and intercostals retraction, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, and change in level of consciousness may occur. Partial airway obstruction may progress to complete obstruction without prompt assessment and treatment.

Teamwork and Collaboration: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the RN may delegate which interventions to the licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Suction the tracheostomy. b. Provide tracheostomy care. c. Determine the need for suctioning. d. Assess the patient's swallowing ability. e. Teach the patient about home tracheostomy care.

a, b, c. LPNs may determine the need for suctioning, suction the tracheostomy, and determine whether the patient has improved after the suctioning when caring for stable patients. They also may perform tracheostomy care using sterile technique. The patient's swallowing ability is assessed by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations. The RN will teach the patient about home tracheostomy care.

Teamwork and Collaboration: The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)? a. Assist the patient to get out of bed. b. Auscultate breath sounds every 4 hours. c. Plan patient activities to minimize exertion. d. Teach the patient pursed lip breathing technique.

a. Assistance with positioning and activities of daily living (ADLs) is within the training of unlicensed assistive personnel (UAP). Teaching, assessing, and planning are all part of the RN's practice.

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.

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.

Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? a. Decreased force of cough b. Decreased functional cilia c. Decreased chest wall compliance d. Small airway closure earlier in expiration e. Decreased functional immunoglobulin A (IgA)

a, b. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. The other options contribute to other age-related changes. Decreased compliance contributes to barrel chest appearance. Early small airway closure contributes to decreased PaO2. Decreased immunoglobulin A (IgA) decreases the resistance to infection.

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.

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.

Priority Decision: A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, PaO2 74 mm Hg, SaO2 92%, PaCO2 40 mm Hg. What is the most appropriate action by the nurse? a. Document the results in the patient's record. b. Repeat the ABGs within an hour to validate the findings. c. Encourage deep breathing and coughing to open the alveoli. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status.

a. Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and SaO2 but normal pH and PaCO2. No interventions are necessary for these findings. Usual PaO2 levels are expected in patients 60 years of age or younger.

During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? a. The postoperative use of nonverbal communication techniques b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis c. The need for frequent, vigorous coughing in the first 24 hours postoperatively d. Self-help groups and community resources for patients with cancer of the larynx

a. With removal of the larynx, the patient will not be able to communicate verbally, and it is important to arrange with the patient a method of communication before surgery so that postoperative communication can take place. Dry mouth and stomatitis result from radiation therapy. Vigorous coughing is not encouraged immediately postoperatively, and information related to community resources is usually introduced during the postoperative period.

Which method of oxygen administration is the safest system to use for a patient with COPD exacerbation? a. Venturi mask b. Nasal cannula c. Simple face mask d. Non-rebreather mask

a. A Venturi mask is helpful to administer low, constant O2 concentrations to patients with COPD and can be set to administer a varied percentage of O2. The amount of O2 inhaled via the nasal cannula depends on room air and the patient's breathing pattern. The simple face mask must have a tight seal and may generate heat under the mask. The non-rebreather mask is more useful for short-term therapy with patients needing high O2 concentrations.

What should the nurse do when preparing a patient for a pulmonary angiogram? a. Assess the patient for iodine allergy. b. Implement NPO orders for 6 to 12 hours before the test. c. Explain the test before the patient signs the informed consent form. d. Inform the patient that radiation isolation for 24 hours after the test is necessary.

a. A pulmonary angiogram involves the injection of an iodine-based radiopaque dye, and iodine or shellfish allergies should be assessed before injection. A bronchoscopy requires NPO status for 6 to 12 hours before the test, and invasive tests (e.g., bronchoscopy, mediastinoscopy, biopsies) require informed consent that the health care provider should obtain from the patient. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient.

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.

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.

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 bacterial pneumonias. Other causes of pneumonia have a more gradual onset with dry, hacking cough; headache; and sore throat.

A patient develops epistaxis upon removal of a nasogastric tube. What action should the nurse take? a. Pinch the soft part of the nose. b. Position the patient on the side. c. Have the patient hyperextend the neck. d. Apply an ice pack to the back of the neck.

a. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. In addition, have the patient upright and leaning forward to prevent swallowing blood.

When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? a. A closed-wound drainage system b. A nasal endotracheal tube in place c. A nasogastric tube with orders for tube feedings d. A tracheostomy tube and mechanical ventilation

a. Following a radical neck dissection, drainage tubes are often used to prevent fluid accumulation in the wound as well as possible pressure on the trachea. A nasal endotracheal tube would not be useful. The patient has placement of a nasogastric tube to suction immediately after surgery, which will later be used to administer tube feedings until swallowing can be accomplished. A tracheostomy tube is in place, but mechanical ventilation is usually not indicated.

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.

Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurse's first action? a. Attempt to replace the tube. b. Notify the health care provider. c. Place the patient in high Fowler's position. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives.

a. If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by using hemostats to spread the opening. The obturator is inserted in the replacement tube, water-soluble lubricant is applied to the tip, and the tube is inserted in the stoma at a 45-degree angle to the neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the HCP should be notified and the patient should be assessed for the level of respiratory distress, positioned in semi-Fowler's position, and ventilated with a manual resuscitation bag (MRB) only if necessary until assistance arrives.

