PNE 105 Adv. Med.Surg. Ch 21: Caring for Clients with Lower Respiratory Disorders. Prep U

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?

0 to 4 mm. Explanation: The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?

Consolidation Rationale: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.

What does a positive Mantoux test indicate?

Development of full-blown tuberculosis. Rationale: The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis.

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax?

Diminished or absent breath sounds on the affected side. Rationale: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

Dyspnea. Rationale: Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?

Elevated B-type natriuretic peptide (BNP) levels. Rationale: Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema.

A client with a pleural effusion was "tapped" to drain the fluid to reduce mediastinal pressure. Which primary condition would most likely have caused the pleural effusion?

Heart failure. Rationale: Pleural effusion may be a complication of pneumonia, lung cancer, TB, pulmonary embolism, and CHF.

Preventing falls in older adults directly correlates to preventing bone fractures. If an older adult falls and fractures one or more ribs, what is a possible complication that could develop after the fracture?

Pneumonia. Rationale: Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to pneumonia after a rib fracture.

A client continues to report dyspnea on exertion and overall weakness. A pulmonary artery catheter is placed and the mean pulmonary arterial pressure is 35 mm Hg. What condition is the client experiencing?

Pulmonary arterial hypertension. Explanation: Pulmonary hypertension (PH) is confirmed with a mean pulmonary artery pressure greater than 25 mm Hg. The main symptom of PH is dyspnea. Clients with restrictive lung disease, asthma, and atelectasis should not have PH.

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

Skin test doesn't differentiate between active and dormant tuberculosis infection. Rationale: The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?

Turn onto the affected side. Rationale: The nurse teaches the client to splint the chest wall by turning onto the affected side. The nurse also instructs the client to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The client can also splint the chest wall with a pillow when coughing.

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?

Turn onto the affected side. Rationale: Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6 Rationale: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

A client with a pleural effusion was "tapped" to drain the fluid to reduce mediastinal pressure. Which primary condition would most likely have caused the pleural effusion?

heart failure Explanation: Pleural effusion may be a complication of pneumonia, lung cancer, TB, pulmonary embolism, and CHF.

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?

Administer intradermal injections into the children's inner forearms. Rationale: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm.

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:

Asbestos. Rationale: Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.

A client with a pleural effusion was "tapped" to drain the fluid and reduce mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

5 - 15 ml Rationale: Under normal conditions, approximately 5 to 15 mL of fluid is between the pleurae prevent friction during pleural surface movement.

The nurse knows that a sputum culture is necessary to identify the causative organism for acute tracheobronchitis. What causative fungal organism would the nurse suspect?

Aspergillus. Rationale: In acute tracheobronchitis, the inflamed mucosa of the bronchi produces mucopurulent sputum, often in response to infection by Streptococcus pneumoniae, Haemophilus influenzae, or Mycoplasma pneumoniae. In addition, a fungal infection (e.g., Aspergillus) may also cause tracheobronchitis. A sputum culture is essential to identify the specific causative organism.

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication?

Atelectasis Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

For a client with pleural effusion, what does chest percussion over the involved area reveal?

Dullness over the involved area. Rationale: Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.

An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care?

Suction the client's airway secretions. Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals. Rationale: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.

Who is the FluMist vaccine is not recommended for? Select all that apply.

All of the options are correct. Rationale: The FluMist vaccine is not recommended for people with underlying medical conditions such as diabetes or renal dysfunction, people with known or suspected immunodeficiency diseases or those receiving immunosuppressive therapy, people with a history of Guillain-Barré syndrome, children or adolescents who regularly take aspirin, pregnant women, and people with a hypersensitivity to eggs.

What should a nurse pay careful attention to when monitoring a client with acute respiratory failure? Select all that apply.

Answer: a, b, d a. respiratory rate and depth b. signs of cyanosis d. response to treatment Rationale: When caring for a client with acute respiratory failure, the nurse must pay particular attention to respiratory rate and depth, signs of cyanosis, other signs and symptoms of respiratory distress, and the client's response to treatment. The nurse monitors ABG results and pulse oximetry findings and implements strategies to prevent respiratory complications, such as turning and ROM exercises.

