Chapter 28 - Lewis
Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis?
Obtain blood cultures from two sites. Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration.
A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon." Which response by the nurse is best?
"Can you tell me what it is that makes you think you will die so soon?" The nurse's initial response should be to collect more assessment data about the patient's 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 nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask?
"Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" Patients who have received the BCG vaccine will have a positive Mantoux test.
After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states
"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.
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse?
"I will continue to do the deep breathing and coughing exercises at home." Patients should continue to cough and deep breathe after discharge.
Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk?
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 side-lying or upright position.
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate?
"Tell me what you know about the various treatments available." More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient.
Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis?
"Your urine, sweat, and tears will be orange colored." Orange-colored body secretions are a side effect of rifampin.
The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about
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.
After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first?
A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration.
The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP
lower the head of the patient's bed to 10 degrees. Positioning the patient with the head of the bed lowered will decrease ventilation.
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 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?
Administer the prescribed PRN morphine. The patient is unlikely to take deep breaths or cough until the pain level is lower.
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?
Arranging for a daily noontime meal at a community center and giving the medication then Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication.
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, 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. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use 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.
A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next?
Listen to the patient's lungs. The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds.
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 the 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 health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take?
Obtain consecutive sputum specimens from the patient for 3 days. Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis.
The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.)
Obtain the oxygen saturation. Check the patient's pulse rate. Notify the health care provider. Document the change in status.
Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider?
Oxygen saturation is 89%. Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring.
To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make?
Peripheral edema Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected.
Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease?
Require the use of protective equipment. Prevention of lung disease requires the use of appropriate protective equipment such as masks.
A patient is admitted to the emergency department with an open stab wound to the right 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.
Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease 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 tuberculosis.
The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action?
The patient's central intravenous 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.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
The patient's white blood cell (WBC) count is 9000/µl. The normal WBC count indicates that the antibiotics have been effective.
Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively.
A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first?
azithromycin (Zithromax) Early initiation of antibiotic therapy has been demonstrated to reduce mortality.
When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for
insertion of a chest tube with a chest drainage system. The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage.
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB
covers the mouth and nose when coughing. Covering the mouth and nose will help decrease airborne transmission of TB.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurse's first action should be to
elevate the head of the bed to 45 to 60 degrees. The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange.
When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes
frequent use of an incentive spirometer. Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis.
A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is
impaired gas exchange related to respiratory congestion. the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
increased tactile fremitus. Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias.
When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about
options for smoking cessation. Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation.
A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about
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.
A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to
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.
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member
puts on a surgical face mask before visiting the patient. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to
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.
A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if
the patient reports decreased exertional dyspnea. Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
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.
When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops
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.