The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment includes a. radiation therapy that preserves the quality of the voice. b. a hemilaryngectomy that prevents the need for a tracheostomy. c. a radical neck dissection that removes possible sites of metastasis. d. a total laryngectomy to prevent development of second primary cancers.

a. If laryngeal tumors are small, radiation is the treatment of choice because it can be curative and can preserve voice quality. Surgical procedures are used if radiation treatment is not successful or if larger or advanced lesions are present.

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.

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.

After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? a. Thoracentesis b. Pulmonary function test c. Ventilation-perfusion scan d. Positron emission tomography (PET) scan

a. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. Pulmonary function tests are noninvasive.

A 36-yr-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. What is the best response by the nurse? a. "You should get the inactivated influenza vaccine that is injected every year." b. "Only health care workers in contact with high-risk patients should be immunized each year." c. "An annual vaccination is not necessary because previous immunity will protect you for several years." d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult."

a. The injected inactivated influenza vaccine is recommended for individuals 6 months of age and older and those at increased risk for influenza-related complications, such as people with chronic medical conditions or those who are immunocompromised, residents of long-term care facilities, health care workers, and providers of care to at-risk persons. The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 but not for those at increased risk of complications or HCPs. The immunity will not protect for several years, as new strains of influenza may develop each year. Antiviral agents will help to reduce the duration and severity of influenza in those at high risk, but immunization is the best control

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.

Pulmonary rehabilitation (PR) is designed to reduce symptoms and improve the patient's quality of life. Along with improving exercise capacity, what are anticipated results of PR (select all that apply)? a. Decreased FEV1 b. Decreased depression c. Increased oxygen need d. Decreased fear of exercise e. Decreased hospitalizations

b, d, e. Decreasing depression, fear of exercise, and hospitalizations along with improving exercise capacity are benefits of pulmonary rehabilitation (PR). Decreased FEV1 and increased oxygen need are not beneficial.

A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? a. Apex to base b. Base to apex c. Lateral sequence d. Anterior then posterior e. Posterior then anterior

b, e. This patient is older and short of breath. To obtain the most information, auscultate the posterior to avoid breast tissue and start at the base because of her respiratory difficulty and the chance that she will tire easily. Important sounds may be missed if the other strategies are used first.

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.

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.

What keeps alveoli from collapsing? a. Carina b. Surfactant c. Empyema d. Thoracic cage

b. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. The other options do not maintain inflation of the alveoli. The carina is the point of bifurcation of the trachea into the right and left bronchi. Empyema is a collection of pus in the thoracic cavity. The thoracic cage is formed by the ribs and protects the thoracic organs.

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.

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.

When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? a. There is a prominent protrusion of the sternum. b. The width of the chest is equal to the depth of the chest. c. There is equal but diminished movement of the two sides of the chest. d. The patient cannot fully expand the lungs because of kyphosis of the spine.

b. An increased AP diameter is characteristic of a barrel chest, in which the AP diameter is about equal to the side-to-side diameter. Normally the AP diameter should be one third to one half the side-to-side diameter. A prominent protrusion of the sternum is the pectus carinatum and diminished movement of the two sides of the chest indicates decreased chest excursion. Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion.

During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To care for the tracheostomy appropriately, what should the nurse do? a. Deflate the cuff, then remove and suction the inner cannula. b. Remove the inner cannula and replace it per institutional guidelines. c. Remove the inner cannula if the patient shows signs of airway obstruction. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube.

b. An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used, but nondisposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur. Cuff deflation is no longer recommended. When signs of airway obstruction occur, suction is needed.

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.

What causes the pulmonary vasoconstriction leading to the development of cor pulmonale in the patient with COPD? a. Increased viscosity of the blood b. Alveolar hypoxia and hypercapnia c. Long-term low-flow oxygen therapy d. Administration of high concentrations of oxygen

b. Constriction of the pulmonary vessels, leading to pulmonary hypertension, is caused by alveolar hypoxia and the acidosis that results from hypercapnia. Polycythemia is a contributing factor in cor pulmonale because it increases the viscosity of blood and the pressure needed to circulate the blood but does not cause vasoconstriction. Long-term low-flow oxygen therapy dilates pulmonary vessels and is used to treat cor pulmonale. High oxygen administration is not related to cor pulmonale.

What is included in the nursing care of the patient with a cuffed tracheostomy tube? a. Change the tube every 3 days. b. Monitor cuff pressure every 8 hours. c. Perform mouth care every 12 hours. d. Assess arterial blood gases every 8 hours

b. Cuff pressure should be monitored at least every 8 hours to ensure that an air leak around the cuff does not occur and that the pressure is not too high to allow adequate tracheal capillary perfusion. Respiratory therapists in some institutions will record the cuff pressure, but the nurse must be able to assess cuff pressure and identify if there is a problem maintaining cuff pressure. Tracheostomy tubes are changed monthly when needed for long-term use. Mouth care should be performed a minimum of every 8 hours and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue.