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. Rationale: 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.

The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action?

Teach the client to splint the rib cage Explanation: Because the client has pain on inspiration, the nurse educates the client to use the hands or a pillow to splint the rib cage while coughing. Deep breathing and coughing would cause more pain, and pursed lip breathing would provide relief. The client is not in obvious respiratory distress, so there is no immediate need to contact the respiratory therapist.

A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?

"Client is becoming agitated and complains of pleuritic pain." Rationale: After a thoracentesis, the nurse monitors the client for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.

A resident in the long-term care facility has been experiencing a chronic, productive cough for the last 3 months. The client tells the nurse "this is just my winter cough." This client most likely has which condition?

Chronic bronchitis. Rationale: Chronic bronchitis is a prolonged (or extended) inflammation of the bronchi, accompanied by a chronic cough and excessive production of mucus for at least 3 months each year for 2 consecutive years. Heart failure is a possible complication of many upper respiratory disorders, including pneumonia and pleural effusion. Septicemia refers to infective microorganisms in the blood, a possible complication of pneumonia. Atelectasis is the collapse of alveoli, which may involve a small portion of the lung or an entire lobe. It is a complication of COPD.

The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action?

Contact the respiratory therapist promptly. Rationale: Because the client has pain on inspiration, the nurse educates the client to use the hands or a pillow to splint the rib cage while coughing. Deep breathing and coughing would cause more pain, and pursed lip breathing would provide relief. The client is not in obvious respiratory distress, so there is no immediate need to contact the respiratory therapist.

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?

"It is all right if I have a grilled cheese sandwich with American cheese." Rationale: Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement by the client should prompt the nurse to refer the client for further assessment?

"Lately, I have this cough that just never seems to go away." Rationale: The most frequent symptom of lung cancer is cough or change in a chronic cough.

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?

"My cough has changed from a dry cough to one with lots of sputum production." Rationale: A cough that changes in character is one of the hallmark signs of lung cancer. Low-grade fever, hoarseness, and weight loss may be attributed to other disease processes and don't necessarily indicate lung cancer.

A client has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the client asks the nurse how the treatment is decided upon. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the client's health status." Rationale: Treatment of lung cancer depends on the cell type, the stage of the disease, and the client's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the client's age or the client's preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the client and the physician of which treatment is best, though this discussion will take place.

A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." Rationale: The objective of management is to provide a cure, if possible. Treatment depends on the cell type, the stage of the disease, and the patient's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend primarily on the patient's age, or the patient's preference between the different treatment modes. The decision surrounding treatment does not depend solely on a discussion between the patient and the health care provider over which treatment is best, although patient preferences are an important consideration.

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?

"The younger you are when you start smoking, the higher your risk of lung cancer." Rationale: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor.

A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend?

"Wear protective attire and devices when working with a toxic substance." Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?

"You must consume a diet rich in protein, such as chicken, fish, and beans." Rationale: The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.

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?

15-mm induration. Rationale: 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.

The nurse is educating a patient who will be started on an antituberculotic medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?

6 to 12 months. Rationale: Pulmonary tuberculosis (TB) is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.

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. Rationale: 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 nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube. Rationale: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

What dietary recommendations should a nurse provide a client with a lung abscess?

A diet rich in protein. Rationale: 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 carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care. Rationale: HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?

A resident who suffered a severe stroke several weeks ago. Rationale: Aspiration may occur if the client cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A client with mid-stage Alzheimer disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have arthritis should not have difficulty swallowing unless it exists secondary to another problem.

A client is brought to the ED after aspirating large amounts of water and nearly drowning. This client is at risk for which complication as a result of this recent trauma?

Acute respiratory distress syndrome (ARDS). Rationale: Some of the factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug or alcohol ingestion/overdose; hematologic disorders; and direct damage to the lungs through prolonged smoke inhalation or corrosive substances. Empyema may follow chest trauma, such as a stab or gunshot wound, or a preexisting disease, such as pneumonia or TB. TB is a bacterial infectious disease primarily caused by Mycobacterium tuberculosis. Bronchiectasis, found in clients with COPD, is characterized by chronic infection and irreversible dilatation of the bronchi and bronchioles. It is caused by a tumor or foreign body, congenital abnormalities, exposure to toxic gases, and chronic pulmonary infections.

