Problems of Oxygenation: Ventilation (Lewis Med-Surg Section 6)

The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. Number the following actions in the order the nurse should complete them. Use 1 for the first action and 7 for the last action. a. Verify breath sounds in all fields. b. Obtain the supplies that will be used. c. Send labeled specimen containers to the laboratory. d. Direct the family members to the waiting room. e. Observe for signs of hypoxia during the procedure. f. Instruct the patient not to talk during the procedure. g. Position the patient sitting upright with the elbows on an over-the-bed table.

1) b. Obtain the supplies that will be used. 2) d. Direct the family members to the waiting room. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. 4) f. Instruct the patient not to talk during the procedure. 5) e. Observe for signs of hypoxia during the procedure. 6) a. Verify breath sounds in all fields. 7) c. Send labeled specimen containers to the laboratory. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. The patient is positioned and instructed not to talk or cough to avoid damage to the lung. Observing for hypoxia is done to keep the HCP informed. Breath sounds in all lobes are verified to be sure that there was no damage to the lung. This is done before sending the sample to the laboratory if there is no one else who can send the sample to the laboratory.

The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? 1) "I should seek immediate medical treatment for any upper respiratory infections." 2) "I should continue to do deep-breathing exercises for at least 12 weeks." 3) "I will increase my food intake to 2400 calories a day to keep my immune system well." 4) "I will need to have a follow-up chest x-ray in six to eight weeks to evaluate the pneumonia's resolution."

A) "I will need to have a follow-up chest x-ray in six to eight weeks to evaluate the pneumonia's resolution." - The follow-up chest x-ray will be done in six to eight weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than seven days. It may be important for the patient to continue with deep-breathing exercises for six to eight weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is recommended to liquefy secretions.

The nurse presents education about pertussis for a group of nursing students and includes which information? Select all that apply. 1) The cough may last from 6 to 10 weeks. 2) It is a highly contagious respiratory tract infection. 3) Treatment usually includes macrolide antibiotics. 4) Cough suppressants and antihistamines should not be used. 5) Corticosteroids and bronchodilators are helpful in reducing symptoms. 6) The patient is infectious from the beginning of the first stage through the second week after the onset of symptoms.

A) 1, 2, 3, 4 - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. The cough with pertussis may last from 6 to 10 weeks. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. Corticosteroids and bronchodilators are not useful in reducing symptoms. The patient is infectious from the beginning of the first stage through the third week after onset of symptoms or until five days after antibiotic therapy has been started.

The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? Select all that apply. 1) SpO2 of 85% 2) PaCO2 of 65 mm Hg 3) Thick yellow mucus expectorant 4) Respiratory rate of 24 breaths/minute 5) Dullness to percussion over the affected area

A) 1, 2, 5 - Indications of impaired gas exchange for this patient include a decreased oxygen saturation level (SpO2 less than 90%) (1) and an increased partial pressure of carbon dioxide level (PaCO2 greater than 45 mm Hg) (2). PaCO2 is the partial pressure of carbon dioxide in arterial blood. Dullness to percussion over the affected area indicates a pleural effusion, which is associated with pneumonia (5). Yellow mucus would indicate clearance of secretions. An increased respiratory rate does not imply impaired gas exchange.

Which instructions does the nurse provide to a patient with acute bronchitis? Select all that apply. 1) Increase oral fluid intake. 2) Avoid secondhand smoke. 3) Maintain a 30-degree head elevation when in bed. 4) Avoid throat lozenges because they may induce coughing. 5) Eat a spoonful of honey to help relieve cough.

A) 1, 2, 5 - The goal of treatment is to relieve symptoms and prevent pneumonia. Treatment is supportive. It includes encouraging oral fluid intake. Honey may help relieve cough. The nurse should encourage patients not to smoke, to avoid secondhand smoke, and to wash their hands often. The patient should be positioned in an upright sitting position (high Fowler's) with the head slightly flexed. Throat lozenges may help relieve cough.

When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Select all that apply. 1) Pregnancy 2) Pneumonia 3) Cancer 4) Oral contraceptive use 5) Hormone therapy

A) 1, 3, 4, 5 - Risk factors for PE include immobility or reduced mobility, surgery within the last three months (especially pelvic and lower extremity surgery), history of venous thromboembolism (VTE), cancer (3), obesity, oral contraceptives (4), hormone therapy (5), cigarette smoking, prolonged air travel, heart failure, pregnancy (1), and clotting disorders. Pneumonia is not a risk factor.

A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. Which instructions does the nurse provide for the patient? Select all that apply. 1) Get adequate rest. 2) Restrict fluid intake. 3) Avoid alcohol and smoking. 4) Resume work to build strength. 5) Take every dose of the prescribed antibiotic.

A) 1, 3, 5 - To ensure complete recovery after pneumonia, the patient should be advised to rest (1), avoid alcohol and smoking (3), and take every dose of the prescribed antibiotic (5). The patient should not resume work if feeling fatigued (4) and should be encouraged to drink plenty of fluids during the recovery period (2).