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

Priority Decision: A patient is admitted to the emergency department with an acute asthma attack. Which patient assessment is of greatest concern to the nurse? a. The presence of a pulsus paradoxus b. Markedly diminished breath sounds with no wheezing c. A respiratory rate of 34 and increased pulse and blood pressure d. Use of accessory muscles of respiration and a feeling of suffocation

b. Diminished or absent breath sounds may indicate a significant decrease in air movement resulting from exhaustion and an inability to generate enough muscle force to ventilate and is an ominous sign. The other symptoms are expected in an asthma attack but are not life threatening.

To what was the resurgence in tuberculosis (TB) resulting from the emergence of multidrug-resistant (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 follow-up 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.

Which dietary modification helps to meet the nutritional needs of patients with COPD? a. Eating a high-carbohydrate, low-fat diet b. Avoiding foods that require a lot of chewing c. Preparing most foods of the diet to be eaten hot d. Drinking fluids with meals to promote digestion

b. Eating is an effort for patients with COPD, and frequently these patients do not eat because of fatigue, dyspnea, altered taste, and decreased appetite. Foods that require much chewing cause more exhaustion and should be avoided. A low-carbohydrate diet is indicated if the patient has hypercapnia because carbohydrates are metabolized into carbon dioxide. Cold foods seem to give less of a sense of fullness than hot foods, and fluids should be avoided at meals to prevent a full stomach.

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.

The nurse recognizes that additional teaching is needed when the patient with asthma says a. "I should exercise every day if my symptoms are controlled." b. "I may use over-the-counter bronchodilator drugs occasionally if I develop chest tightness." c. "I should inform my spouse about my medications and how to get help if I have a severe asthma attack." d. "A diary to record my medication use, symptoms, peak expiratory flow rates, and activity levels will help in adjusting my therapy."

b. Nonprescription drugs should not be used by patients with asthma because of dangers associated with rebound bronchospasm, interactions with prescribed drugs, and undesirable side effects. All of the other responses are appropriate for the patient with asthma.

What is an indication of marked bronchoconstriction with air trapping and hyperinflation of the lungs in a patient with asthma? a. SaO2 of 85% b. PEF rate of <150 L/min c. FEV1 of 85% of predicted d. Chest x-ray showing a flattened diaphragm

b. Peak expiratory flow rates are normally up to 600 L/ min and in a severe asthma attack may be as low as 100 to 150 L/min. An SaO2 of 85% and a FEV1 of 85% of predicted are typical of mild to well controlled asthma. A flattened diaphragm may be present in the patient with long-standing asthma but does not reflect current bronchoconstriction.

What should the nurse include in discharge teaching for the patient with a total laryngectomy? a. How to use esophageal speech to communicate b. How to use a mirror to suction the tracheostomy c. The necessity of never covering the laryngectomy stoma d. The need to use baths instead of showers for personal hygiene

b. Suctioning of the tracheostomy with the use of a mirror is a self-care activity taught to the patient before discharge. Voice rehabilitation is usually managed by a speech therapist or speech pathologist, but the nurse should discuss the various types of voice rehabilitation and the advantages and disadvantages of each option. The laryngectomy stoma should be covered with a shield during showering and covered with light scarves or fabric when aspiration of foreign materials is likely.

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.

What covers the larynx during swallowing? a. Trachea b. Epiglottis c. Turbinates d. Parietal pleura

b. The epiglottis is a small flap closing over the larynx during swallowing. The trachea connects the larynx and the bronchi. The turbinates in the nose warm and moisturize inhaled air. The parietal pleura is a membrane that lines the chest cavity.

What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? a. Undergo weekly immunotherapy. b. Identify and avoid triggers of the allergic reaction. c. Use cromolyn nasal spray prophylactically year round. d. Use over-the-counter antihistamines and decongestants during an acute attack

b. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion.

What is characteristic of a partial rebreather mask? a. Used for long-term O2 therapy b. Reservoir bag conserves oxygen c. Provides highest oxygen concentrations d. Most comfortable and causes the least restriction on activities

b. The partial rebreather mask has O2 flow into the reservoir bag and mask during inhalation. The O2- conserving cannula is used for long-term therapy at home versus during hospitalization. The Venturi mask is able to deliver the highest concentrations of O2. The nasal cannula is the most comfortable and mobile delivery device.

Priority Decision: To decrease the patient's sense of panic during an acute asthma attack, what is the best action for the nurse to do? a. Leave the patient alone to rest in a quiet, calm environment. b. Stay with the patient and encourage slow, pursed lip breathing. c. Reassure the patient that the attack can be controlled with treatment. d. Let the patient know that frequent monitoring is being done using measurement of vital signs and SpO2.

b. The patient in an acute asthma attack is very anxious and fearful. It is best to stay with the patient and interact in a calm, unhurried manner. Helping the patient to breathe with pursed lips will facilitate expiration of trapped air and help the patient to gain control of breathing. Pursed lip breathing is also used with COPD for this same reason. The other options will not decrease the panic of an acute asthma attack.

