Chapter 30: Chest thoracic problems

An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? a. Sudden onset of confusion b. Oral temperature of 102.3°F c. Coarse crackles in lung bases d. Clutching chest on inspiration

ANS: A Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department with severe shortness of breath and decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood.

ANS: A The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? a. Basilar crackles b. Oxygen saturation of 85% c. Presence of greenish sputum d. Respiratory rate of 28 breaths/min

ANS: A The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with impaired airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with other lower respiratory problems.

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 (AP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A AP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%

ANS: A The weak cough effort indicates that the patient is unable to clear the airway effectively. A patient who produces profuse sputum may be able to clear it with effective coughing. An increased respiratory rate or low SpO2 suggest problems with gas exchange.

The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) a. Maintain adequate fluid intake b. Maintain a 15-degree elevation. c. Splint the chest when coughing d. Have the patient use incentive spirometry. E. Teach the patient to cough at end of exhalation.

ANS: A, C, E Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should teach the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. Incentive spirometry promotes lung expansion. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

Which health promotion information would the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

ANS: A, D, E Because smoking is the major cause of lung cancer, an important role for the nurse is teaching patients about the benefits of and means of smoking cessation. Screening for using low-dose CT is recommended for high-risk patients Encourage those at risk for pneumonia (e.g., those who smoke) to obtain both influenza and pneumococcal vaccines. Sputum cytology is a diagnostic test but is not used for cancer screening. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery b. A 26-yr-old patient with continuous enteral feedings through a nasogastric tubeCorrect Answer c. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

ANS: B Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without enteral nutrition. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

Which action would the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Raise the head of the bed for a patient who is receiving tube feedings. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

ANS: B Patients who have an orogastric or nasogastric tube are at risk for aspiration pneumonia. Elevating the head of the bed can help prevent this complication. 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 O2 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.

An hour after a left thoracotomy, a patient reports 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 would the nurse take? a. Turn and reposition the patient. b. Administer prescribed morphine. c. Clamp the chest tube in two places. d. Assist the patient with incentive spirometry.

ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough or tolerate repositioning until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

ANS: B When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered

While ambulating a patient with metastatic lung cancer, the nurse observes a decrease in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? a. Continue with ambulation. b. Obtain a provider's order for arterial blood gas. c. Obtain a provider's order for supplemental oxygen. d. Move the oximetry probe from the finger to the earlobe.

ANS: C An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 93 to 88 while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.

ANS: C The drop in SpO2 to 85 indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.

The nurse is caring for a patient with right lower lobe lung cancer. What is the priority nursing action to enhance oxygenation in this patient? a. Positioning patient on right side b. Maintaining adequate fluid intake c. Positioning patient with the left side down d. Performing postural drainage every 4 hours

ANS: C Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action would the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer

ANS: C 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.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action would the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

ANS: C 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 O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large, bruised area on the chest

ANS: C Paradoxical 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

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site

ANS: C The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain would be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema would 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 would the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101F (38.3C)

ANS: C The patient's 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.

A patient is admitted to the emergency department with an open stab wound to the left chest. Which action would the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.

ANS: D 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.

The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92 c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patients oxygenation.

The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist the patient to expectorate thick lung secretions? a. Humidify the oxygen as able. b. Administer a cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated.

ANS: D Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

An older adult patient is admitted with acute respiratory distress from cor pulmonale. Which nursing action is most appropriate during admission of this patient? a. Perform a comprehensive health history with the patient to review prior respiratory problems. b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

ANS: D Because the patient is having respiratory difficulty, the nurse would ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89 percent to 90 percent). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patients caregiver to be present during the teaching.

ANS: D Hypoxemia interferes with the patients ability to learn and retain information, so having the patients caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse understand is the reason for using this type of surgery? a. The patient has lung cancer. b. The incision will be medial sternal or lateral. c. Chest tubes will not be needed postoperatively. d. Less discomfort and faster return to normal activity.

ANS: D The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowlers position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.

The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

ANS: D To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

A patient with pneumonia has a fever of 101.4F (38.6C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem would the nurse assign as the priority? a. Fatigue b. Altered temperature c. Musculoskeletal problem d. Impaired respiratory function

ANS: D All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the respiratory function is improved.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. ―I am going to buy a rib binder to wear during the day.‖ b. ―I can take shallow breaths to prevent my chest from hurting.‖ c. ―I should plan on taking the pain pills only at bedtime so I can sleep.‖ d. ―I will use the incentive spirometer every hour or two during the day.‖

ANS: D 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.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

ANS: D 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 to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.