CH 23 Management of Patients with Chest and Lower Respiratory Tract Disorders (E2)
Put the steps in order for obtaining a sputum specimen. 1. Cough deeply 2. Breathe deeply several times 3. Spit sputum into a sterile container 4. Rinse the mouth
4, 2, 1, 3
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? A) Increase oral fluids unless contraindicated. B) Call the nurse for oral suctioning, as needed. C) Lie in a low Fowler's or supine position. D) Increase activity.
A
An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care? A) Suction the patient's airway secretions. B) Immobilize the ribs with an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate and intubate the patient.
A
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A) A resident who suffered a severe stroke several weeks ago B) A resident with mid-stage Alzheimer's disease C) A 92-year-old resident who needs extensive help with ADLs D) A resident with severe and deforming rheumatoid arthritis
A
The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment? A) Lately, I have this cough that just never seems to go away. B)I find that I don't have nearly the stamina that I used to. C) I seem to get nearly every cold and flu that goes around my workplace. D) I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair.
A
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration
A
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a firstline measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy
A
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds
A
The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? A) The younger you are when you start smoking, the higher your risk of lung cancer. B) The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays. C) The risk for lung cancer is determined mostly by what type of cigarettes you smoke. D) The risk for lung cancer depends primarily on the other risk factors for cancer that you have.
A
While planning a patient's care, the nurse identifies nursing actions to minimize the patient's pleuritic pain. Which intervention should the nurse include in the plan of care? A) Avoid actions that will cause the patient to breathe deeply. B) Ambulate the patient at least three times daily. C) Arrange for a soft-textured diet and increased fluid intake. D) Encourage the patient to speak as little as possible
A
The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? SELECT ALL THAT APPLY. A) Time frame of exposure B) Type of respiratory protection used C) Immunization status D) Breath sounds E) Intensity of exposure
A, B, D, E
A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the fallowing clients should the nurse expect to be at risk? SELECT ALL THAT APPLY. A) A client who has dysphagia B) A client who has AIDS C) Client who was vaccinated for pneumonoccous and influenza 6 months ago D) Client who is postoperative and has received local anesthesia E) Client who has a closed head injury and is receiving ventilation F) Client who has myasthenia gravis
A, B, E, F
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A) Administration of prophylactic antibiotics B) Administration of pneumococcal vaccine to vulnerable individuals C) Obtaining culture and sensitivity swabs from all newly admitted patients D) Administration of antiretroviral medications to patients over age 65
B
A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patient's exposure risk to toxic substances? A) Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air. B) Wear protective attire and devices when working with a toxic substance. C) Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins. D) Always wear a disposable paper face mask when you are working with inhalable toxins.
B
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A) A chest tube B) A tracheostomy C) An endotracheal tube D) A feeding tube
B
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication? A) Acute respiratory distress syndrome (ARDS) B) Atelectasis C) Aspiration D) Pulmonary embolism
B
What is the nurses main role during a thoracentesis? A) Documentation B) Positioning the patient C) Administering medications D) Inserting the needle
B
A nurse is caring for a client who has pneumonia. Assessment findings include temperature 100 respirations 30/min, BP 130/76, HR 100/min, and O2 91 on room air. Prioritize the following nursing interventions A) Administer antibiotics. B) Administer oxygen therapy C) perform a sputum culture D) Administer an antipyretic medication to promote client comfort
B, C, A D
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? SELECT ALL THAT APPLY. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs
B, D, E
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A) Older adults have less compliant lung tissue than younger adults. B) Older adults are not normally candidates for pneumococcal vaccination. C) Older adults often lack the classic signs and symptoms of pneumonia. D) Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.
C
The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patient's level of consciousness (LOC). B) Assess the patient's extremities for signs of cyanosis. C) Assess the patient's oxygen saturation level. D) Review the patient's hemoglobin, hematocrit, and red blood cell levels.
C
The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patient's history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer
C
Thoracentesis presents a risk for what major complication? A) Lung cancer B) Infection C) Pneumothorax D) Pain
C
When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following? A) Organic acids B) Propane C) Asbestos D) Gypsum
C
An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patient's plan of care? A) Nasogastric intubation B) Administration of probiotic supplements C) Bedrest D) Cautious hydration
D
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action? A) Smoking decreases the amount of mucus production. B) Smoke particles compete for binding sites on hemoglobin. C) Smoking causes atrophy of the alveoli. D) Smoking damages the ciliary cleansing mechanism.
D
When should a blood culture be obtained when assessing for pneumonia? A) Only when pneumonia presents as severe B) After starting antibiotics C) A blood culture would not be appropriate D) Before starting any antibiotics
D
What are some nursing interventions to prevent aspiration? A) Keep HOB elevated >30 degrees B) Avoid stimulation of gag reflex with suctioning or other procedures C) Check for placement before tube feedings D) Thickened fluids for swallowing probems E) All of the above
E
T/F: In atelectasis, clinical signs and symptoms will appear before it would be suggested on the chest x-ray.
False
T/F: S. Pneumonia and H. Influenzae are the main causative agents of pneumonia.
True