Meeting the developmental tasks of young adults with cystic fibrosis becomes a major problem primarily because a. they eventually need a lung transplant. b. they must also adapt to a chronic disease. c. any children they have will develop cystic fibrosis. d. their illness keeps them from becoming financially independent.

b. The presence of a chronic disease that is present at birth, delayed sexual development, difficulty in marrying and having children, and the many treatments needed by those with CF affects all relationships and development of these patients. Although a lung transplant may be needed, not all CF patients need one. Not all children will inherit CF (e.g., 25% chance for offspring with both parents having the defective gene). Many men with CF are sterile, and women may have difficulty becoming pregnant. Educational and vocational goals may be met in those who maintain treatment programs and health.

When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? a. Long-term denture use b. Heavy tobacco and/or alcohol use c. Persistent swelling of the neck and face d. Chronic herpes simplex infections of the mouth and lips

b. The primary risk factors associated with head and neck cancers are heavy tobacco and alcohol use. Oral cancer may cause a change in the fit of dentures, but denture use is not a risk factor for oral cancer. Chronic infections are not known to be risk factors, although cancers in patients younger than age 50 have been associated with human papillomavirus (HPV) infection.

The patient has had COPD for years, and his ABGs usually show hypoxia (PaO2 <60 mm Hg or SaO2 <88%) and hypercapnia (PaCO2 >45 mm Hg). Which ABG results show movement toward respiratory acidosis and further hypoxia indicating respiratory failure? a. pH 7.35, PaO2 62 mm Hg, PaCO2 45 mm Hg b. pH 7.34, PaO2 45 mm Hg, PaCO2 65 mm Hg c. pH 7.42, PaO2 90 mm Hg, PaCO2 43 mm Hg d. pH 7.46, PaO2 92 mm Hg, PaCO2 32 mm Hg

b. These results show worsening respiratory function and failure with the pH at 7.34, the lower PaO2, and the higher PaCO2. The pH results of 7.35 and 7.42 show potential normal results for the patient described. The pH of 7.46 shows alkalosis, probably respiratory with the low PaCO2, but the HCO3− results are needed to be sure.

What is the most normal functioning method of speech restoration for the patient with a total laryngectomy? a. Esophageal speech b. A transesophageal puncture c. An electrolarynx held to the neck d. An electrolarynx placed in the mouth

b. Transesophageal puncture provides the most normal voice reproduction but requires a surgical fistula made between the esophagus and the trachea and a valve prosthesis. Esophageal speech involves air trapped in the esophagus and expelled past the pharyngoesophageal segment, but it is difficult, takes a lot of time, and voice quality is reduced. The electrolarynx, whether placed in the mouth or held to the neck, allows speech that has a metallic or robotic sound.

Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? a. Stridor b. Finger clubbing c. Tracheal deviation d. Limited chest expansion e. Increased tactile fremitus f. Use of accessory muscles

c, d, e. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Stridor is identified with auscultation. Finger clubbing and accessory muscle use are identified with inspection.

A patient is being discharged with plans for home O2 therapy provided by an O2 concentrator with a portable O2-concentrator unit. In preparing the patient to use the equipment, what should the nurse teach the patient? a. The portable unit will last about 6 to 8 hours. b. The unit is strictly for portable and emergency use. c. The unit concentrates O2 from the air, providing a continuous O2 supply. d. Weekly delivery of one large cylinder of O2 will be necessary for a 7- to 10-day supply of O2.

c. Oxygen concentrators or extractors continuously supply O2 concentrated from the air. Portable liquid O2 units will hold about 6 to 8 hours of O2, but because of the expense they are only used for portable and emergency use. Portable O2-conserving units slow the use of oxygen. Compressed O2 comes in various tank sizes, but generally it requires weekly deliveries of four to five large tanks to meet a 7- to 10-day supply.

What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? a. A tracheostomy is safer to perform in an emergency. b. An ET tube has a higher risk of tracheal pressure necrosis. c. A tracheostomy tube allows for more comfort and mobility. d. An ET tube is more likely to lead to lower respiratory tract infection.

c. With a tracheostomy(versusanendotracheal[ET]tube), patient comfort is increased because there is no tube in the mouth. Because the tube is more secure, mobility is improved. The ET tube is more easily inserted in an emergency situation. It is preferable to perform a tracheostomy in the operating room because it requires careful dissection, but it can be performed with local anesthetic in the intensive care unit (ICU) or in an emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube, and infection is also as likely to occur because the defenses of the upper airway are bypassed.

Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? a. Patient with a fever b. Patient who is anesthetized c. Patient in hypovolemic shock d. Patient receiving oxygen therapy

c. Poor peripheral perfusion that occurs with hypovolemia or other conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may have to be used to monitor oxygenation status and ventilation status in these patients. Pulse oximetry would not be affected by fever or anesthesia and is a method of monitoring arterial oxygen saturation in patients who are receiving oxygen therapy.

