Ch 19: Management of Patients with Chest and Lower Respiratory Tract Disorders

d) Partial pressure of arterial oxygen (PaO2) Pg. 529 The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

1. A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) Bicarbonate (HCO3-) b) Partial pressure of arterial carbon dioxide (PaCO2) c) pH d) Partial pressure of arterial oxygen (PaO2)

d) PaO2 Pg. 556 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

17. The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? a) pH b) HCO3 c) PCO2 d) PaO2

d) Aspiration pneumonia Pg. 531-534 Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

22. Which is a potential complication of a low pressure in the endotracheal tube cuff? a) Tracheal ischemia b) Tracheal bleeding c) Pressure necrosis d) Aspiration pneumonia

d) Vitamin B6 Pg. 546-550 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

27. Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin E b) Vitamin C c) Vitamin D d) Vitamin B6

c) Intubate the client and control breathing with mechanical ventilation Pg. 571 A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

42. A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? a) Administer a large dose of furosemide (Lasix) IVP stat b) Increase oxygen administration c) Intubate the client and control breathing with mechanical ventilation d) Schedule the client for pulmonary surgery

c) Crackles in the lung bases Pg. 529 When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

5. The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? a) Sibilant wheezes b) Low-pitched rhonchi during expiration c) Crackles in the lung bases d) Pleural friction rub

c) Using the minimal-leak technique with cuff pressure less than 25 cm H2O Pg. 559 To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.

54. A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: a) Using a cuffed tracheostomy tube b) Keeping the tracheostomy tube plugged c) Using the minimal-leak technique with cuff pressure less than 25 cm H2O d) Suctioning the tracheostomy tube frequently

b) 15-mm induration Pg. 548 A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.

93. 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? a) A blister b) 15-mm induration c) Reddened area d) 5-mm induration

a) Auscultating the lungs for bilateral breath sounds Pg. 557 For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

10. For a client with an endotracheal (ET) tube, which nursing action is the most important? a) Auscultating the lungs for bilateral breath sounds b) Monitoring serial blood gas values every 4 hours c) Turning the client from side to side every 2 hours d) Providing frequent oral hygiene

b) Chemical irritation Pg. 530 Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

11. You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? a) Drug ingestion b) Chemical irritation c) Direct lung damage d) Aspiration

a) Auscultate the lung for adventitious sounds Pg. 558 When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

12. A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? a) Auscultate the lung for adventitious sounds b) Have the patient inform the nurse of the need to be suctioned c) Assess the CO2 level to determine if the patient requires suctioning d) Have the patient cough

c) 84 mm Hg Pg. 570 In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

13. A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? a) 45 mm Hg b) 58 mm Hg c) 84 mm Hg d) 120 mm Hg

a) Regularly assess the client's vital signs every 2 to 4 hours b) Monitor pulmonary status as directed and needed d) Encourage deep breathing exercises Pg. 565 Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. The nurse would request an order for patient-controlled analgesia if appropriate for the client, but that would be an intervention related to post-surgical pain, not impaired gas exchange. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance but not directly related to impaired gas exchange.

14. A client who is undergoing thoracic surgery has a nursing diagnosis of "impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. a) Regularly assess the client's vital signs every 2 to 4 hours b) Monitor pulmonary status as directed and needed c) Request order for patient-controlled analgesia pump d) Encourage deep breathing exercises e) Monitor and record hourly intake and output

d) Symmetry of the client's chest expansion Pg. 557 Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

15. The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: a) Tracheal cuff pressure set at 30 mm Hg b) Cool air humidified through the tube c) A scheduled time for deflation of the tracheal cuff d) Symmetry of the client's chest expansion

d) Dyspnea and wheezing Pg. 543 In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

16. A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Hemoptysis and dysuria c) Sore throat and abdominal pain d) Dyspnea and wheezing

b) Auscultation Pg. 552 The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

18. What assessment method would the nurse use to determine the areas of the lungs that need draining? a) Arterial blood gas (ABG) levels b) Auscultation c) Chest X-ray d) Inspection

a) Dyspnea d) Fatigue e) Substernal pain Pg. 556 Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.

19. A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Dyspnea b) Mood swings c) Bradycardia d) Fatigue e) Substernal pain

c) Water-seal chamber Pg. 596 Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

2. After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Suction control chamber b) Collection chamber c) Water-seal chamber d) Air-leak chamber

c) Streptococcus pneumoniae Pg. 532 Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.

20. 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? a) Mycobacterium tuberculosis b) Staphylococcus aureus c) Streptococcus pneumoniae d) Pseudomonas aeruginosa

c) Cough or change in chronic cough Pg. 579 A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.

21. A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? a) Obvious trauma b) Pain on inspiration c) Cough or change in chronic cough d) Shortness of breath

b) To remove air from the pleural space Pg. 595 Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

23. 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? a) To monitor bleeding around the lungs b) To remove air from the pleural space c) To assist with mechanical ventilation d) To drain copious sputum secretions

d) pH 7.28, PaO2 50 mm Hg Pg. 556 ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

24. A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? a) pH 7.46, PaO2 80 mm Hg b) pH 7.36, PaCO2 32 mm Hg c) pH 7.35, PaCO2 48 mm Hg d) pH 7.28, PaO2 50 mm Hg

c) 0 to 4 mm Pg. 548 The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

25. A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? a) 9 mm b) 5 to 6 mm c) 0 to 4 mm d) 7 to 8 mm

d) The system has an air leak Pg. 596 Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.

26. A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The client has a pneumothorax b) The chest tube is obstructed c) The system is functioning normally d) The system has an air leak

d) Cancer Pg. 553 A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure. Blood fluid typically suggests trauma. Purulent fluid is diagnostic for infection. Complications that may follow a thoracentesis include pneumothorax and subcutaneous emphysema.

28. A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? a) Emphysema b) Infection c) Trauma d) Cancer

a) Ineffective airway clearance Pg. 542 Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

29. A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Ineffective airway clearance b) Risk for falls c) Ineffective breathing pattern d) Impaired tissue integrity

b) Fit all employees with protective masks Pg. 577 The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases.

3. You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? a) Insist on adequate breaks for each employee b) Fit all employees with protective masks c) Provide employees with smoking cessation materials d) Give workshops on disease prevention

d) Administer oxygen by nasal cannula as ordered Pg. 576 When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client re-inhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

30. A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH 7.49 PaO2 60 mm Hg PaCO2 30 mm Hg HCO3- 25 mEq/L What should the nurse do first? a) Encourage the client to deep-breathe and cough every 2 hours b) Auscultate breath sounds bilaterally every 4 hours c) Instruct the client to breathe into a paper bag d) Administer oxygen by nasal cannula as ordered

a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher Pg. 539 As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

31. A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher b) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher c) The client exhibits bronchial breath sounds over the affected area d) The client exhibits restlessness and confusion

a) Monitor the pressure in the cuff at least every 8 hours Pg. 559 Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the client from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

32. The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? a) Monitor the pressure in the cuff at least every 8 hours b) Keep the tracheostomy tube plugged at all times c) Inflate the cuff to the highest possible pressure in order to prevent aspiration d) Deflate the cuff overnight to prevent tracheal tissue trauma

b) Flail chest Pg. 591 During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

33. 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? a) Tension pneumothorax b) Flail chest c) Pneumothorax d) ARDS

c) Acute respiratory distress syndrome Pg. 571 Factors associated with the development of acute respiratory distress syndrome include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.

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

d) Correct use of incentive spirometry Pg. 580 Instruction in the use of incentive spirometry begins before surgery to familiarize the client with its correct use. You do not teach a client the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

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

a) Assess the client's lung sounds and SaO2 via pulse oximeter Pg. 557 Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the client's level of oxygenation. Explaining the procedure, performing hand hygiene, and turning on the suction source are interventions that should follow assessment. As with all interventions, assessment should be performed first.

36. The nurse is preparing to suction a client with an endotracheal tube. What should be the nurse's first step in the suctioning process? a) Assess the client's lung sounds and SaO2 via pulse oximeter b) Explain the suctioning procedure to the client and reposition the client c) Turn on suction source at a pressure not exceeding 120 mm Hg d) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask

b) Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Pg. 557-558 For a new tracheostomy, two people should assist with tie changes to help make sure the new tracheostomy is not dislodged. A dislodged tracheostomy is a medical emergency. The other actions, if performed by the nurse during tracheostomy care, are correct. The wound and plate should be cleaned with sterile cotton-tipped applicators moistened with saline or sterile water or with hydrogen peroxide if infection is present. The inner cannula should be dried before reinsertion or if a disposable is being used, a new disposable cannula should be reinserted. The nurse should put on clean gloves and discard the soiled dressing in a biohazard container.

