Respiratory System
A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? a. Protective b. Airborne c. Droplet d. Contact
B. Airborne---Tuberculosis requires airborne precautions, which are protocols that prevent the spread of infections via very small droplets (e.g. measles and varicella).
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during
C. Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, highpitched sounds of short duration heard on inspiration.
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? a. The client is unable to speak. b. The client's airway secretions were last suctioned 2 hr ago. c. The client coughs and expectorates a large mucous plug. d. The nurse auscultates coarse crackles in the lung fields.
D. The nurse auscultates coarse crackles in the lung fields.---The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions.
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.
A. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
On auscultation of a patients lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes
A. Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? a. Hyperoxygenate the client before suctioning b. Insert the catheter during exhalation c. Apply suction during insertion of the catheter d. Apply suction for no more than 15 sec
A. Hyperoxygenate the client before suctioning---The nurse should use a manual resuscitation bag to hyperoxygenate the client for several minutes prior to suctioning.
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation
A. Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? a. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing b. Allow 30 sec between suctioning passes c. Hyperventilate the client with 50% oxygen for 30 sec d. Perform a maximum of 4 passes with the suction catheter
A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing---The nurse should pull the suction catheter back 1 cm (0.5 in) when the client starts to cough or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning.
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? a. Excessive airway secretions b. A leak within the ventilator's circuitry c. Decreased lung compliance d. The client coughing or attempting to talk
B. A leak within the ventilator's circuitry---The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? a. Exhale slowly to reach the goal volume b. Hold the breath for 5 sec after goal volume is reached c. Continue to breathe deeply between each cycle d. Limit the repeat pattern of breathing to 5 breaths
B. Hold the breath for 5 sec after goal volume is reached---The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia.
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? a. I will call the doctor if I still feel tired after a week. b. I will continue to do the deep breathing and coughing exercises at home. c. I will schedule two appointments for the pneumonia and influenza vaccines. d. Ill cancel my chest x-ray appointment if I'm feeling better in a couple weeks.
B. Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) a. Set the suction machine at 120 mmHg b. Provide oral hygiene frequently c. Measure the amount of drainage from the NG tube every shift d. Secure the NG tube to the client's gown e. Apply petroleum jelly to the client's nares
B. Provide oral hygiene frequently---Frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. C. Measure the amount of drainage from the NG tube every shift---Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. D. Secure the NG tube to the client's gown---An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? a. Friction rub b. Crackles c. Crepitus d. Tactile fremitus
C. Crepitus--- Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax.
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.
C. Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.
A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? a. Place a non-rebreather mask on the client and increase the oxygen flow to 3 L/min b. Prepare the client for possible endotracheal intubation and mechanical ventilation c. Increase the oxygen flow and request an arterial blood gas determination d. Position the client supine and administer an anti-anxiety medication
C. Increase the oxygen flow and request an arterial blood gas determination---The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.
A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? a. Pericardial friction rub b. Weight gain c. Night sweats d. Cyanosis of the fingertips
C. Night sweats--- Night sweats and fevers are clinical manifestations of tuberculosis.
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Gurin (BCG) vaccine
C. The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Using clean technique to perform the procedure b. Applying suction while inserting the catheter c. Lubricating the suction catheter with an oil-based lubricating jelly d. D. Administering high-flow oxygen prior to the procedure---The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.Administering high-flow oxygen prior to the procedure
D. Administering high-flow oxygen prior to the procedure---The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.
A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion
D. All these nursing diagnoses are appropriate for the patient, but the patients oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)
D. Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. Is there any family history of TB? b. How long have you lived in the United States? c. Do you take any over-the-counter (OTC) medications? d. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?
D. Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply) a. Oxygen equipment b. Incentive spirometer c. Pulse oximeter d. Sterile dressing e. Suture removal kit
a. Oxygen equipment c. Pulse oximeter d. Sterile dressing
Which patients have the greatest risk for aspiration pneumonia? (select all that apply) a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding
a. Patient with seizures b. Patient with head injury e. Patient who is receiving nasogastric tube feeding
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patients room.
b. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patients room because the HEPA mask can filter out 100% of small airborne particles.