How does the nurse assess the patient's chest expansion? a. Put the palms of the hands against the chest wall. b. Put the index fingers on either side of the trachea. c. Place the thumbs at the midline of the lower chest. d. Place one hand on the lower anterior chest and one hand on the upper abdomen.

c. To assess the extent and symmetry of chest movement, the nurse places the hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at the midline and then asks the patient to breathe deeply and observes the movement of the thumbs away from each other. The palms are placed against the chest wall to assess tactile fremitus. To determine the tracheal position, the nurse places the index fingers on either side of the trachea just above the suprasternal notch and gently presses backward.

Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. b. CO2 causes an increase in the amount of hydrogen ions available in the body. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume.

c. A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of cerebrospinal fluid and stimulates an increase in the respiratory rate. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid.

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) 500mg every 24hr 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.

When teaching the patient with mild asthma about the use of the peak flow meter, what should the nurse instruct the patient to do? a. Carry the flowmeter with the patient at all times in case an asthma attack occurs. b. Use the flowmeter to check the status of the patient's asthma every time the patient takes quick-relief medication. c. Follow the written asthma action plan (e.g., take quick-relief medication) if the expiratory flow rate is in the yellow zone. d. Use the flowmeter by emptying the lungs, closing the mouth around the mouthpiece, and inhaling through the meter as quickly as possible.

c. A yellow zone reading with the peak flow meter indicates that the patient's asthma is getting worse and quick-relief medications should be used. The meter is routinely used only each morning before taking medications after the personal best peak flow number has been determined and does not have to be on hand at all times. The meter measures the ability to empty the lungs and involves blowing through the meter.

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 low-grade 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 bronchiolitis is a late complication of lung transplantation, reflecting chronic rejection.

A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. On inspection, the throat is reddened and edematous with patchy yellow exudates. The nurse anticipates that interprofessional management will include a. treatment with antibiotics. b. treatment with antifungal agents. c. a throat culture or rapid strep antigen test. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days

c. Although inadequately treated β-hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. The manifestations of viral, fungal, and bacterial infections are similar, and appearance is not diagnostic except when the white, irregular patches on the oropharynx suggest that candidiasis is present.

What accurately describes the alveolar sacs? a. Line the lung pleura b. Warm and moisturize inhaled air c. Terminal structures of the respiratory tract d. Contain dead air that is not available for gas exchange

c. Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. Turbinates warm and moisturize inhaled air. The 150 mL of air is dead space in the trachea and bronchi.

Which respiratory defense mechanism is most impaired by smoking? a. Cough reflex b. Filtration of air c. Mucociliary clearance d. Reflex bronchoconstriction

c. Ciliary action impaired by smoking and increased mucus production may be caused by the irritants in tobacco smoke, leading to impairment of the mucociliary clearance system. Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages.

What is the pathophysiologic mechanism of cystic fibrosis leading to obstructive lung disease? a. Fibrosis of mucous glands and destruction of bronchial walls b. Destruction of lung parenchyma from inflammation and scarring c. Production of secretions low in sodium chloride and resulting thickened mucus d. Increased serum levels of pancreatic enzymes that are deposited in the bronchial mucosa

c. Cystic fibrosis (CF) is an autosomal recessive, multisystem disease involving gene mutations that make secretions of the lungs, pancreas, intestines low in sodium chloride and thus water, so they are abnormally thick and sticky. This leads to a chronic, diffuse, obstructive pulmonary disorder in almost all patients, whereas exocrine pancreatic insufficiency occurs in about 85% to 90% of patients with CF. Fibrosis occurs in the subepithelium of the lungs and pancreas, which plugs the exocrine ducts. Bronchiectasis occurs when bronchial walls are changed.

The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? a. Inspection b. Palpation c. Percussion d. Auscultation

c. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques.

A patient with asthma has the following arterial blood gas (ABG) results early in an acute asthma attack: pH 7.48, PaCO2 30 mm Hg, PaO2 78 mm Hg. What is the most appropriate action by the nurse? a. Prepare the patient for mechanical ventilation. b. Have the patient breathe in a paper bag to raise the PaCO2. c. Document the findings and monitor the ABGs for a trend toward acidosis. d. Reduce the patient's oxygen flow rate to keep the PaO2 at the current level.

c. Early in an asthma attack, an increased respiratory rate and hyperventilation create a respiratory alkalosis with increased pH and decreased PaCO2, accompanied by hypoxemia. As the attack progresses, pH shifts to normal, then decreases, with arterial blood gases (ABGs) that reflect respiratory acidosis with hypoxemia. During the attack, high-flow oxygen should be provided. Breathing in a paper bag, although used to treat some types of hyperventilation, would increase the hypoxemia.

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.