A patient started treatment for sputum smear-positive tuberculosis (TB) 1 week prior to the home health nurse's visit. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? Select all that apply. 1) Increase the intake of foods that are high in vitamin C. 2) Ensure that the home is well ventilated. 3) Sleep alone. 4) Spend as much time as possible outdoors. 5) Minimize time in congregate settings. 6) Minimize time on public transportation.

A) 2, 3, 4, 5, 6 - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time spent in congregate settings or on public transportation. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others.

The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. Which action does the nurse take next?

A) Administer antibiotics. - Culture and Gram staining of the sputum are required for prescribing specific antibiotics. However, if there is a delay in obtaining the lab reports, antibiotic administration should not be delayed. Deferring the antibiotics may lead to increased morbidity and mortality because the infection can worsen. Chest physiotherapy can be advised later once the antibiotic therapy is started. Sending a sample to a different lab would not be helpful because the lab will take a similar amount of time to provide the report.

A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. Assessment findings include a new onset of confusion, a respiratory rate of 42 breaths/minute, a blood urea nitrogen (BUN) of 24 mg/dL, and a BP of 80/50 mm Hg. The nurse expects which treatment plan?

A) Admit the patient to the intensive care unit. - According to the Expanded CURB-65 scale, which is used as a supplement to clinical judgment to determine the severity of pneumonia, the patient's score is a 5; placement in the intensive care unit is recommended. The patient receives 1 point for each criterion: confusion (compared to baseline); BUN greater than 20 mg/dL; respiratory rate greater than or equal to 30 breaths/min; systolic BP of less than 90 mm Hg; and age greater than or equal to 65 yrs. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Discharging the patient is unsafe. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case.

Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue?

A) Teaching the patient how to cough effectively and expectorate secretions - Although several interventions may help the patient expectorate mucus, the nursing interventions should focus on teaching the patient how to cough effectively and expectorate secretions. Postural drainage may help to loosen the secretions. Administering analgesics does not help to manage thick secretions. Administering oxygen also does not help the patient manage secretions.

When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? 1) Waiting until the patient is afebrile for 72 to 96 hours before stopping treatment 2) Administering a bronchodilator every four hours 3) Turning and repositioning the patient at least once per hour 4) Increasing fluids to at least 6 to 10 glasses/day, unless contraindicated

A) Increasing fluids to at least 6 to 10 glasses/day, unless contraindicated - Hydration is important in the supportive treatment of pneumonia to prevent dehydration and to thin and loosen secretions. The nurse should tell the patient to drink plenty of liquids (at least 6 to 10 glasses/day, unless contraindicated). The patient should be afebrile for 48 to 72 hours before stopping treatment. Although cough suppressants, mucolytics, bronchodilators, and corticosteroids are often prescribed as adjunctive therapy, the use of these drugs is debatable. The nurse should turn and reposition patients at least every two hours to promote adequate lung expansion and mobilization of secretions.

A patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). During a follow-up visit one week after starting the medication, the patient tells the nurse, "In the last week, my urine turned orange, and I am very worried about it." How does the nurse respond?

A) Inform the patient that it is one of the side effects of the medication. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. It may also cause hepatitis. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. However, it is highly unlikely that TB has spread to the liver. The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. It is also inappropriate to advise the patient to stop taking antitubercular drugs.

A patient's initial purified protein derivative (PPD) skin test result is positive. A repeat skin test is also positive. No signs or symptoms of tuberculosis or allergies are evident. Which medication therapy does the nurse anticipate will be prescribed?

A) Isoniazid (INH) - The standard treatment regimen for latent tuberculosis infection (LTBI) is nine months of daily isoniazid. It is an effective and inexpensive drug that the patient can take orally. Penicillin and theophylline would not be prescribed for the treatment of TB exposure. INH plus an antibiotic would not likely be prescribed for this scenario.

A patient presents to the emergency department with a temperature of 101.4°F (38.6°C) and a productive cough with rust-colored sputum. The nurse suspects which diagnosis?

A) Pneumonia - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). Tuberculosis frequently presents with a dry cough. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. Pink, frothy sputum would be present in CHF and pulmonary edema.

The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding?

A) Purulent sputum that has a foul odor - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Fever and vomiting are not manifestations of a lung abscess. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung.

The nurse identifies which factor that places a patient at risk for aspiration pneumonia? 1) Seizures 2) Guillain-Barré syndrome 3) Illicit drug intake 4) Recent abdominal surgery

A) Seizures - Conditions that increase the risk for aspiration include a decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric (NG) tubes with or without enteral feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Guillain-Barré syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia.

The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. The patient reports a sudden onset of shortness of breath, slight chest pain, and that "something is wrong." The assessment findings include a temperature of 98.4°F (36.9°C), BP 130/88 mm Hg, respirations 36 breaths/min, and an oxygen saturation reading of 91% on room air. Which immediate action does the nurse take?

A) Sit the patient up in bed as tolerated and apply oxygen. - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. The prognosis of a patient with PE is good if therapy is started immediately. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. The nurse should assess the patient's cardiopulmonary status with careful monitoring of vital signs, cardiac rhythm, pulse oximetry, arterial blood gases (ABGs), and lung sounds. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. A Code Blue would not be called unless the patient experiences a loss of pulse and/or respirations. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

The home health nurse provides which instruction for a patient being treated for pneumonia?

