Ch 10 - Pt's w/ Chest & Lower Respiratory Tract Disorders

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "I will come back in 1 week to have the test read." "If the test area turns red that means I have tuberculosis." "Because I had a previous reaction to the test, this time I need to get a chest X-ray." "I will avoid contact with my family until I am done with the test."

"Because I had a previous reaction to the test, this time I need to get a chest X-ray."

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? "Hold the spirometer at your lips and breathe in and out like you normally would." "When you're ready, blow hard into the spirometer for as long as you can." "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." "Take a deep breath and then blow short, forceful breaths into the spirometer."

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

The nurse is caring for a client who has started therapy for tuberculosis. The client demonstrates an understanding of tuberculosis transmission when stating: "I'll follow airborne precautions until I have three negative sputum specimens." "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm clear when my chest X-ray is negative." "I'm not contagious even if I have night sweats."

"I'll follow airborne precautions until I have three negative sputum specimens."

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." "The type of treatment depends on the discussion between the patient and the health care provider over which treatment is best." "The type of treatment depends on what the patient wants when given the options." "The type of treatment depends on the patient's age and health status."

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Viruses like influenza are the most common cause of pneumonia." "Influenza vaccine will prevent typical pneumonias." "Getting the flu can complicate pneumonia." "Influenza is the major cause of death in the United States."

"Viruses like influenza are the most common cause of pneumonia."

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? 5-mm induration A blister 15-mm induration Reddened area

15-mm induration

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? 13 to 18 months 6 to 12 months 3 to 5 months 3 months

6 to 12 months

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Acute respiratory distress syndrome Metabolic alkalosis Atelectasis Respiratory acidosis

Acute respiratory distress syndrome

Which action should the nurse take first when providing care for a client during an acute asthma attack? Send for STAT chest x-ray. Administer prescribed short-acting bronchodilator. Obtain arterial blood gases. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

Administer prescribed short-acting bronchodilator.

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal ischemia Pressure necrosis Tracheal bleeding Aspiration pneumonia

Aspiration pneumonia

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? Productive cough Bradypnea Respiratory alkalosis Blood-tinged sputum

Blood-tinged sputum

A nurse should include what instruction for the client during postural drainage? Change positions frequently and cough up secretions. Lie supine to rest the lungs. Sit upright to promote ventilation. Remain in each position for 30 to 45 minutes for best results.

Change positions frequently and cough up secretions.

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? Drug ingestion Chemical irritation Aspiration Direct lung damage

Chemical irritation

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays Legislation that requires homes and apartments be checked for asbestos leakage Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes Classes at community centers to teach about smoking cessation strategies

Classes at community centers to teach about smoking cessation strategies

A 72-year-old patient who was admitted to the hospital for a total hip arthroplasty has developed increasing dyspnea and leukocytosis over the past 48 hours and has been diagnosed with hospital-acquired pneumonia (HAP). The choice of antibiotic therapy for this patient will be primarily based on which of the nurse's assessments? Collection of a sputum sample for submission to the hospital laboratory Assessment of the patient's activities of daily living Analysis of the patient's leukocytosis and the white blood cell (WBC) differential Auscultation and percussion of the patient's thorax

Collection of a sputum sample for submission to the hospital laboratory

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? Correct technique for rhythmic breathing Correct use of a ventilator Correct use of a mini-nebulizer Correct use of incentive spirometry

Correct use of incentive spirometry

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? Administering oxygen, coughing, breathing deeply, and maintaining bed rest Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer Administering pain medications, frequent repositioning, and limiting fluid intake

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A patient is diagnosed with hypoxemic hypoxia. The nurse knows that the etiology directs medical and nursing interventions. Which of the following is the cause? Decreased oxygen diffusion into the tissues Inability of tissues to use available oxygen due to a toxic substance Inadequate capillary circulation Decreased effective hemoglobin concentration

Decreased oxygen diffusion into the tissues

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? Developing a list of people with whom the client has had contact Client teaching about the importance of TB testing Client teaching about the cause of TB Reviewing the risk factors for TB

Developing a list of people with whom the client has had contact

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Draining secretions, air, and blood from the thoracic cavity is necessary.

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 Elevated troponin levels Elevated myoglobin levels Elevated white blood count

Elevated B-type natriuretic peptide (BNP) levels

A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention? Perform chest physiotherapy Perform nasotracheal suctioning Encourage the client to cough Perform postural drainage

Encourage the client to cough

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Elevating the head of the bed 30 degrees Encouraging increased fluid intake Maintaining a cool room temperature Turning the client every 2 hours

Encouraging increased fluid intake

The nurse knows the mortality rate is high in lung cancer clients due to which factor? Increased exposure to industrial pollutants Few early symptoms Increase in women smokers Increased incidence among the elderly

Few early symptoms

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? Fibrotic changes in lungs Damage to surrounding tissues Lung contusion Hemorrhage

Fibrotic changes in lungs

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? Pneumothorax Tension pneumothorax ARDS Flail chest

Flail chest

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hypercapnia, hypoventilation, and hypoxemia Hypotension, hyperoxemia, and hypercapnia Hyperoxemia, hypocapnia, and hyperventilation

Hypercapnia, hypoventilation, and hypoxemia

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Anxiety Ineffective tissue perfusion (cardiopulmonary) Impaired gas exchange Decreased cardiac output