What does the nurse include when planning for postural drainage for the patient with COPD? a. Schedules the procedure 1 hour before and after meals b. Has the patient cough before positioning to clear the lungs c. Assesses the patient's tolerance for dependent (head-down) positions d. Ensures that percussion and vibration are performed before positioning the patient

c. Many postural drainage positions require placement in Trendelenburg position, but patients with head injury, heart disease, hemoptysis, chest trauma, and others should not be placed in these positions. Postural drainage should be done 1 hour before and 3 hours after meals if possible. Coughing, percussion, and vibration are all performed after the patient has been positioned.

Why is the classification of pneumonia as community-acquired pneumonia (CAP) or hospital-acquired 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.

Priority Decision: A pulse oximetry monitor indicates that the patient has a drop in SpO2 from 95% to 85% over several hours. What is the first action the nurse should take? a. Order stat ABGs to confirm the SpO2 with a SaO2. b. Start oxygen administration by nasal cannula at 2 L/min. c. Check the position of the probe on the finger or earlobe. d. Notify the health care provider of the change in baseline PaO2.

c. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Before other measures are taken, the nurse should check the probe site. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status.

Which breathing technique should the nurse teach the patient with moderate COPD to promote exhalation? a. Huff coughing b. Thoracic breathing c. Pursed lip breathing d. Diaphragmatic breathing

c. Pursed lip breathing prolongs exhalation and prevents bronchiolar collapse and air trapping. Huff coughing is a technique used to increase coughing patterns to remove secretions. Thoracic breathing is not as effective as diaphragmatic breathing and is the method most naturally used by patients with COPD. Diaphragmatic breathing emphasizes the use of the diaphragm to increase maximum inhalation, but it may increase the work of breathing and dyspnea.

What is a primary nursing responsibility after obtaining a blood specimen for ABGs? a. Add heparin to the blood specimen. b. Apply pressure to the puncture site for 2 full minutes. c. Take the specimen immediately to the laboratory in an iced container. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure.

c. Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1 minute) and taken directly to the lab. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. Changes in oxygen therapy or interventions should be avoided for 15 minutes before the specimen is drawn because these changes might alter blood gas values.

What should the nurse include when teaching the patient with COPD about the need for physical exercise? a. All patients with COPD should be able to increase walking gradually up to 20 minutes per day. b. A bronchodilator inhaler should be used to relieve exercise-induced dyspnea immediately after exercise. c. Shortness of breath is expected during exercise but should return to baseline within 5 minutes after the exercise. d. Monitoring the heart rate before and after exercise is the best way to determine how much exercise can be tolerated.

c. Shortness of breath usually increases during exercise, but the activity is not being overdone if breathing returns to baseline within 5 minutes after stopping. Bronchodilators can be administered 10 minutes before exercise but should not be administered for at least 5 minutes after activity to allow recovery. Patients are encouraged to walk 15 to 20 minutes per day with gradual increases, but actual patterns will depend on patient tolerance. Dyspnea most frequently limits exercise and is a better indication of exercise tolerance than is heart rate in the patient with COPD.

Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? a. Provide tracheostomy care every 24 hours. b. Keep the patient in the semi-Fowler's position at all times. c. Keep a same-size or larger replacement tube at the bedside. d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy.

d, e. Changing the tracheostomy tapes soon after placement of the tracheostomy will be irritating to the trachea and could contribute to dislodgement of the tracheostomy tube. Suctioning should be done when increased secretions are evident in the tube to prevent the patient from severe coughing, which could cause tube dislodgement. Tracheostomy care is done every 8 hours. Keeping the patient in a semi-Fowler's position will not prevent dislodgement. Keeping an extra tube at the bedside will speed reinsertion if the tracheostomy tube is dislodged, but it will not prevent dislodgement. The physician will not change the trach tube until the insertion site is healed, approximately 3 to 5 days after original insertion.

A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. When is the nurse considered infected? a. There is no redness or induration at the injection site. b. There is an induration of only 5 mm at the injection site. c. A negative skin test is followed by a negative chest x-ray. d. Testing causes a 10-mm red, indurated area at the injection site.

d. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Because antibody production in response to infection with the TB bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, two-step testing is recommended for individuals likely to be tested often, such as health care professionals. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. All other answers indicate a negative response to skin testing.

The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. For which problem is this test most commonly used as a diagnostic measure? a. Tuberculosis (TB) b. Cancer of the lung c. Airway obstruction d. Pulmonary embolism

d. A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray or CT scan, MRI, or PET scans. Airway obstruction is most often diagnosed with pulmonary function testing.

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

Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. What is the first patient assessment the nurse should make? a. Patient's temperature b. Level of the patient's pain c. Drainage on the nasal dressing d. Oxygen saturation by pulse oximetry

d. All of the assessments are appropriate, but the most important is the patient's oxygen status. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration, and the nurse should monitor the patient's respiratory rate and rhythm and SpO2.

Which values indicate a need for the use of continuous oxygen therapy? a. SpO2 of 92%; PaO2 of 65mm Hg b. SpO2 of 95%; PaO2 of 70mm Hg c. SpO2 of 90%; PaO2 of 60mm Hg d. SpO2 of 88%; PaO2 of 55mm Hg

d. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy. (see Table 25-3). These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur, but will affect the patients' activity tolerance.

