NCLEX Lung and Thorax, Disorders
Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. A Auscultation of breath sounds B Auscultation of bowel sounds C Presence of chest pain D Presence of peripheral edema E Color of nail beds
A, C, E A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? A It is likely that the client is developing a secondary bacterial pneumonia. B The assessment findings are consistent with influenza and are to be expected. C The client is getting dehydrated and needs to increase her fluid intake to decrease secretions. D The client has not been taking her decongestants and bronchodilators as prescribed.
A. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.
A client with COPD reports steady weight loss and being "too tired from just breathing to eat." Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client? A Altered nutrition: Less than body requirements related to fatigue. B Activity intolerance related to dyspnea. C Weight loss related to COPD. D Ineffective breathing pattern related to alveolar hypoventilation.
A. The client's problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Activity intolerance is a likely diagnosis but is not related to the client's nutritional problems. Weight loss is not a nursing diagnosis. Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss described by the client.
A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A Dyspnea B Bradypnea C Bradycardia D Decreased respirations
A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.
A male client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? A Inflamed lung tissue B Sudden onset C Responsiveness to penicillin D Elevated white blood cell (WBC) count
A. The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Although most types of pneumonia have a sudden onset, a few (such as anaerobic bacterial pneumonia and mycoplasmal pneumonia) have an insidious onset. Antibiotic therapy is the primary treatment for most types of pneumonia; however, the antibiotic must be specific for the causative agent, which may not be responsive to penicillin. A few types of pneumonia, such as viral pneumonia, aren't treated with antibiotics. Although pneumonia usually causes an elevated WBC count, some types, such as mycoplasmal pneumonia, don't.
Which of the following is a priority goal for the client with COPD? A Maintaining functional ability B Minimizing chest pain C Increasing carbon dioxide levels in the blood D Treating infectious agents
A. A priority goal for the client with COPD is to manage the s/s of the disease process so as to maintain the client's functional ability. Chest pain is not a typical sign of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.
An elderly client with pneumonia may appear with which of the following symptoms first? A Altered mental status and dehydration B Fever and chills C Hemoptysis and dyspnea D Pleuritic chest pain and cough
A. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD? A Increased anteroposterior chest diameter B Underdeveloped neck muscles C Collapsed neck veins D Increased chest excursions with respiration
A. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump into pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.
he nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? A It helps prevent early airway collapse B It increases inspiratory muscle strength C It decreases use of accessory breathing muscles D It prolongs the inspiratory phase of respiration
A. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A Pallor B Low arterial PaO2 C Elevated arterial PaO2 D Decreased respiratory rate
B. The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? A Diaphragmatic breathing B Use of accessory muscles C Pursed-lip breathing D Controlled breathing
B. The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? A Hypocapnia B A hyperinflated chest noted on the chest x-ray C Increased oxygen saturation with exercise D A widened diaphragm noted on the chest x-ray
B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitation? A Chronic obstructive bronchitis B Emphysema C Bronchial asthma D Bronchial asthma and bronchitis
B. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, which is referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? A Encouraging the patient to drink three glasses of fluid daily B Keeping the patient in semi-fowler's position C Using a high-flow venturi mask to deliver oxygen as prescribe D Administering a sedative, as prescribe
C. The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: A Pleural effusion B Pulmonary edema C Atelectasis D Oxygen toxicity
C. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.
The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching? A Make inhalation longer than exhalation B Exhale through an open mouth C Use diaphragmatic breathing D Use chest breathing
C. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.
The most reliable index to determine the respiratory status of a client is to: A Observe the chest rising and falling B Observe the skin and mucous membrane color C Listen and feel the air movement D Determine the presence of a femoral pulse
C. To check for breathing, the nurse places her ear and cheek next to the client's mouth and nose to listen and feel for air movement. The chest rising and falling (1) is not conclusive of a patent airway. Observing skin color (2) is not an accurate assessment of respiratory status, nor is checking the femoral pulse.
A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? A Acute pain related to lung expansion secondary to lung infection B Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever C Anxiety related to dyspnea and chest pain D Ineffective airway clearance related to retained secretions
D. Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: A Promote oxygen intake B Strengthen the diaphragm C Strengthen the intercostal muscles D Promote carbon dioxide elimination
D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? A Activity intolerance related to fatigue B Anxiety related to actual threat to health status C Risk for infection related to retained secretions D Impaired gas exchange related to airflow obstruction
D. A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected? A Normal breath sounds B Prolonged inspiration C Normal chest movement D Coarse crackles and rhonchi
D. Exacerbations of COPD are frequently caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged antero-posterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.
Which of the following best describes pleural effusion? A The collapse of alveoli B The collapse of bronchiole C The fluid in the alveolar space D The accumulation of fluid between the linings of the pleural space
D. The pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion.