PrepU Chapter 23: Chest and Lower Resp. Tract Disorders (Exam 2)

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? -Aspiration -Drug ingestion -Chemical irritation -Direct lung damage

-Chemical irritation Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. 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.

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? -Crackles in the lung bases -Low-pitched rhonchi during expiration -Pleural friction rub -Sibilant wheezes

-Crackles in the lung bases 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.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? -Hypotension, hyperoxemia, and hypercapnia -Hyperventilation, hypertension, and hypocapnia -Hyperoxemia, hypocapnia, and hyperventilation -Hypercapnia, hypoventilation, and hypoxemia

-Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply. -Banker -Rock quarry worker -Nurse -Miner -Mechanic

-Rock quarry worker -Miner A quarry worker is exposed to rock dust and silica. A miner can inhale dust causing silicosis or pneumoconiosis. A banker, nurse, and mechanic may have work hazards but not specific to the development of an occupational lung disease.

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? -Tension pneumothorax -Cardiac tamponade -Flail chest -Pulmonary contusion

-Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as -pleural effusion. -pneumothorax. -hemothorax. -consolidation.

-pleural effusion. Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

What dietary recommendations should a nurse provide a client with a lung abscess? -A diet low in calories -A diet rich in protein -A carbohydrate-dense diet -A diet with limited fat

-A diet rich in protein For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.

A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? -Paradoxical chest movement -Cyanosis -Hypertension -Wheezing

-Paradoxical chest movement 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. Upon expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the client's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

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? -Staphylococcus aureus -Mycobacterium tuberculosis -Pseudomonas aeruginosa -Streptococcus pneumoniae

-Streptococcus pneumoniae

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? -Vitamin B6 -Vitamin C -Vitamin D -Vitamin E

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

Class 1 with regard to TB indicates -no exposure and no infection. -exposure and no evidence of infection. -latent infection with no disease. -disease that is not clinically active.

-exposure and no evidence of infection. Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection with no disease. Class 4 is disease, but not clinically active.

A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient? -"Only wear your contact lenses during the day and take them out in the evening before bed." -"You should switch to wearing your glasses while taking this medication." -"The physician can give you eye drops to prevent any problems." -"There are no significant problems with wearing contact lenses."

-"You should switch to wearing your glasses while taking this medication." The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.

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? -Rapid onset of severe dyspnea -Inspiratory crackles -Bilateral wheezing -Cyanosis

-Rapid onset of severe dyspnea 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.

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

-pH 7.28, PaO2 50 mm Hg 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.

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

-"It is all right if I have a grilled cheese sandwich with American cheese." 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.

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? -"Chest tube will allow air to be restored to the lung." -"The tube will drain secretions from the lung." -"Chest tubes provide a route for medication instillation to the lung." -"The tube will drain air from the space around the lung."

-"The tube will drain air from the space around the lung." Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.

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

-"You must consume a diet rich in protein, such as chicken, fish, and beans." 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.

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? -0 to 4 mm -5 to 6 mm -7 to 8 mm -9 mm

-0 to 4 mm 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.

Approximately what percentage of people who are initially infected with TB develop active disease? -10% -20% -30% -40%

-10% Approximately 10% of people who are initially infected develop active disease. The other percentages are inaccurate.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? -3 to 5 days -1 to 3 weeks -2 to 4 months -6 to 12 months

-6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? -3 months -3 to 5 months -6 to 12 months -13 to 18 months

-6 to 12 months Pulmonary tuberculosis (TB) is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.

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

-A client with a nasogastric tube 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.

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? -A positive reaction indicates that the client has active tuberculosis (TB). -A positive reaction indicates that the client has been exposed to the disease. -A negative reaction always excludes the diagnosis of TB. -The PPD can be read within 12 hours after the injection.

-A positive reaction indicates that the client has been exposed to the disease. A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

On auscultation, which finding suggests a right pneumothorax? -Bilateral inspiratory and expiratory crackles -Absence of breath sounds in the right thorax -Inspiratory wheezes in the right thorax -Bilateral pleural friction rub

-Absence of breath sounds in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

On auscultation, which finding suggests a right pneumothorax? -Bilateral inspiratory and expiratory crackles -Absence of breath sounds in the right thorax -Inspiratory wheezes in the right thorax -Bilateral pleural friction rub

-Absence of breath sounds in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? -Atelectasis -Acute respiratory distress syndrome -Metabolic alkalosis -Respiratory acidosis

-Acute respiratory distress syndrome Factors associated with the development of ARDS 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. Options A, C and D are incorrect.

