Med/Surg Ch 23 PU

Which of the following is a potential complication of a low pressure in the endotracheal cuff? 1. Aspiration pneumonia 2. Tracheal bleeding 3. Tracheal ischemia 4. Pressure necrosis

1. Aspiration pneumonia

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? 1. Crackles in the lung bases 2. Low-pitched rhonchi during expiration 3. Pleural friction rub 4. Sibilant wheezes

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

What is the reason for chest tubes after thoracic surgery? 1. Draining secretions, air, and blood from the thoracic cavity is necessary. 2. Chest tubes allow air into the pleural space. 3. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. 4. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

1. Draining secretions, air, and blood from the thoracic cavity is necessary.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? 1. Encourage breathing exercises. 2. Institute droplet precautions. 3. Place suspected patients together. 4. Do not allow visitors with respiratory infection.

1. Encourage breathing exercises.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? 1. Initiate oxygen therapy. 2. Administer a heparin bolus and begin an infusion at 500 units/hour. 3. Administer analgesics as ordered. 4. Perform nasopharyngeal suctioning.

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

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? 1. Progressive loss of lung function associated with chronic disease 2. Sudden loss of lung function associated with chronic disease 3. Progressive loss of lung function with history of normal lung function 4. Sudden loss of lung function with history of normal lung function

1. Progressive loss of lung function associated with chronic disease

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? 1. Rapid onset of severe dyspnea 2. Inspiratory crackles 3. Bilateral wheezing 4. Cyanosis

1. 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.

A mediastinal shift occurs in which type of chest disorder? 1. Tension pneumothorax 2. Traumatic pneumothorax 3. Simple pneumothorax 4. Cardiac tamponade

1. Tension pneumothorax

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? 1. Tension pneumothorax 2. Cardiac tamponade 3. Flail chest 4. Pulmonary contusion

1. Tension pneumothorax

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? 1. Vitamin B6 2. Vitamin C 3. Vitamin D 4. Vitamin E

1. Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as 1. pleural effusion. 2. pneumothorax. 3. hemothorax. 4. consolidation.

1. pleural effusion.

Which action should the nurse take first in caring for a client during an acute asthma attack? 1. Obtain arterial blood gases. 2. Send for STAT chest x-ray. 3. Administer bronchodilator as ordered. 4. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

3. Administer bronchodilator as ordered.

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? 1. Mobilizing early 2. Using incentive spirometry 3. Receiving vaccinations 4. Using prescribed opioids

3. Receiving vaccinations

The nurse knows the mortality rate is high in lung cancer clients due to which factor? 1. Increase in women smokers 2. Increased incidence among the elderly 3. Increased exposure to industrial pollutants 4. Few early symptoms

4. Few early symptoms

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? 1. Staphylococcus aureus 2. Mycobacterium tuberculosis 3. Pseudomonas aeruginosa 4. Streptococcus pneumoniae

4. Streptococcus pneumoniae

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? 1. Cough 2. Hemoptysis 3. Syncope 4. Tachypnea

4. Tachypnea

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? 1. "You must consume a diet rich in protein, such as chicken, fish, and beans." 2. "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." 3. "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." 4. "You must consume a diet low in fat by limiting dairy products and concentrated sweets."

1. "You must consume a diet rich in protein, such as chicken, fish, and beans."

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? 1. 0 to 4 mm 2. 5 to 6 mm 3. 7 to 8 mm 4. 9 mm

1. 0 to 4 mm

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? 1. Institute isolation precautions. 2. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. 3. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. 4. Obtain a sputum specimen for enzyme immunoassay testing.

1. Institute isolation precautions.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? 1. Intubate the client and control breathing with mechanical ventilation 2. Increase oxygen administration 3. Administer a large dose of furosemide (Lasix) IVP stat 4. Schedule the client for pulmonary surgery

1. Intubate the client and control breathing with mechanical ventilation

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? 1. Negative 2. Positive 3. Borderline 4. Uncertain

1. Negative

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? 1. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. 2. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. 3. The client exhibits restlessness and confusion. 4. The client exhibits bronchial breath sounds over the affected area.

1. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to: 1. asbestos. 2. silica. 3. coal dust. 4. pollen.

1. asbestos.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? 1. pH 7.28, PaO2 50 mm Hg 2. pH 7.46, PaO2 80 mm Hg 3. pH 7.36, PaCO2 32 mm Hg 4. pH 7.35, PaCO2 48 mm Hg

1. pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows 1. redness and induration. 2. drainage. 3. tissue sloughing. 4. bruising.

1. redness and induration.

A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient? 1. "Only wear your contact lenses during the day and take them out in the evening before bed." 2. "You should switch to wearing your glasses while taking this medication." 3. "The physician can give you eye drops to prevent any problems." 4. "There are no significant problems with wearing contact lenses."

2. "You should switch to wearing your glasses while taking this medication."

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? 1. The X-ray is inconclusive. 2. A disease process is present. 3. The ET tube must be advanced. 4. The ET tube must be pulled back.

