Ch 10 Chest and Lower Respiratory Disorders

Turn onto the affected side.

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?

exposure and no evidence of infection.

Class 1 with regard to TB indicates 1-exposure and no evidence of infection. 2-no exposure and no infection. 3-latent infection with no disease. 4-disease that is not clinically active.

Rapid onset of severe dyspnea

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? 1-Rapid onset of severe dyspnea 2-Inspiratory crackles 3-Bilateral wheezing 4-Cyanosis

Chemical irritation

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate? 1-Aspiration 2-Chemical irritation 3-Drug ingestion 4-Direct lung damage

A disease process is present.

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? 1-The ET tube must be advanced. 2-The ET tube must be pulled back. 3-A disease process is present. 4-The X-ray is inconclusive.

Increased restlessness

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? 1-Decreased level of consciousness (LOC) 2-Decreased heart rate 3-Increased blood pressure 4-Increased restlessness

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

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? 1-"I am going to have a tuna fish sandwich for lunch." 2-"It is fine if I eat sushi with a little bit of soy sauce." 3-"It is all right if I drink a glass of red wine with my dinner." 4-"It is all right if I have a grilled cheese sandwich with American cheese."

Decreased oxygen diffusion into the tissues

A patient is diagnosed with hypoxemic hypoxia. The nurse knows that the etiology directs medical and nursing interventions. Which of the following is the cause? 1-Decreased oxygen diffusion into the tissues 2-Inability of tissues to use available oxygen due to a toxic substance 3-Inadequate capillary circulation 4-Decreased effective hemoglobin concentration

Dyspnea

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? 1-Dyspnea 2-Hypertension 3-Syncope 4-Ascites

The patient will experience acceptable control of his pain.

A 22-year-old male patient developed a pulmonary embolism (PE) several days ago and has undergone a course of treatment in the hospital. Discharge has been delayed indefinitely, however, because the patient has developed pleurisy as a complication of his PE. When planning this patient's care, what outcome should the nurse prioritize? 1-The patient will successfully demonstrate breathing retraining. 2-The patient will demonstrate appropriate use of metered-dose inhalers (MDIs) with a spacer. 3-The patient will experience acceptable control of his pain. 4-The patient will adhere to his prescribed treatment regimen.

Sudden onset in client who had normal lung function

The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? 1-Sudden onset in client who had compromised lung function 2-Sudden onset in client who had normal lung function 3-Insidious onset in client who had compromised lung function 4-Insidious onset in client who had normal lung function

Aspiration pneumonia

Which of the following is a potential complication of a low pressure in the endotracheal cuff? 1-Pressure necrosis 2-Tracheal ischemia 3-Aspiration pneumonia 4-Tracheal bleeding

Adenocarcinoma; moderate rate of growth with early metastasis

A 68-year-old man who has smoked two packs of cigarettes a day has been diagnosed with lung cancer. The nurse gives his family the most current information about the type of tumor. Which of the following is the correct information about a tumor? 1-Small cell; rapid rate of growth with late metastasis 2-Squamous cell; slow rate of growth with early metastasis 3-Large cell; slow rate of growth with early metastsis 4-Adenocarcinoma; moderate rate of growth with early metastasis

Providing anticipatory interventions

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP? 1-Providing extra nutrition for the elderly patient 2-Giving antibiotics as ordered 3-Providing anticipatory interventions 4-Providing emotional support

Pneumothorax

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? 1-Myocardial infarction (MI) 2-Pulmonary embolism 3-Heart failure 4-Pneumothorax

pH 7.28, PaO2 50 mm Hg

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? 1-pH 7.46, PaO2 80 mm Hg 2-pH 7.36, PaCO2 32 mm Hg 3-pH 7.28, PaO2 50 mm Hg 4-pH 7.35, PaCO2 48 mm Hg

Ineffective airway clearance

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: 1-Risk for falls. 2-Ineffective breathing pattern. 3-Impaired tissue integrity. 4-Ineffective airway clearance.

Change positions frequently and cough up secretions.

A nurse should include what instruction for the client during postural drainage? 1-Sit upright to promote ventilation. 2-Remain in each position for 30 to 45 minutes for best results. 3-Lie supine to rest the lungs. 4-Change positions frequently and cough up secretions.

Older adults often lack a fever when they develop pneumonia

A nurse who provides care in a long-term care facility has observed a sharp decline in an 88-year-old man's level of consciousness and activity over the past 36 hours. The nurse recognizes the high incidence of pneumonia among older adults. How does pneumonia present differently among the elderly than among younger patients? 1-Oxygen saturation levels remain stable among older adults despite increased sputum production. 2-Older adults who have pneumonia are usually asymptomatic. 3-Older adults often lack a fever when they develop pneumonia. 4-Pneumonia is usually intensely painful for older adults but lacks an increase in white blood cells (WBCs).

Impaired gas exchange

A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized? 1-Risk for aspiration 2-Impaired gas exchange 3-Anxiety 4-Acute pain

Flail chest

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? 1-ARDS 2-Tension pneumothorax 3-Flail chest 4-Pneumothorax

Preparing to assist with intubating the patient

A patient has been brought to the emergency department (ED) by the paramedics. The patient is suspected of having acute respiratory distress syndrome (ARDS). What action should the nurse anticipate? 1-Setting up oxygen at 3 LPM by nasal prongs 2-Setting up a nebulizer 3-Preparing to assist with intubating the patient 4-Consulting physiotherapy

Toxicity

A patient has been receiving 100% oxygen therapy by way of a non-rebreather mask for several days. He complains of tingling in his fingers and shortness of breath. He has limitations, is extremely restless, and states that he has pain beneath his breastbone. The nurse should suspect oxygen-induced: 1-Hypoventilation. 2-Toxicity. 3-Atelectasis. 4-Embolism.

primary drug resistance

Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as 1-multidrug resistance. 2-primary drug resistance. 3-tertiary drug resistance. 4-secondary drug resistance.

Tachypnea

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? 1-Tachypnea 2-Syncope 3-Hemoptysis 4-Cough