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

-Acute respiratory distress syndrome Factors associated with the development of ARDS 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. Options A, C, and D are incorrect.

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? -Acute respiratory distress syndrome -Lung cancer -Bronchitis -Tracheobronchitis

-Acute respiratory distress syndrome Factors associated with the development of ARDS 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. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

Which action should the nurse take first in caring for a client during an acute asthma attack? -Obtain arterial blood gases. -Send for STAT chest x-ray. -Administer bronchodilator as ordered. -Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

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

The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension? -Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. -Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. -Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. -Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.

-Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. In secondary pulmonary arterial hypertension, alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Therefore options A, B, and C are incorrect.

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? -Blood-tinged sputum -Bradypnea -Respiratory alkalosis -Productive cough

-Blood-tinged sputum 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.

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

-Classes at community centers to teach about smoking cessation strategies 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.

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? -Crackles -Rhonchi -Decreased breath sounds -Wheezes

-Decreased breath sounds In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? -Client teaching about the cause of TB -Reviewing the risk factors for TB -Developing a list of people with whom the client has had contact -Client teaching about the importance of TB testing

-Developing a list of people with whom the client has had contact To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

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

-Draining secretions, air, and blood from the thoracic cavity is necessary. After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.

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

-Dyspnea 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 rightsided 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.

Which intervention does a nurse implement for clients with empyema? -Encourage breathing exercises -Place suspected clients together -Institute droplet precautions -Do not allow visitors with respiratory infections

-Encourage breathing exercises The nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function.

Which interventions does a nurse implement for clients with empyema? -Institute droplet precautions -Place suspected clients together -Encourage breathing exercises -Do not allow visitors with respiratory infection

-Encourage breathing exercises The nurse teaches the client with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions and isolate suspected and clients with confirmed influenza in private rooms or place suspected and confirmed clients together. The nurse does not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? -Encourage breathing exercises. -Institute droplet precautions. -Place suspected patients together. -Do not allow visitors with respiratory infection.

-Encourage breathing exercises. The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.

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? -Give antibiotics as ordered. -Place client on bed rest. -Encourage increased fluid intake. -Offer nutritious snacks 2 times a day.

-Encourage increased fluid intake. 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.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? -Turning the client every 2 hours -Elevating the head of the bed 30 degrees -Encouraging increased fluid intake -Maintaining a cool room temperature

-Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

The nurse knows the mortality rate is high in lung cancer clients due to which factor? -Increase in women smokers -Increased incidence among the elderly -Increased exposure to industrial pollutants -Few early symptoms

-Few early symptoms 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.

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? -Fibrotic changes in lungs -Hemorrhage -Lung contusion -Damage to surrounding tissues

-Fibrotic changes in lungs 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.

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? -Fit all employees with protective masks. -Insist on adequate breaks for each employee. -Give workshops on disease prevention. -Provide employees with smoking cessation materials.

-Fit all employees with protective masks. 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.

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? -Pneumothorax -Flail chest -ARDS -Tension pneumothorax

-Flail chest 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.

The nurse is caring for a client with tuberculosis. Why should the nurse always encourage a client with tuberculosis to perform active range-of-motion (ROM) exercises three times a day? -For medication absorption -For maintaining muscle strength -For use as a baseline for evaluation -For effective pain control

-For maintaining muscle strength The nurse should always encourage active ROM exercises three times a day. Active ROM exercises maintain muscle strength and joint ROM. Assessment of pain level and other factors provide a baseline for treatment and evaluation. Proper pain assessment and appropriate analgesic administration provide more effective pain control. The nurse typically instructs the client to administer medication 1 hour before or 2 hours after meals because food interferes with medication absorption.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? -Decreased heart rate -Increased restlessness -Increased blood pressure -Decreased level of consciousness (LOC)

-Increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

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: -Risk for falls. -Ineffective breathing pattern. -Impaired tissue integrity. -Ineffective airway clearance.

-Ineffective airway clearance. 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.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? -Initiate oxygen therapy. -Administer a heparin bolus and begin an infusion at 500 units/hour. -Administer analgesics as ordered. -Perform nasopharyngeal suctioning.

-Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? -Institute isolation precautions. -Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. -Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. -Obtain a sputum specimen for enzyme immunoassay testing.

-Institute isolation precautions. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

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? -Intubate the client and control breathing with mechanical ventilation -Increase oxygen administration -Administer a large dose of furosemide (Lasix) IVP stat -Schedule the client for pulmonary surgery

-Intubate the client and control breathing with mechanical ventilation 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.

Which community-acquired pneumonia demonstrates the highest occurrence during summer and fall? -Legionnaires disease -Streptococcal (pneumococcal) pneumonia -Mycoplasmata pneumonia -Viral pneumonia

-Legionnaires disease Legionnaires disease accounts for 15% of community-acquired pneumonias; it occurs mainly in summer and fall. Streptococcal and viral pneumonias demonstrate the highest occurrence during the winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter.

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? -Pain in the feet -Coolness to lower extremities -Decreased urinary output -Localized calf tenderness

-Localized calf tenderness If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? -Negative -Positive -Borderline -Uncertain

-Negative The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis? -Pain in the feet -Inability to dorsiflex -Negative Homan's sign -Pain in the calf

-Pain in the calfWhen assessing the client's potential for pulmonary emboli, the client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain during this maneuver, he or she may have a deep vein thrombosis.

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? -Respiratory acidosis -Paradoxical chest movement -Chest pain on inspiration -Clubbing of fingers and toes

-Paradoxical chest movement Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall 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.

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? -Progressive loss of lung function associated with chronic disease -Sudden loss of lung function associated with chronic disease -Progressive loss of lung function with history of normal lung function -Sudden loss of lung function with history of normal lung function

-Progressive loss of lung function associated with chronic disease In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? -Apply a compression dressing to the area -Measure the patient's pulse oximetry -Report the finding to the physician immediately -Record the observation

-Record the observation The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.

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? -Shortness of breath -Weight loss -Fever -Headache

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

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

-Significant 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.

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

-Stabbing pain during respiratory movement 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.

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

-Stabbing pain during respiratory movement 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.

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

-Stabbing pain during respiratory movements. 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.

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? -Staphylococcus aureus -Mycobacterium tuberculosis -Pseudomonas aeruginosa -Streptococcus pneumoniae

-Streptococcus pneumoniae 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.

The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? -Insidious onset in client who had normal lung function -Sudden onset in client who had normal lung function -Insidious onset in client who had compromised lung function -Sudden onset in client who had compromised lung function

-Sudden onset in client who had normal lung function Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus? -Tense and relax muscles in the lower extremities. -Wear tight-fitting clothing. -Consume the majority of daily fluid intake prior to bed. -Begin estrogen replacement.

-Tense and relax muscles in the lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

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

-The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically 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.

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

-The tissues give a crackling sensation when palpated. 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.

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? -Turn onto the affected side. -Use a prescribed analgesic. -Avoid using a pillow while splinting. -Use a heat or cold application.

-Turn onto the affected side. The nurse teaches the client to splint the chest wall by turning onto the affected side. The nurse also instructs the client to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The client can also splint the chest wall with a pillow when coughing.

A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication? -Venous thromboemboli -Pneumothorax -Pulmonary hypertension -Cor pulmonale

-Venous thromboemboli Neuromuscular blockers predispose the client to venous thromboemboli (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The client may have discomfort or pain but be unable to communicate these sensations.

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to: -asbestos. -silica. -coal dust. -pollen.

-asbestos. Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: -follow up with the physician in 2 weeks. -continue to take antibiotics for the entire 10 days. -turn and reposition himself every 2 hours. -maintain fluid intake of 40 oz (1,200 ml) per day.

-continue to take antibiotics for the entire 10 days. The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: -follow up with the physician in 2 weeks. -continue to take antibiotics for the entire 10 days. -turn and reposition himself every 2 hours. -maintain fluid intake of 40 oz (1,200 ml) per day.

-continue to take antibiotics for the entire 10 days. The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

A positive Mantoux test indicates that a client: -is actively immune to tuberculosis. -has produced an immune response. -will develop full-blown tuberculosis. -has an active case of tuberculosis.

-has produced an immune response. The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis.

Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as -primary drug resistance. -secondary drug resistance. -tertiary drug resistance. -multidrug resistance.

-primary drug resistance. Primary drug resistance refers to resistance to one of the first-line antituberculotic agents in people who have not received previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in clients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.