NUR320 Chap 23
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
= "Viruses like influenza are the most common cause of pneumonia." Influenza type A is the most common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action . Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection . Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
= 6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?
= Apply ice and keep the patient's head elevated. Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated.
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?
= 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.
Which intervention does a nurse implement for clients with empyema?
= Encourage breathing exercises Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.
A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan?
= Wearing a disposable particulate respirator that fits snugly around the face Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face when entering the client's room. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. 수혜자가 항상 마스크를 착용하게하면 가래 객담을 방해하고 호흡하면 마스크가 촉촉해집니다. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?
=A positive reaction indicates that the client has been exposed to the disease. The purified protein derivative test confirms whether someone has had exposure to tuberculosis, a serious infectious disease. A positive test result indicates that the person may have a tuberculosis infection, but it does not necessarily mean that they have active tuberculosis. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.
Which type of lung cancer is the most prevalent among both men and women?
=Adenocarcinoma Adenocarcinoma is most prevalent in both men and women and presents more peripherally as masses or nodules and often metastasizes. Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposure. Small cell carcinomas arise primarily as proximal lesions, but may arise in any part of the tracheobronchial tree.
Which action should the nurse take first in caring for a client during an acute asthma attack?
=Administer bronchodilator as ordered. Administering bronchodilator will dilate the airway and allow oxygen to reach the lungs. Although ABGs and chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?
=Developing a list of people with whom the client has had contact To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.
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?
=Encourage increased fluid intake. Antibiotics are not given for viral pneumonia. 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?
=Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
=Few early symptoms
A nurse observes a new environmental services employee enter the room of a client with 코로나 속해 잇음 severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse?
=The employee enters the room wearing a gown, gloves, and a mask. The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. To prevent the spread of infection, a stethoscope, blood pressure cuff, and thermometer for single client use should be kept in the room of a client who requires isolation. Removing all personal protective equipment and washing hands before leaving the client's room are correct procedures.
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
=Vitamin B6 Isoniazid = Description Antibiotics It can treat and prevent tuberculosis (TB).
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
=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.
Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as
=primary drug resistance. Primary drug resistance refers to resistance to one of the first-line antituberculotic agents in people who have not received previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in clients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:
continue to take antibiotics for the entire 10 days. = The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. 재발 The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.
What dietary recommendations should a nurse provide a client with a lung abscess?
=A diet rich in protein For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state.
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?
=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.
What does the nurse know is the most common organism that causes community-acquired pneumonia?
=Streptococcus pneumoniae Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.
A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.
A chest radiograph Complete history and physical examination Drug susceptibility testing =Once a client had a positive skin test or a positive sputum culture for acid-fast bacilli, additional tests such as complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing are done. The nurse does not need to teach about a complete blood count or a repeat multiple puncture skin test, as the initial positive skin test will serve as the indicator of tuberculosis.