2. A disease process is present.

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? 1. A positive reaction indicates that the client has active tuberculosis (TB). 2. A positive reaction indicates that the client has been exposed to the disease. 3. A negative reaction always excludes the diagnosis of TB. 4. The PPD can be read within 12 hours after the injection.

2. A positive reaction indicates that the client has been exposed to the disease.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? 1. Atelectasis 2. Acute respiratory distress syndrome 3. Metabolic alkalosis 4. Respiratory acidosis

2. Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? 1. Droplet precautions 2. Airborne and contact precautions 3. Contact and droplet precautions 4. Contact precautions

2. Airborne and contact precautions

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? 1. Ascites 2. Dyspnea 3. Hypertension 4. Syncope

2. Dyspnea

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? 1. Pneumothorax 2. Flail chest 3. ARDS 4. Tension pneumothorax

2. Flail chest

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? 1. Decreased heart rate 2. Increased restlessness 3. Increased blood pressure 4. Decreased level of consciousness (LOC)

2. Increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? 1. Respiratory acidosis 2. Paradoxical chest movement 3. Chest pain on inspiration 4. Clubbing of fingers and toes

2. Paradoxical chest movement

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: 1. follow up with the physician in 2 weeks. 2. continue to take antibiotics for the entire 10 days. 3. turn and reposition himself every 2 hours. 4. maintain fluid intake of 40 oz (1,200 ml) per day.

2. continue to take antibiotics for the entire 10 days.

Class 1 with regard to TB indicates 1. no exposure and no infection. 2. exposure and no evidence of infection. 3. latent infection with no disease. 4. disease that is not clinically active.

2. exposure and no evidence of infection

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? 1. 5-mm induration 2. Reddened area 3. 15-mm induration 4. A blister

3. 15-mm induration A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? 1. A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago 2. A client who ambulates in the hallway every 4 hours 3. A client with a nasogastric tube 4. A client who is receiving acetaminophen (Tylenol) for pain

3. A client with a nasogastric tube

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? 1. Aspiration 2. Drug ingestion 3. Chemical irritation 4. Direct lung damage

3. Chemical irritation

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? 1. Aspiration 2. Drug ingestion 3. Chemical irritation 4. Direct lung damage

3. Chemical irritation

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? 1. Administering oxygen, coughing, breathing deeply, and maintaining bed rest 2. Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer 3. Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer 4. Administering pain medications, frequent repositioning, and limiting fluid intake

3. Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? 1. Anxiety 2. Social isolation 3. Deficient knowledge (disease process and treatment regimen) 4. Impaired social interaction

3. Deficient knowledge (disease process and treatment regimen) treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? 1. Client teaching about the cause of TB 2. Reviewing the risk factors for TB 3. Developing a list of people with whom the client has had contact 4. Client teaching about the importance of TB testing

3. Developing a list of people with whom the client has had contact

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? 1. Give antibiotics as ordered. 2. Place client on bed rest. 3. Encourage increased fluid intake. 4. Offer nutritious snacks 2 times a day.

3. Encourage increased fluid intake. The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? 1. Turning the client every 2 hours 2. Elevating the head of the bed 30 degrees 3. Encouraging increased fluid intake 4. Maintaining a cool room temperature

3. Encouraging increased fluid intake

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? 1. "I will come back in 1 week to have the test read." 2. "If the test area turns red that means I have tuberculosis." 3. "I will avoid contact with my family until I am done with the test." 4. "Because I had a previous reaction to the test, this time I need to get a chest X-ray."

4. "Because I had a previous reaction to the test, this time I need to get a chest X-ray."

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? 1. "Chest tube will allow air to be restored to the lung." 2. "The tube will drain secretions from the lung." 3. "Chest tubes provide a route for medication instillation to the lung." 4. "The tube will drain air from the space around the lung."

4. "The tube will drain air from the space around the lung."

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? 1. Hyperoxemia, hypocapnia, and hyperventilation 2. Hypotension, hyperoxemia, and hypercapnia 3. Hyperventilation, hypertension, and hypocapnia 4. Hypercapnia, hypoventilation, and hypoxemia

4. Hypercapnia, hypoventilation, and hypoxemia

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? 1. Pain in the feet 2. Coolness to lower extremities 3. Decreased urinary output 4. Localized calf tenderness

4. Localized calf tenderness

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? 1. See if the chest tube is clogged. 2. See if the wall suction unit has malfunctioned. 3. See if a kink has developed in the tubing. 4. See if there are leaks in the system.

4. See if there are leaks in the system.

The most diagnostic clinical symptom of pleurisy is: 1. Dullness or flatness on percussion over areas of collected fluid. 2. Dyspnea and coughing. 3. Fever and chills. 4. Stabbing pain during respiratory movements.

4. Stabbing pain during respiratory movements.

The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer? 1. Symptoms are often minimized by clients. 2. There are no early symptoms of lung cancer. 3. Symptoms often mimic other infectious diseases. 4. Symptoms often do not appear until the disease is well established.

4. Symptoms often do not appear until the disease is well established.