Chapter 27: Lower Respiratory Problems

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

After change-of-shift report, which patient should the nurse assess first?

64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion The patients history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse?

A surgical face mask is applied before visiting the patient. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patients room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patients room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Appropriate use of cough suppressants Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

Arrange for a daily noon meal at a community center where the drug will be administered. Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

Ask the patient whether medications have been taken as directed. The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance?

Assist the patient to splint the chest when coughing. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) whenever I take a deep breath. Which action will the nurse take next?

Auscultate breath sounds. The patients statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

A patient with newly diagnosed lung cancer tells the nurse, I dont think Im going to live to see my next birthday. Which response by the nurse is best?

Can you tell me what it is that makes you think you will die so soon? The nurses initial response should be to collect more assessment data about the patients statement. The answer beginning Can you tell me what it is is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, Are you afraid implies that the patient thinks that the cancer will be immediately fatal, although the patients statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every eight hours. UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?

Elevate the head of the bed to a semi-Fowlers position. The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse?

Explain that orange discolored urine and tears are normal while taking this medication. Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patients postoperative care?

Frequent use of an incentive spirometer Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

Have you received the bacille Calmette-Gurin (BCG) vaccine for TB? Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?

I will call the health care provider right away if I develop a fever. Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and oxygen desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

I will continue to do the deep breathing and coughing exercises at home. Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

I will use the incentive spirometer every hour or two during the day. Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?

Impaired gas exchange related to respiratory congestion All these nursing diagnoses are appropriate for the patient, but the patients oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

Increased tactile fremitus Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Insertion of a chest tube with a chest drainage system The patients history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patients clinical manifestations are not consistent with these problems. DIF: Cognitive

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

My husband will be sleeping in the guest bedroom. Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

Observe for distended neck veins. Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be elevated with cor pulmonale than decreased.

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include?

Options for smoking cessation Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

Oxygen saturation is 88%. Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxic chest movement Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patients condition is improving?

Patient reports decreased exertional dyspnea. Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

Piperacillin/tazobactam (Zosyn) Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?

Place patients with altered consciousness in side-lying positions. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a sidelying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medicatio

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

Placing the patient on droplet precautions and in a private hospital room Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

Position the patient sitting upright on the edge of the bed and leaning forward. When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?

Require the use of protective equipment. Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suctioncontrol chamber of the collection device. Which action by the nurse is most appropriate?

Take no further action with the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?

Tape a nonporous dressing on three sides over the chest wound. The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

Teach about the need for prolonged antibiotic therapy after discharge from the hospital. Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

Teach about the need to get sputum specimens for 2 to 3 consecutive days. Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

Teaching patients about the need for adult pertussis immunizations The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

A lobectomy is scheduled for a patient with stage I nonsmall cell lung cancer. The patient tells the nurse, I would rather have chemotherapy than surgery. Which response by the nurse is most appropriate?

Tell me what you know about the various treatments available. More assessment of the patients concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, Surgery is the treatment of choice is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patients reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In nonsmall cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?

The patient is being treated with antiretrovirals for HIV infection. Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?

The patients central IV line is disconnected The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?

The patients white blood cell (WBC) count is 9000/L. The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

A patient is admitted with active tuberculosis (TB). The nurse should question a health care providers order to discontinue airborne precautions unless which assessment finding is documented?

Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

UAP lower the head of the patients bed to 15 degrees. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

Use and side effects of isoniazid (INH) The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

Yellow-tinged skin Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.