A patient with TB has been admitted to the hospital and is placed on airborne precautions and in an isolation room. What should the nurse teach the patient? (select all that apply) a. Expect routine TB testing to evaluate the infection. b. No visitors will be allowed while in airborne isolation. c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multidrug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation
c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multidrug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation
An appropriate nursing intervention to assist a patient with pneumonia manage thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively and expectorate secretions
d. teach the patient how to cough effectively and expectorate secretions
Which respiratory assessment finding does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields
d. Bronchial breath sounds in the lower lung fields
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. I will avoid being outdoors whenever possible. b. My husband will be sleeping in the guest bedroom. c. I will take the bus instead of driving to visit my friends. d. I will keep the windows closed at home to contain the germs.
B. Teach the patient how to minimize exposure to close contacts and household members. 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 in congregate settings or on public transportation.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system
D. The patients history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patients clinical manifestations are not consistent with these problems.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%
A. The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
A nurse is caring for a client who is suspected to have tuberculosis. Which of the following findings should the nurse expect? a. Recent weight gain b. High fever c. Rhinitis d. Blood-streaked sputum
D. Blood-streaked sputum--- The nurse should expect blood-streaked sputum in a client who has tuberculosis. Sputum cultures are used to diagnose pulmonary tuberculosis.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository
B. Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
A nurse is teaching a client who tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements? a. "I will begin vacuuming once a week." b"Carpeting the entire house will be very expensive, but it will be worth it." c. "I will put a mattress cover on my bed." d. "Installing curtains on the windows will help control the dust in my house."
C. "I will put a mattress cover on my bed."--- The nurse should instruct the client to apply a hypoallergenic mattress cover that can be zipped over her bed to control the amount of dust. The client should remove and machine-wash the mattress cover periodically.
A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? a. Provide chest physiotherapy b. Perform oropharyngeal suction c. Encourage deep-breathing and coughing d.Assist the client with ambulation
C. Encourage deep-breathing and coughing--- The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway.
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. Position the client in an upright position, leaning over the bedside table b. Explain the procedure c. Obtain ABG'S d. Administer benzocaine spray
a. Position the client in an upright position, leaning over the bedside table
A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
B. Respiratory acidosis--- Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? a. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask b. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula c. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar d. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula
A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask---The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask. Oxygen is a gas that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.
A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) a. Assign the client to a private room with negative-pressure airflow. b.Add contact precautions to the client's plan of care. c. Wear an N95 respirator when entering the client's room. d. Ensure the client's environment provides 4 exchanges of fresh air per minute. e. Institute protective environment precautions as soon as the client arrives on the unit.
A. Assign the client to a private room with negative-pressure airflow. C. Wear an N95 respirator when entering the client's room.---This client's history and present status suggest tuberculosis, a communicable infection that mandates a private room with negative-pressure airflow. Airborne precautions will be required, including wearing an N95 respirator when entering the client's room.
A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? a. Initiate airborne precautions b. Administer antimicrobial therapy c. Tell the client that the infection will be communicable for 2-3 weeks from the start of medication therapy d. Teach the client about the manifestations of tuberculosis
A. Initiate airborne precautions--- The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client (and, in this case, to other clients and staff). When there are several risks to safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat. Clients who have or might have tuberculosis require immediate airborne isolation precautions because of the highly communicable nature of the infection. Airborne precautions prevent transmission of pathogens that remain infectious in the air, including Mycobacterium tuberculosis, which causes tuberculosis.
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patients oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.
B. The first action should be to attempt to reinsert the tracheostomy tube to maintain the patients airway. Assessing the patients oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? a. Perform tracheostomy care using medical asepsis b. Allow enough slack under the tracheostomy ties to insert three fingers c. Soak the inner cannula of the tracheostomy tube in normal saline d. Cut a sterile gauze pad to place between the neck and tracheostomy tube
C. Soak the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions.
A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.
C. This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP splint the patients chest during coughing. b. UAP assist the patient to ambulate to the bathroom. c. UAP help the patient to a bedside chair for meals. d. UAP lower the head of the patients bed to 15 degrees.
D. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.
A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) a. Tracheal deviation to the left b. Temperature of 38.8°C (102°F) c. Absent breath sounds on the right side d. Neck vein distention e. Bradypnea
A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the return blood flow compresses, causing the neck veins to distend.