37. The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? a) Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide b) Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting c) Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula d) Puts on clean gloves; removes and discards the soiled dressing in a biohazard container

c) Rapid onset of severe dyspnea Pg. 571 The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

38. 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? a) Bilateral wheezing b) Cyanosis c) Rapid onset of severe dyspnea d) Inspiratory crackles

d) Nonrebreather mask Pg. A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

39. A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen? a) Simple mask b) Face tent c) Nasal cannula d) Nonrebreather mask

c) Pulmonary arterial hypertension Pg. 574 Pulmonary hypertension (PH) is confirmed with a mean pulmonary artery pressure greater than 25 mm Hg. The main symptom of PH is dyspnea. Clients with restrictive lung disease, asthma, and atelectasis should not have PH.

4. 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? a) Atelectasis b) Restrictive lung disease c) Pulmonary arterial hypertension d) Asthma

a) "It is all right if I have a grilled cheese sandwich with American cheese" Pg. 550 Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

40. A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? a) "It is all right if I have a grilled cheese sandwich with American cheese" b) "It is fine if I eat sushi with a little bit of soy sauce" c) "I am going to have a tuna fish sandwich for lunch" d) "It is all right if I drink a glass of red wine with my dinner"

a) Draining secretions, air, and blood from the thoracic cavity is necessary Pg. 581 After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.

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

c) To decrease the work of breathing d) To provide adequate transport of oxygen in the blood Pg. Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions.

43. A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. a) To reduce stress on the myocardium b) To clear respiratory secretions c) To decrease the work of breathing d) To provide adequate transport of oxygen in the blood e) To provide visual feedback to encourage the client to inhale slowly and deeply

d) Turn onto the affected side Pg. 554 Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

44. Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? a) Avoid using a pillow while splinting b) Use a prescribed analgesic c) Use a heat or cold application d) Turn onto the affected side

d) Black-streaked sputum Pg. 577 A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time.

45. The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease? a) Barrel chest b) Tenacious secretions c) Cough and dyspnea d) Black-streaked sputum

d) Apply a dressing over the wound and tape it on three sides Pg. 582 The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

46. A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare to start an I.V. line b) Draw blood for a hematocrit and hemoglobin level c) Prepare a chest tube insertion tray d) Apply a dressing over the wound and tape it on three sides

c) Dyspnea Pg. 574 Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

47. A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? a) Ascites b) Hypertension c) Dyspnea d) Syncope

a) The tissues give a crackling sensation when palpated Pg. 598 Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.

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

d) Sit in an upright position a) Place the mouthpiece of the spirometer in the mouth b) Breathe air in through the mouth e) Hold breath for about 3 seconds c) Exhale air slowly through the mouth Pg. 529 The nurse instructs the client, when using the incentive spirometer, the proper use of it. First, the client is to sit in an upright position. The client is then to place the mouthpiece of the spirometer in the client's mouth. Next, the client breathes air in through the mouth. This causes the incentive spirometer to be activated. The client holds his breath for about 3 seconds. Then, the client exhales slowly through the mouth.

49. The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order: a) Place the mouthpiece of the spirometer in the mouth b) Breathe air in through the mouth c) Exhale air slowly through the mouth d) Sit in an upright position e) Hold breath for about 3 seconds

d) "Client is becoming agitated and complains of pleuritic pain" Pg. 593 After a thoracentesis, the nurse monitors the client for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.

50. A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately? a) "Client has subcutaneous emphysema around needle insertion site" b) "Client is drowsy and complains of headache" c) "Client has oxygen saturation of 93%" d) "Client is becoming agitated and complains of pleuritic pain"

d) Chest tube drainage, 190 mL/hr Pg. 593-595 The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required.

51. The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? a) Moderate amounts of colorless sputum b) Heart rate, 112 bpm c) Pain of 5 on a 1-to-10 scale d) Chest tube drainage, 190 mL/hr

a) The patient will have an insertion of a tracheostomy tube Pg. 557 Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing.

