Ch. 28 Lower Respiratory
An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)
Pneumococcal
The nurse is caring for a patient with unilateral lung cancer. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours
Positioning patient with "good lung" down
The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.
Sit the patient up in bed as tolerated and apply oxygen.
After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which provider orders must the nurse verify have been completed before administering a dose of cefuroxime? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM
Sputum culture and sensitivity
21. The nurse assesses a patient for a possible pulmonary embolism. The nurse looks for the most frequent sign of: a. cough. b. hemoptysis. c. syncope. d. tachypnea.
d
3. The nurse expects that Theresa will be medicated with the usual antibiotic of choice, which is: a. cephalosporin. b. clindamycin. c. erythromycin. d. penicillin G.
d
7. For the tubercle bacillus to multiply and initiate a tissue reaction in the lungs, it must be deposited in: a. the alveoli. b. the bronchi. c. the trachea. d. all of the above.
a
8. A Mantoux skin test is considered not significant if the size of the induration is: a. 0 to 4 mm. b. 5 to 6 mm. c. 7 to 8 mm. d. 9 mm.
a
4. Streptococcus pneumoniae is the most common organism responsible for which of the following types of pneumonia? a. Hospital-acquired b. Immunocompromised c. Aspiration-specific d. Community-acquired
d
An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? Sudden onset of confusion Oral temperature of 102.3° F Coarse crackles in lung bases Clutching chest on inspiration
Sudden onset of confusion
During admission of a patient diagnosed with non-small cell lung cancer, the nurse questions the patient related to a history of which risk factors for this type of cancer? (Select all that apply.) Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which they were born
Asbestos exposure Exposure to uranium History of cigarette smoking
The nurse determines that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of a fungal lung infection with Candida albicans. What patient statement indicates to the nurse that further teaching is required? "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."
"I need to be isolated from my family and friends so they won't get it."
The nurse teaches a patient with a pulmonary embolism how to administer enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."
"The medicine will be prescribed for 10 days."
10. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding? a. SpO2 of 86% b. Crackles in both lower lobes c. Temperature of 101.4ºF (38.6ºC) d. Production of greenish purulent sputum
. a. Oxygen saturation obtained by pulse oximetry should be between 90% and 100%. An SpO2 lower than 90% indicates hypoxemia and impaired gas exchange. Crackles, purulent sputum, and fever are all manifestations of pneumonia, but do not necessarily relate to impaired gas exchange
14. Priority Decision: A patient diagnosed with class 3 TB 1 week ago is admitted to the hospital with symptoms of chest pain and coughing. What nursing action has the highest priority? a. Administering the patient's antitubercular drugs b. Admitting the patient to an airborne infection isolation room c. Preparing the patient's room with suction equipment and extra linens d. Placing the patient in an intensive care unit where he can be closely monitored
. b. A patient with class 3 TB has clinically active disease and airborne infection isolation is required for active disease until the patient is noninfectious, indicated by negative sputum smears. Cardiac monitoring and observation will need to be done with the patient in isolation. The nurse will administer the antitubercular drugs after the patient is in isolation. There should be no need for suction or extra linens after the TB patient is receiving drug therapy.
18. Priority Decision: To reduce the risk for most occupational lung diseases, what is the most important measure the occupational nurse should promote? a. Maintaining smoke-free work environments for all employees. b. Using masks and effective ventilation systems to reduce exposure to irritants. c. Inspection and monitoring of workplaces by national occupational safety agencies. d. Requiring periodic chest x-rays and pulmonary function tests for exposed employees.
. b. Although all of the precautions identified in this question are appropriate in decreasing the risk of occupational lung diseases, using masks and effective ventilation systems to reduce exposure is the most efficient and affects the greatest number of employees.
8. Priority Decision: After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which order should the nurse implement first? a. Anterior/posterior and lateral chest x-rays b. Start IV levofloxacin (Levaquin) 500 mg every 24 hr c. Sputum specimen for Gram stain and culture and sensitivity d. Complete blood count (CBC) with white blood cell (WBC) count and differential
. c. A sputum specimen for Gram stain and culture should be done before initiating antibiotic therapy and while waiting for the antibiotic to be delivered from the pharmacy in a hospitalized patient with suspected pneumonia and then antibiotics should be started without delay. If the sputum specimen cannot be obtained rapidly, the chest x-ray will be done to assess the typical pattern characteristic of the infecting organism. Blood cell tests will not be altered significantly by delaying the tests until after the first dose of antibiotics.
26. Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest? a. Severe hypotension b. Chest pain over ribs c. Absence of breath sounds d. Paradoxical chest movement
. d. Flail chest may occur when two or more ribs are fractured, causing an unstable segment. The chest wall cannot provide the support for ventilation and the injured segment will move paradoxically to the stable portion of the chest (in on expiration; out on inspiration). Hypotension occurs with a number of conditions that impair cardiac function, and chest pain occurs with a single fractured rib and will be of high priority with flail chest. Absent breath sounds occur following pneumothorax or hemothorax.