A) Use a cool mist humidifier to help with breathing. - A cool mist humidifier or warm bath may help the patient breathe easier. The nurse should tell the patient to drink plenty of liquids (at least 6 to 10 glasses/day, unless contraindicated). The nurse should explain that a follow-up chest x-ray may be done in 6 to 8 weeks to evaluate the resolution of pneumonia. The nurse should tell patients that it may be several weeks before their usual vigor and sense of well-being return. The older adult or chronically ill patient may have a prolonged period of convalescence.

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

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

Identify 1 specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates a risk factor for respiratory problems or a patient response to an actual respiratory problem. Functional Health Pattern a. Health perception-health management b. Nutritional-metabolic c. Elimination d. Activity-exercise e. Sleep-rest f. Cognitive-perceptual g. Self-perception-self-concept h. Role-relationship i. Sexuality-reproductive j. Coping-stress tolerance k. Value-belief

Risk Factor for or Response to Respiratory Problem a. Health perception-health management: Tobacco use history, gradual change in health status, family history of lung disease, sputum production, no immunizations for influenza or pneumococcal pneumonia received, travel to developing countries b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity c. Elimination: Constipation, incontinence d. Activity-exercise: Decreased exercise or activity tolerance, dyspnea on rest or exertion, sedentary habits e. Sleep-rest: Sleep apnea. Awakening with dyspnea, wheezing, or cough. Night sweats f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems k. Value-belief: Noncompliance with treatment plan, conflict with values

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

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

Match the descriptions or possible causes with the appropriate abnormal assessment findings. a. Finger clubbing b. Stridor c. Wheezes d. Pleural friction rub e. Increased tactile fremitus f. Hyperresonance g. Fine crackles h. Absent breath sounds 1. Lung consolidation with fluid or exudate 2. Air trapping 3. Atelectasis 4. Interstitial edema 5. Bronchoconstriction 6. Partial obstruction of trachea or larynx 7. Chronic hypoxemia 8. Pleurisy

a) 7. Chronic hypoxemia b) 6. Partial obstruction of trachea or larynx c) 5. Bronchoconstriction d) 8. Pleurisy e) 1. Lung consolidation with fluid or exudate f) 2. Air trapping g) 4. Interstitial edema h) 3. Atelectasis

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

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

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

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

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

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

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

a. Document the results in the patient's record. 6. a. Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and arterial oxygen saturation (SaO2) but normal pH and PaCO2. No interventions are necessary for these findings. Usual PaO2 levels are expected in patients 60 years of age or younger.

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

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

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

a. Suction the tracheostomy. b. Provide tracheostomy care.

Match the following pulmonary capacities and function tests with their descriptions. a. Vt b. RV c. TLC d. VC e. FVC f. PEFR g. FEV1 h. FRC 1. Amount of air exhaled in first second of forced vital capacity 2. Maximum amount of air lungs can contain 3. Volume of air inhaled and exhaled with each breath 4. Maximum amount of air that can be exhaled after maximum inspiration 5. Amount of air that can be quickly and forcefully exhaled after maximum inspiration 6. Maximum rate of airflow during forced expiration 7. Amount of air remaining in lungs after forced expiration 8. Volume of air in lungs after normal exhalation

a. Vt: (3) Volume of air inhaled and exhaled with each breath b. RV: (7) Amount of air remaining in lungs after forced expiration c. TLC: (2) Maximum amount of air lungs can contain d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration f. PEFR: (6) Maximum rate of airflow during forced expiration g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity h. FRC: (8) Volume of air in lungs after normal exhalation

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

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

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

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

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

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

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

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

When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? a. There is a prominent protrusion of the sternum. b. The width of the chest is equal to the depth of the chest. c. There is equal but diminished movement of the 2 sides of the chest. d. The patient cannot fully expand the lungs because of kyphosis of the spine.

b. The width of the chest is equal to the depth of the chest. An increased anterior-posterior (AP) diameter is characteristic of a barrel chest, in which the AP diameter is about equal to the side-to-side diameter. Normally the AP diameter should be 1⁄3 to 1⁄2 the side-to-side diameter. A prominent protrusion of the sternum is the pectus carinatum and diminished movement of both sides of the chest indicates decreased chest excursion. Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion.

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

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

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

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

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

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

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

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

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

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

How does the nurse assess the patient's chest expansion? a. Put the palms of the hands against the chest wall. b. Put the index fingers on either side of the trachea. c. Place the thumbs at the midline of the lower chest. d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

d. Pleural friction rub Pleural friction rub occurs with pneumonia and is a grating or creaking sound. Stridor is a continuous musical or crowing sound and unrelated to pneumonia. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance.

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

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

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

d. SpO2 of 88%; PaO2 of 55 mm Hg An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect the patients' activity tolerance.

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

d. Testing causes a 10-mm red, indurated area at the injection site. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Because antibody production in response to infection with the tuberculosis (TB) bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, 2-step testing is recommended for individuals likely to be tested often, such as health care professionals. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. All other answers indicate a negative response to skin testing.