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem?

Acute respiratory failure, Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest.

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardia with an elevated blood pressure. This client may be in the early stages of what respiratory problem?

Acute respiratory failure. Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.

Answer: a, b a. vaccinations b. hand antisepsis Rationale: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.

Which clients may be at risk for the development of a pulmonary embolism? Select all that apply.

Answer: a, b, d a. a 43-year-old male on prolonged bed rest. b. a 66-year-old female taking estrogen replacement. d. an overweight sedentary 27-year-old client. Rationale: Risk factors associated with the development of pulmonary embolism include recent surgery, prolonged bed rest, long journeys, trauma, postpartum state, heart valve malfunction, dehydration, and debilitating diseases. Family history, smoking, overweight, and taking estrogen replacement also place clients at risk.

A new influenza vaccine is developed annually from three different strains of "flu" virus expected to arrive in the upcoming flu season. Annual flu vaccines are recommended for healthcare workers, populations at high risk for developing complications, and those exposed to many different people daily. The flu vaccine is not recommended for individuals who: Select all that apply.

Answer: b, c, d . Rationale: Flu vaccine is not recommended for people with underlying medical conditions such as diabetes or renal dysfunction, people with known or suspected immunodeficiency diseases or those receiving immunosuppressive therapy, people with a history of Guillain-Barré syndrome, children or adolescents who regularly take aspirin, pregnant women, and people with a hypersensitivity to eggs.

A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply.

Answer: b, d, e b. Level of consciousness d. Arterial blood gases e. Vital signs Rationale: Clients are usually treated in the ICU. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.

The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology?

Brain natriuretic peptide (BNP) level. Rationale: Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care?

Cautious hydration. Rationale: Supportive treatment of pneumonia in the older adults includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the older adults); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the client.

A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply. Do not smoke, or quit smoking if currently smoking. Try to find another occupation as soon as possible. Wear appropriate protective equipment when around airborne irritants and dusts. Schedule an annual lung x-ray to monitor health.

Do not smoke, or quit smoking if currently smoking. Wear appropriate protective equipment when around airborne irritants and dusts. Rationale: The nurse may instruct clients that the following precautions may help prevent occupational lung disease: not smoking, wearing appropriate protective equipment when around airborne irritants and dusts, scheduling lung function evaluation with spirometry as recommended, becoming educated about lung diseases, and paying attention to risk evaluation of the workplace to identify risks for lung disease.

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?

Early ambulation and the use of compression stockings. Rationale: For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.

The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema?

Elevated B-type natriuretic peptide (BNP) levels. Rationale: Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

Empyema. Rationale: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

Which intervention does a nurse implement for clients with empyema?

Encourage breathing exercises. Rationale: The nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function.

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. Rationale: 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.

Class 1 with regard to TB indicates.

Exposure and no evidence of infection. Rationale: Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection with no disease. Class 4 is disease, but not clinically active.

Class 1 with regard to TB indicates:

Exposure and no evidence of infection. Rationale: Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection with no disease. Class 4 is disease, but not clinically active.

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?

Flail chest. Rationale: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

A client in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter should the nurse monitor most closely on a client who is postoperative following an embolectomy?

Pulmonary arterial pressure. Rationale: If the client has undergone surgical embolectomy, the nurse measures the client's pulmonary arterial pressure and urinary output. Pressure is not monitored in a client's vena cava. White cell levels would be monitored, but not to the extent of the client's pulmonary arterial pressure. Lung function testing cannot be carried out on an acutely ill postsurgical client.

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail chest. Rationale: When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia. Rationale: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange. Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized?

Impaired gas exchange. Rationale: Anxiety and pain are both possible during treatment for ARDS. However, maintenance of the patient's airway with the goal of facilitating gas exchange is an absolute priority. The patient's risk of aspiration is low due to NPO status and the presence of inline suctioning.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry. Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?