52. A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a) The patient will have an insertion of a tracheostomy tube b) The patient will be extubated and another endotracheal tube will be inserted c) The patient will be extubated and a nasotracheal tube will be inserted d) The patient will begin the weaning process

a) Coughing Pg. 579 The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection.

53. The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? a) Coughing b) Copious sputum production c) Dyspnea d) Severe pain

c) Shortness of breath Pg. 552-553 Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.

55. The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? a) Headache b) Fever c) Shortness of breath d) Weight loss

d) Blood pressure increase of 20 mm Hg Pg. 567-569 Criteria for terminating the weaning process include heart rate increase of 20 beats/min and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

56. Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated? a) Vital capacity of 12 mL/kg b) Heart rate <100 bpm c) PaO2 60 mmHg with an FiO2 <40% d) Blood pressure increase of 20 mm Hg

b) Receiving vaccinations Pg. 540 Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis.

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

c) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pg. 580 Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

58. 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? a) Promote the strengthening of the client's diaphragm b) Promote more efficient and controlled ventilation and to decrease the work of breathing c) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing d) Promote the client's ability to take in oxygen

d) Manual resuscitation bag Pg. 563 The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

59. A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? a) Oxygen analyzer b) Tracheostomy cleaning kit c) Water-seal chest drainage set-up d) Manual resuscitation bag

a) Encourage breathing exercises Pg. 556 Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.

6. Which intervention does a nurse implement for clients with empyema? a) Encourage breathing exercises b) Institute droplet precautions c) Do not allow visitors with respiratory infections d) Place suspected clients together

b) A client requires permanent ventilation Pg. 558 A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed client. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

60. What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? a) A client has a respiratory rate of 10 breaths per minute b) A client requires permanent ventilation c) A client exhibits symptoms of dyspnea d) A client has respiratory acidosis

c) Dyspnea and wheezing Pg. 543 In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

61. A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Hemoptysis and dysuria b) Nonproductive cough and normal temperature c) Dyspnea and wheezing d) Sore throat and abdominal pain

b) Administer prescribed short-acting bronchodilator Pg. Administering a short-acting bronchodilator will dilate the airway and enable oxygen to reach the lungs. Although ABGs and a chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute asthma attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.

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

c) Document that the chest drainage system is operating as it is intended Pg. 596 Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

63. The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? a) Inform the physician promptly that there is in imminent leak in the drainage system b) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes c) Document that the chest drainage system is operating as it is intended d) Encourage the client to do deep breathing and coughing exercises

a) Daily doses of isoniazid, 300 mg for 6 months to 1 year Pg. 549 All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.

64. A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? a) Daily doses of isoniazid, 300 mg for 6 months to 1 year b) Isolation until 24 hours after antitubercular therapy begins c) Nothing, until signs of active disease arise d) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years

d) Encourage increased fluid intake Pg. 543 The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.

65. You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? a) Give antibiotics as ordered b) Offer nutritious snacks 2 times a day c) Place client on bed rest d) Encourage increased fluid intake

c) Encourage the patient to take approximately 10 breaths per hour, while awake Pg. 529 The patient should be instructed to perform the procedure approximately 10 times in succession, repeating the 10 breaths with the spirometer each hour during waking hours. The patient should assume a semi-Fowler's position or an upright position before initiating therapy, not be supine. Coughing during and after each session is encouraged, not discouraged. The patient should Splint the incision when coughing postoperatively. The patient should still use the spirometer when in pain.

66. A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? a) Inform the patient that using the spirometer is not necessary if the patient is experiencing pain b) Encourage the patient to try to stop coughing during and after using the spirometer c) Encourage the patient to take approximately 10 breaths per hour, while awake d) Have the patient lie in a supine position during the use of the spirometer

a) Measuring and documenting the drainage in the collection chamber Pg. 596 The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

67. For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) Measuring and documenting the drainage in the collection chamber b) Maintaining continuous bubbling in the water-seal chamber c) Keeping the collection chamber at chest level d) Stripping the chest tube every hour

b) Circulatory hypoxia Pg. Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.