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? Acute pain Impaired gas exchange Anxiety Risk for aspiration

Impaired gas exchange

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote the strengthening of the client's diaphragm Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote more efficient and controlled ventilation and to decrease the work of breathing Promote the client's ability to take in oxygen

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote the strengthening of the client's diaphragm Promote the client's ability to take in oxygen Promote more efficient and controlled ventilation and to decrease the work of breathing Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? Bronchoscopy Intermittent positive pressure-breathing (IPPB) Incentive spirometry Positive end-expiratory pressure (PEEP)

Incentive spirometry

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? Increased blood pressure Decreased heart rate Decreased level of consciousness (LOC) Increased restlessness

Increased restlessness

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? It prolongs exhalation. It will prevent the alveoli from overexpanding. It will assist with widening the airway. It increases the respiratory rate to improve oxygenation.

It prolongs exhalation.

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? Pain in the feet Decreased urinary output Localized calf tenderness Coolness to lower extremities

Localized calf tenderness

Which is a key characteristic of pleurisy? Anxiety Pain Dyspnea Blood-tinged secretions

Pain

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis? Negative Homan's sign Inability to dorsiflex Pain in the feet Pain in the calf

Pain in the calf

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? Progressive loss of lung function associated with chronic disease Sudden loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function Sudden loss of lung function with history of normal lung function

Progressive loss of lung function associated with chronic disease

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP? Providing extra nutrition for the elderly patient Providing anticipatory interventions Providing emotional support Giving antibiotics as ordered

Providing anticipatory interventions

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? Restrictive lung disease Pulmonary arterial hypertension Atelectasis Asthma

Pulmonary arterial hypertension

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Inspiratory crackles Cyanosis Bilateral wheezing Rapid onset of severe dyspnea

Rapid onset of severe dyspnea

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Receiving vaccinations Using incentive spirometry Using prescribed opioids Mobilizing early

Receiving vaccinations

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? See if a kink has developed in the tubing. See if the chest tube is clogged. See if there are leaks in the system. See if the wall suction unit has malfunctioned.

See if there are leaks in the system.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Dullness or flatness on percussion over areas of collected fluid Dyspnea and coughing Fever and chills Stabbing pain during respiratory movement

Stabbing pain during respiratory movement

The most diagnostic clinical symptom of pleurisy is: Fever and chills. Dullness or flatness on percussion over areas of collected fluid. Dyspnea and coughing. Stabbing pain during respiratory movements.

Stabbing pain during respiratory movements.

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? Mycobacterium tuberculosis Staphylococcus aureus Pseudomonas aeruginosa Streptococcus pneumoniae

Streptococcus pneumoniae

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

Tachypnea

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? Begin estrogen replacement. Consume the majority of daily fluid intake prior to bed. Tense and relax muscles in the lower extremities. Wear tight-fitting clothing.

Tense and relax muscles in the lower extremities.

A 44-year-old homeless man presented to the emergency department with hemoptysis. The patient was diagnosed with tuberculosis (TB) after diagnostic testing and has just begun treatment with INH, pyrazinamide, and rifampin (Rifater). When providing patient education, what should the nurse emphasize? The rationale and technique for using incentive spirometry The importance of adhering to the prescribed treatment regimen The need to maintain good nutrition and adequate hydration The correct use of a metered-dose inhaler (MDI) for bronchodilators

The importance of adhering to the prescribed treatment regimen

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Bloody drainage is observed in the collection chamber. Absence of bloody drainage in the anterior/upper tube The tissues give a crackling sensation when palpated. Skin around tube is pink.

The tissues give a crackling sensation when palpated.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? To remove air from the pleural space To assist with mechanical ventilation To drain copious sputum secretions To monitor bleeding around the lungs

To remove air from the pleural space

A patient has been receiving 100% oxygen therapy by way of a non-rebreather mask for several days. He complains of tingling in his fingers and shortness of breath. He has limitations, is extremely restless, and states that he has pain beneath his breastbone. The nurse should suspect oxygen-induced: Embolism. Toxicity. Atelectasis. Hypoventilation.

Toxicity.

Which comfort technique does a nurse teach to a client with pleurisy to assist with splinting the chest wall? Turn onto the affected side Use a heat application Use a prescribed analgesic Elevate the head of the bed

Turn onto the affected side

The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. For each client statement, click to specify if the finding indicates understanding or the need for reinforcement of the teaching.

Understanding: "Sleeping with a humidifier can help loosen secretions." "I will seek medical attention if my cough worsens." "I should get the PPSV23 this year because I got the PCV13 last year." "I will rest and avoid overexertion." Requires reinforcement of teaching: "I will take the antibiotics until the secretions clear up." "I will drink 1 liter of fluid each day." "A persistent or recurring fever is normal after starting antibiotics." "I will perform deep-breathing exercises once per day."

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 Tachypnea Diminished alveolar dilation Increased PaO2

Unresponsive arterial hypoxemia

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Providing oral hygiene daily Keeping the head of the bed at 15 degrees or less Using strict hand hygiene Turning the client every 4 hours to prevent fatigue

Using strict hand hygiene

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin C Vitamin B6 Vitamin E Vitamin D

Vitamin B6

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 hemothorax. consolidation. pneumothorax. pleural effusion.

pleural effusion.