Increase oral fluids unless contraindicated. Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

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. Rationale: 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.

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?

Intubate the client and control breathing with mechanical ventilation. Explanation: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

Which type of lung cancer is characterized as fast growing and tends to arise peripherally?

Large cell carcinoma. Rationale: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and usually grows slowly. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

Pulmonary hypertension. Rationale: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside?

Monitor pulse oximetry readings. Rationale: The nurse assesses the patient with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy.

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?

Negative. Rationale: The size of the induration determines the significance of the reaction. A reaction of 0-4 mm is not considered to be significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.

A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures should be initiated in this client?

Nutritional support Rationale: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS.

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?

Older adults often lack the classic signs and symptoms of pneumonia. Explanation: The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult clients. Mortality from pneumonia in older adults is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults.

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's:

Oxygen saturation level. Rationale: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's:.

Oxygen saturation level. Rationale: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of hypoxemia?

PaO2 < 60 mm Hg. Rationale: Hypoxemia is a decrease in the arterial oxygen content or arterial oxygen tension (partial pressure of oxygen = PaO2) and is measured by arterial blood gas analysis (ABG) or pulse oximetry (POX). Hypoxemia is defined as a PaO2 of less than 60 mm Hb and/or a POX of less than 90%. When administering oxygen to a patient, a nurse must keep in mind that oxygen transport to the tissues is not dependent solely on the arterial oxygen content.

Which is a key characteristic of pleurisy?

Pain Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.

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:

Pleural effusion. Rationale: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

Pneumothorax. Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, or aspiration.

The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client?

Residual effects of compromised oxygenation. Rationale: The home care nurse should monitor the client for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.

A client who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this client's care?

Restoration of adequate gas exchange. Explanation: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.

An adult client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurse's response?

Small cell cancer of the lung grows rapidly and metastasizes early and extensively. Rationale: Surgery is primarily used for NSCLCs, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a client's medical instability are not the limiting factors. Lung cancer is not a self-limiting disease.

The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action?

Smoking damages the ciliary cleansing mechanism. Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

Stabbing pain during respiratory movement. Rationale: When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

The most diagnostic clinical symptom of pleurisy is:

Stabbing pain during respiratory movements. Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.

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?

Streptococcus pneumoniae. Rationale: 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 (Wunderink & Niederman, 2012). 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 involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the client for which clinical manifestation that would indicate the presence of a pneumothorax?

Sucking sound at the site of injury. Rationale: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed "sucking chest wounds."

The nurse is caring for an adult client recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating clients with non-small cell tumors is what?

Surgical resection. Rationale: Surgical resection is the preferred method of treating clients with localized non-small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

Tachypnea. Rationale: Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

Tense and relax muscles in the lower extremities. Rationale: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

A mediastinal shift occurs in which type of chest disorder?

Tension pneumothorax. Rationale: A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.

The nurse is caring for a client who has been in a motor vehicle accident and the care team suspects that the client has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis?

The client's pain intensifies when he coughs or takes a deep breath. Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The client's ABGs would most likely be abnormal and shortness of breath would be expected.

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak. Rationale: Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

A water seal system for chest drainage has been inserted into a patient who suffered chest trauma during a motor vehicle accident. At the beginning of the night shift, the nurse has entered the patient's room to assess the system and the patient's condition. Which of the following assessment findings suggests that the system is operating correctly and the patient is maintaining oxygenation?

The water level in the water seal chamber increases when the patient inhales. Rationale: The water seal chamber has a one-way valve or water seal that prevents air from moving back into the chest when the patient inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Water levels should at no time reach the top of the water seal chamber.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia. Rationale: Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

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 Rationale: 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.

A client with broken ribs following a MVA is being kept overnight for observation. The nurse should notify the physician of which findings? Select all that apply.

respiratory distress signs of infection increased pain. Explanation: The nurse assesses and monitors the client for signs of respiratory distress, infection, and increased pain. Rib fractures are painful but not generally life threatening. However, other structures may be injured as well. For example, the sharp end of the broken rib may tear the lung or thoracic blood vessels.