68. The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? a) Hypoxemic hypoxia b) Circulatory hypoxia c) Anemic hypoxia d) Histotoxic hypoxia

a) Oxygen toxicity Pg. Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

69. A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? a) Oxygen toxicity b) Hypoxia c) Oxygen-induced hypoventilation d) Oxygen-induced atelectasis

b) Paradoxical chest movement Pg. 591 Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

7. A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? a) Respiratory acidosis b) Paradoxical chest movement c) Clubbing of fingers and toes d) Chest pain on inspiration

b) Notify the physician Pg. 596 Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.

70. The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? a) Milk the chest tube b) Notify the physician c) Place the head of the patient's bed flat d) Disconnect the system and get another

b) Blood-tinged sputum Pg. 592 The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.

71. 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? a) Bradypnea b) Blood-tinged sputum c) Respiratory alkalosis d) Productive cough

a) Impaired gas exchange Pg. 589 For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety,Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

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

a) Oxygen supports combustion Pg. 597 Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post "No Smoking" signs when oxygen is in use, particularly in facilities that are not smoke free.

73. A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors? a) Oxygen supports combustion b) Oxygen prevents the dispersion of smoke particles c) Oxygen is combustible d) Oxygen is explosive

c) Oxygen saturation level Pg. 540 The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

74. The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: a) Extremities for signs of cyanosis b) Level of consciousness (LOC) c) Oxygen saturation level d) Hemoglobin, hematocrit, and red blood cell levels

a) Continuous positive airway pressure (CPAP) Pg. 560 CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

75. A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? a) Continuous positive airway pressure (CPAP) b) Bi-level positive airway pressure (BiPAP) c) Surgery to remove the tonsils and adenoids d) Medications to assist the patient with sleep at night

b) Stabbing pain during respiratory movements Pg. 553 The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.

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

c) How to splint the incision when coughing Pg. 580 Prior to thoracotomy, the nurse educates the client about how to splint the incision with the hands, a pillow, or a folded towel. The client is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.

77. The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client? a) How to take prophylactic antibiotics correctly b) How to manage the need for fluid restriction c) How to splint the incision when coughing d) How to milk the chest tubing

c) Impaired gas exchange related to ventilator setting adjustments Pg. 564 All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

78. A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? a) Risk for trauma related to endotracheal intubation and cuff pressure b) Impaired physical mobility related to being on a ventilator c) Impaired gas exchange related to ventilator setting adjustments d) Risk for infection related to endotracheal intubation and suctioning

b) Place the chest tube in sterile water Pg. 597 If the client is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, place the end of the chest tube in sterile water. Reattaching the chest tube to the drainage system is a source for infection. Do not clamp the chest tube during transport. Notifying the health care provider will not help the client in the situation.

79. A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Clamp the chest tube close to the connection site b) Place the chest tube in sterile water c) Notify the health care provider d) Immediately reconnect the chest tube to the drainage apparatus

b) Fibrotic changes in lungs Pg. 576 For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

8. 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? a) Lung contusion b) Fibrotic changes in lungs c) Hemorrhage d) Damage to surrounding tissues

d) Few early symptoms Pg. 579 Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

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

a) Removal from the ventilator, tube, and then oxygen Pg. 569 The process of withdrawing the client from dependence on the ventilator takes place in three stages: the client is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

81. The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? a) Removal from the ventilator, tube, and then oxygen b) Removal from oxygen, tube, and then ventilator c) Removal from oxygen, ventilator, and then tube d) Removal of the tube, oxygen, and then ventilator

b) Suction the client, withdraw residual air from the cuff, and reinflate it Pg. 565 After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.

82. A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? a) Call the physician b) Suction the client, withdraw residual air from the cuff, and reinflate it c) Add more air to the cuff d) Remove the malfunctioning cuff

b) Encourage coughing and deep breathing Pg. 543 When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

83. After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) Clamp the chest tube once every shift b) Encourage coughing and deep breathing c) Report fluctuations in the water-seal chamber d) Milk the chest tube every 2 hours

a) Teach him how to perform huffing Pg. 580 The technique of "huffing" may be helpful for the client with diminished expiratory flow rates or for the client who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

84. The nurse has explained to the client that after his thoracotomy, it will be important to adhere to a coughing schedule. The client is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? a) Teach him how to perform huffing b) Teach him how to use a metered dose inhaler c) Teach him postural drainage d) Teach him to use a mini-nebulizer

d) Pneumonia Pg. 531 Pneumonia and influenza are the most common causes of death from infectious diseases in the United States. Pneumonia accounted for close to 51,000 deaths in the United States in 2009 and 1.1 million discharges from hospitals.