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? a. Have the client wear a surgical mask. b. Wear a gown for protection from the client's infection. c. Ask the radiology staff to perform a portable chest X-ray in the client's room. d. Place an N-95 respirator on the client.
A. Have the client wear a surgical mask.---The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? a. Obtaining hydrogen peroxide for tracheostomy care b. Obtaining cotton balls for tracheostomy care c. Obtaining sterile gloves for tracheostomy care d. Obtaining a sterile brush for tracheostomy care
B. Obtaining cotton balls for tracheostomy care---Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.
A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? a. The client has active tuberculosis. b. The client had an exposure to tuberculosis. c. The nurse must re-evaluate the result in 24 hr. d. The test is negative for tuberculosis.
B. The client had an exposure to tuberculosis. A Mantoux test is a skin test that determines exposure to tuberculosis. The nurse should look at the test site and palpate the area to determine if the injection site is raised and feels hard to the touch (induration). Then, the nurse should record the results in millimeters to represent the size of the raised bump. Redness alone does not determine a positive result.
A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. Using clean technique to perform the procedure b. Applying suction while inserting the catheter c. Lubricating the suction catheter with an oil-based lubricating jelly d. Administering high-flow oxygen prior to the procedure
D. Administering high-flow oxygen prior to the procedure---The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.
A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? a. Lying flat on the affected side b. Prone with the arms raised over the head c. Supine with the head of the bed elevated d. Sitting while leaning forward over the bedside table
D. Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air.
The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.
D. To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue
While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.
c. Administer the PRN supplemental O2.
The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.
B. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a sidelying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.
A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? a. "If the test is positive, it means you have an active case of tuberculosis." b. "If the test is positive, you should have another tuberculin skin test in 3 weeks." c. "You must return to the clinic to have the test read in 2 or 3 days." d. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."
C. "You must return to the clinic to have the test read in 2 or 3 days."---The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hours, another tuberculin skin test is necessary.
A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? a. Instruct the client to cough b. Administer oxygen via face mask c. Evaluate the client for stridor d. Keep the client in a semi- to high-Fowler's position
C. Evaluate the client for stridor--- The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices
A. Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
A. Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) whenever I take a deep breath. Which action will the nurse take next? a. Auscultate breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.
A. The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "If I do this often, I won't experience muscle wasting." b. "If I do this often, I won't get pneumonia." c. "If I do this often, I won't get constipated." d. "If I do this often, I won't have a fast heartbeat."
B. "If I do this often, I won't get pneumonia."--- Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal.
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.
B. The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? a. "I should take this medication with food." b. "I need to take a B-complex vitamin while using this medication." c. "I can expect this medication to turn my skin orange." d. "I can expect this medication to make my vision blurry."
C. "I can expect this medication to turn my skin orange."---The nurse should instruct the client to expect the skin and urine to turn a reddish-orange color while taking rifampin.
The nurse observes a student who is listening to a patients lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
C. Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.
A nurse is assessing a client who has a positive tuberculin skin test. Which of the following findings indicates that the client has active tuberculosis? a. Rhinitis b. Air hunger c. Night sweats d. Weight gain
C. Night sweats Manifestations of active tuberculosis include a fever, coughing, night sweats, anorexia, and fatigue.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach about the need to get sputum specimens for 2 to 3 consecutive days. d. Instruct the patient to expectorate three specimens as soon as possible.
C. Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? a. Limit the client's fluid intake b. Assist the client into a supine position c. Administer oxygen at 2 L/min d. Encourage the client to cough
D. Encourage the client to cough Rhonchi are loud, low-pitched, rumbling sounds primarily detected over the trachea and bronchi. The nurse should encourage the client to cough because doing so often clears this adventitious sound.
A nurse is preparing to administer a Mantoux skin test to a client. What is the purpose of a Mantoux skin test using purified protein derivative (PPD)? a. To identify if a client lacks immunity to tuberculosis b. To find out if a client has active tuberculosis c. To decrease the hypersensitivity of the client's reaction to PPD d. To identify if a client has been infected with Mycobacterium tuberculosis
D. To identify if a client has been infected with Mycobacterium tuberculosis---The nurse should inform the client that the Mantoux skin test is used to identify individuals who have been infected with Mycobacterium tuberculosis.