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.

During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? a. Cough and sore throat b. Copious nasal discharge c. Temperature of 100°F (38°C) d. Dyspnea and severe sinus pain

d. Dyspnea and severe sinus pain as well as tender swollen glands, severe ear pain, or significantly worsening symptoms or changes in sputum characteristics in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Cough, sore throat, low-grade elevated temperature, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza.

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.

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.

In an adult patient with bronchiectasis, what is a nursing assessment likely to reveal? a. Chest trauma b. Childhood asthma c. Smoking or oral tobacco use d. Recurrent lower respiratory tract infectio

d. In adults, most forms of bronchiectasis are associated with bacterial infections that damage the bronchial walls. In children, cystic fibrosis is the prominent cause of bronchiectasis. The incidence of bronchiectasis has decreased with the use of measles and pertussis vaccines and better treatment of lower respiratory tract infections.

Tobacco smoke causes defects in multiple areas of the respiratory system. What is a long-term effect of smoking? a. Bronchospasm and hoarseness b. Decreased mucus secretions and cough c. Increased function of alveolar macrophages d. Increased risk of infection and hyperplasia of mucous glands

d. Increased risk of infection, hyperplasia of mucous glands, cancer, chronic cough, chronic bronchitis, and COPD are the long-term effects of smoking. Bronchospasm and hoarseness are acute effects of smoking.

Priority Decision: In planning care for the patient with bronchiectasis, which nursing intervention is the priority? a. Relieve or reduce pain b. Prevent paroxysmal coughing c. Prevent spread of the disease to others d. Promote drainage and removal of mucus

d. Mucus production is increased in bronchiectasis and collects in the dilated, pouched bronchi. A major goal of treatment is to promote drainage and removal of the mucus, primarily through ACT, including deep breathing, coughing, and especially postural drainage. Pleuritic chest pain and prevention of coughing will occur with the removal of mucus. The disease is not contagious.

A patient's ABGs include a PaO2 of 88 mm Hg and a PaCO2 of 38 mm Hg, and mixed venous blood gases include a PvO2 of 40 mm Hg and PvCO2 of 46 mm Hg. What do these findings indicate? a. Impaired cardiac output b. Unstable hemodynamics c. Inadequate delivery of oxygen to the tissues d. Normal capillary oxygen-carbon dioxide exchange

d. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. The pH is also decreased in mixed venous blood gases because of the higher PvCO2. Normal mixed venous blood gases also have much lower PvO2 and SvO2 than ABGs. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues.

The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. How should the nurse document this sound? a. Stridor b. Bronchophony c. Course crackles d. Pleural friction rub

d. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. Stridor is a continuous musical or crowing sound and unrelated to pneumonia. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. See Table 25-8 for more thorough descriptions of these sounds and their possible etiologies and significance.

What is the primary principle involved in the various airway clearance devices used for mobilizing secretions? a. Vibration b. Inhalation therapy c. Chest physiotherapy d. Positive expiratory pressure

d. Positive expiratory pressure (PEP) is the principle behind the airway clearance devices that mobilize secretions and benefit patients. Vibration, a form of chest physiotherapy, and inhalation therapy are therapies to assist patients with excessive secretions or to increase bronchodilation, but they are not principles of airway clearance device function.

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.

While assisting a patient with intermittent asthma to identify specific triggers of asthma, what should the nurse explain? a. Food and drug allergies do not manifest in respiratory symptoms. b. Exercise-induced asthma is seen only in individuals with sensitivity to cold air. c. Asthma attacks are psychogenic in origin and can be controlled with relaxation techniques. d. Viral upper respiratory infections are a common precipitating factor in acute asthma attacks.

d. Respiratory infections are one of the most common precipitating factors of an acute asthma attack. Sensitivity to food and drugs may also precipitate attacks, and exercise-induced asthma occurs after exercise, especially in cold, dry air. Psychologic factors may interact with the asthmatic response to worsen the disease, but it is not a psychosomatic disease.

In addition to smoking cessation, what treatment is included for COPD to slow the progression of the disease? a. Use of bronchodilator drugs b. Use of inhaled corticosteroids c. Lung volume-reduction surgery d. Prevention of respiratory tract infections

d. Smoking cessation is one of the most important factors in preventing further damage to the lungs in COPD, but prevention of infections that further increase lung damage is also important. The patient is very susceptible to infections, and these infections make the disease worse, creating a vicious cycle. Bronchodilators, inhaled corticosteroids, and lung volume-reduction surgery help to control symptoms, but these are symptomatic measures.

The husband of a patient with severe COPD tells the nurse that he and his wife have not had any sexual activity since she was diagnosed with COPD because she becomes too short of breath. What is the nurse's best response? a. "You need to discuss your feelings and needs with your wife so that she knows what you expect of her." b. "There are other ways to maintain intimacy besides sexual intercourse that will not make her short of breath." c. "You should explore other ways to meet your sexual needs since your wife is no longer capable of sexual activity." d. "Would you like me to talk with you and your wife about some modifications that can be made to maintain sexual activity?"

d. Specific guidelines for sexual activity help to preserve energy and prevent dyspnea, and maintenance of sexual activity is important to the healthy psychologic well-being of the patient. Open communication between partners is needed so that the modifications can be made with consideration of both partners.