85. The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States? a) Tracheobronchitis b) Atelectasis c) Pulmonary embolus d) Pneumonia

a) Elevated B-type natriuretic peptide (BNP) levels Pg. 572 Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. Cardiogenic pulmonary edema is an acute event that results from heart failure, in which the cardiac chambers release atrial natriuretic peptide (ANP) and BNP to promote vasodilation and diuresis. BNP levels are not similarly elevated with ARDS.

86. 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? a) Elevated B-type natriuretic peptide (BNP) levels b) Elevated troponin levels c) Elevated myoglobin levels d) Elevated white blood count

c) "The mucus-secreting glands are abnormal" Pg. 534 Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.

87. Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? a) "There are fibrous cysts in the lungs" b) "Allergic reactions cause inflammation in the lungs" c) "The mucus-secreting glands are abnormal" d) "Early treatment can stop the progression of the disease"

a) Stabbing pain during respiratory movement Pg. 553 When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

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

c) Classes at community centers to teach about smoking cessation strategies Pg. 578 Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.

89. 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? a) Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays b) Legislation that requires homes and apartments be checked for asbestos leakage c) Classes at community centers to teach about smoking cessation strategies d) Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes

a) Significant Pg. 548 An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

9. After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: a) Significant b) Nonreactive c) Not significant d) Negative

a) "Inhale through your nose" d) "Slowly count to 3" b) "Exhale slowly through pursed lips" c) "Slowly count to 7" Pg. Pursed-lip breathing is a technique used to prolong exhalation by propping the airways open and promoting the removal of trapped air and carbon dioxide. The nurse should instruct the client to first inhale through the nose to a slow count of 3. Next, the client should exhale slowly through pursed lips for a count of 7.

90. A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client. a) "Inhale through your nose" b) "Exhale slowly through pursed lips" c) "Slowly count to 7" d) "Slowly count to 3"

b) A client with a nasogastric tube Pg. 535 Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

91. A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client who ambulates in the hallway every 4 hours b) A client with a nasogastric tube c) A client who is receiving acetaminophen (Tylenol) for pain d) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago

c) Synchronized intermittent mandatory ventilation (SIMV) Pg. 562 In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level. In AC ventilation, the ventilator delivers a preset number of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the preset tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client.

92. A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: a) Assist-control (AC) ventilation b) Continuous positive airway pressure (CPAP) c) Synchronized intermittent mandatory ventilation (SIMV) d) Pressure support ventilation (PSV)

b) Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved Pg. 563 If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.

94. The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? a) Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops b) Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved c) Call respiratory therapy and wait until they arrive to determine what is happening d) Suction the patient since the patient may be obstructed by secretions

c) Skin test doesn't differentiate between active and dormant tuberculosis infection Pg. 548 The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

95. A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) Presence of a wheal at the injection site in 2 days indicates active tuberculosis b) Test stimulates a reddened response in some clients and requires a second test in 3 months c) Skin test doesn't differentiate between active and dormant tuberculosis infection d) Area of redness is measured in 3 days and determines whether tuberculosis is present

a) Hand antisepsis d) Vaccinations Pg. 536 A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.

96. A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. a) Hand antisepsis b) Prescribed opioids c) Incentive spirometry d) Vaccinations

d) "You must consume a diet rich in protein, such as chicken, fish, and beans" Pg. 551-552 The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.

97. A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? a) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta" b) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables" c) "You must consume a diet low in fat by limiting dairy products and concentrated sweets" d) "You must consume a diet rich in protein, such as chicken, fish, and beans"

a) Impaired gas exchange Pg. 466 The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis of acute pain is probable, gas exchange is a higher priority. Ineffective airway clearance is not the greatest concern because the problem is with ventilation. Infection risk is present but is not the highest-priority client need.

98. A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority? a) Impaired gas exchange b) Ineffective airway clearance c) Infection risk d) Acute pain