A male 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.

When teaching the patient about going from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI), which statement by the patient shows the nurse that the patient needs more teaching? a. "I do not need to use the spacer like I used to." b. "I will hold my breath for 10 seconds or longer if I can." c. "I will not shake this inhaler like I did with my old inhaler." d. "I will store it in the bathroom so I will be able to clean it when I need to."

d. Storing the dry powder inhaler (DPI) in the bathroom will expose it to moisture, which could cause clumping of the medication and an altered dose. The other statements show patient understanding.

Priority Decision: Which medication should the nurse anticipate being used first in the emergency department for relief of severe respiratory distress related to asthma? a. Prednisone orally b. Tiotropium inhaler c. Fluticasone inhaler d. Albuterol nebulizer

d. The albuterol nebulizer will rapidly cause bronchodilation and be easier to use in an emergency situation than an inhaler. It will be used every 20 minutes to 4 hours as needed. The tiotropium inhaler is only approved for COPD. Oral or inhaled corticosteroids will be used to decrease the inflammation and provide better symptom control after the emergency situation is over.

What is the most effective treatment for cystic fibrosis? a. Heart-lung transplant b. Administration of prophylactic antibiotics c. Administration of nebulized bronchodilators d. Vigorous and consistent airway clearance techniques

d. The major objectives of therapy in CF are to relieve airway obstruction and control infection. Airway clearance techniques (ACT) are the mainstay of treatment. Aerobic exercise is also effective in clearing the airways, requiring increased nutrition and fluid, plus salt loss replacement. Antibiotics are used for early signs of infection, and long courses are necessary, but they are not used prophylactically. Bronchodilators have shown no long-term benefit. Although CF has become a leading indication for heart-lung transplant, this treatment option may not be available for many patients.

A 73-year-old patient has an SpO2 of 70%. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? a. What the oxygenation status is with a stress test b. Trend and rate of development of the hyperkalemia c. Comparison of patient's SpO2 values with the normal values d. Comparison of patient's current vital signs with normal vital signs

d. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. The position of the oximeter should also be assessed. The oxygenation status with a stress test would not assist the nurse in caring for the patient now. Hyperkalemia is not occurring and will not directly affect oxygenation initially. The SpO2 compared with normal values will not be helpful in this older patient or in a patient with respiratory disease as the patient's expected normal will not be the same as standard normal values.

Priority Decision: During an acute exacerbation of mild COPD, the patient is severely short of breath, and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to alveolar hypoventilation and anxiety. What is the best nursing action? a. Prepare and administer routine bronchodilator medications. b. Perform chest physiotherapy to promote removal of secretions. c. Administer oxygen at 5 L/min until the shortness of breath is relieved. d. Position the patient upright with the elbows resting on the over-the-bed table.

d. The tripod position with an elevated backrest and supported upper extremities to fix the shoulder girdle maximizes respiratory excursion and an effective breathing pattern. Staying with the patient and encouraging pursed lip breathing also helps. Rescue short-acting, not routine bronchodilators, will be ordered but can also increase nervousness and anxiety. Postural drainage is not tolerated by a patient in acute respiratory distress, and oxygen is titrated to an effective rate based on ABGs because of the possibility of carbon dioxide narcosis.

Which obstructive pulmonary disease would a 30-yr-old white female patient with a parent with the disease be most likely to be diagnosed with? a. COPD b. Asthma c. Cystic fibrosis d. α1-Antitrypsin (AAT) deficiency

d. α1-Antitrypsin (AAT) deficiency is an autosomal recessive disorder that is a genetic risk factor for COPD with symptoms (often by age 40) in people with no tobacco use and family history of COPD or liver disease. AAT occurs in approximately 3% of people diagnosed with COPD. Although cystic fibrosis occurs in 1 in 3000 white births, legislation requires babies to be screened at birth, so it would have been previously diagnosed. Asthma is a multifactorial genetic disorder.

What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? a. The cuff passively fills with air. b. Cuff pressure monitoring is not required. c. It has two tubings with one opening just above the cuff. d. Patient can speak with an attached air source with the cuff inflated. e. Airway obstruction is likely if the exact steps are not followed to produce speech. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted.

e, f. The fenestrated tracheostomy tube has openings on the outer cannula to allow air to pass over the vocal cords to allow speaking. If the steps of using the fenestrated tracheostomy tube are not completed in the correct order, severe respiratory distress may result. The cuff of the tracheostomy tube with a foam-filled cuff passively fills with air and does require pressure monitoring, although cuff integrity must be assessed daily. The speaking tracheostomy tube has two tubes attached. One tube allows air to pass over the vocal cords to enable the person to speak with the cuff inflated.