The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 26-yr-old patient with continuous enteral feedings through a nasogastric tube A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields
A 26-yr-old patient with continuous enteral feedings through a nasogastric tube
1. Nursing management for a person diagnosed as having acute tracheobronchitis includes: a. increasing fluid intake to remove secretions. b. encouraging the patient to remain in bed. c. using cool-vapor therapy to relieve laryngeal and tracheal irritation. d. all of the above.
d
The nurse is caring for a patient with a fever due to pneumonia. What assessment data does the nurse obtain that correlates with the patient having a fever? (Select all that apply.) A temperature of 101.4° F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days
A temperature of 101.4° F Heart rate of 120 beats/min A productive cough with yellow sputum
10. Diagnostic confirmation of a lung abscess is made by: a. chest x-ray. b. bronchoscopy. c. sputum culture. d. evaluating all of the above studies.
d
11. The most diagnostic clinical symptom of pleurisy is: a. dullness or flatness on percussion over areas of collected fluid. b. dyspnea and coughing. c. fever and chills. d. stabbing pain during respiratory movement.
d
A patient with a persistent cough is diagnosed with pertussis. What medication does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant
Antibiotic
The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min
Basilar crackles
A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and now has exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)
Bronchiolitis obliterans (BOS)
The nurse is admitting a patient with a diagnosis of pulmonary embolism. Which risk factors are a priority for the nurse to assess? (Select all that apply.) Cancer Obesity Pneumonia Cigarette smoking Prolonged air travel
Cancer Obesity Cigarette smoking Prolonged air travel
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Water-seal chamber has 5 cm of water No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site
Chest tube with a loose-fitting dressing
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? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity.
Less discomfort and faster return to normal activity.
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? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.
Cover the chest wound with a nonporous dressing taped on three sides.
A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? IV antibiotic therapy will be started as soon as possible. Lobectomy surgery is usually needed to drain the abscess. Oral antibiotics will be used until there is evidence of improvement. Culture and sensitivity tests are needed for 1 year after resolving the abscess.
IV antibiotic therapy will be started as soon as possible.
The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist this patient to expectorate thick lung secretions? Humidify the oxygen as able. Administer a cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.
Increase fluid intake to 3 L/day if tolerated.
The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation would the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation
Increased vocal fremitus on palpation
The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) Maintain adequate fluid intake. Maintain a 15-degree elevation. Splint the chest when coughing. Have the patient use incentive spirometry. Teach the patient to cough at end of exhalation.
Maintain adequate fluid intake. Splint the chest when coughing. Teach the patient to cough at end of exhalation.
The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. What should the nurse assess this patient for? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the air
Mucociliary clearance
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? Continue with ambulation. Obtain a provider's order for arterial blood gas. Obtain a provider's order for supplemental oxygen. Move the oximetry probe from the finger to the earlobe.
Obtain a provider's order for supplemental oxygen.
The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.
Obtain a sputum specimen for culture and Gram stain.
17. A key characteristic feature of adult respiratory distress syndrome (ARDS) is: a. unresponsive arterial hypoxemia. b. diminished alveolar dilation. c. tachypnea. d. increased PaO2.
a
2. The nurse knows that a sputum culture is necessary to identify the causative organism for acute tracheobronchitis. If the culture identifies a fungal agent, the nurse knows it would most likely be: a. Aspergillus. b. Haemophilus. c. Mycoplasma pneumoniae. d. Streptococcus pneumoniae.
a
12. A pleural effusion results when fluid accumulation in the pleural space is greater than: a. 5 mL. b. 10 mL. c. 15 mL. d. 20 mL.
d
15. The pathophysiology of ARF is directly related to: a. decreased respiratory drive. b. chest wall abnormalities. c. dysfunction of lung parenchyma. d. all of the above mechanisms.
d
24. To assess for a positive Homans' sign, the nurse should: a. dorsiflex the foot while the leg is elevated to check for calf pain. b. elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. c. extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. d. lower the patient's legs and massage the calf muscles to note any areas of tenderness.
a
25. As a cause of death among men and women in the United States, lung cancer ranks: a. first. b. second. c. third. d. fourth.
a
26. More than 80% of all lung cancers are primarily caused by: a. cigarette smoking. b. fibrosis. c. inhalation of environmental carcinogens. d. tuberculosis.
a
27. The most prevalent lung carcinoma that is peripherally located and frequently metastasizes is: a. adenocarcinoma. b. bronchioalveolar. c. large cell. d. squamous cell.
a
29. The nurse is aware that the most common surgical procedure for a small, apparently curable tumor of the lung is a: a. lobectomy. b. pneumonectomy. c. segmentectomy. d. wedge resection.
a
13. Auscultation can be used to diagnose the presence of pulmonary edema when the following adventitious breath sounds are present: a. crackles in the lung bases. b. low-pitched rhonchi during expiration. c. pleural friction rub. d. sibilant wheezes.
a
14. Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than _____ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than ______ mm Hg (hypercapnia). a. 50 and 50 b. 60 and 60 c. 75 and 75 d. 80 and 80
a
16. Which medications would be used in four-drug treatment for the initial phase of TB (select all that apply)? a. Isoniazid (INH) b. Rifampin (Rifadin) c. Pyrazinamide (PZA) d. Rifabutin (Mycobutin) e. Levofloxacin (Levaquin) f. Ethambutol (Myambutol)
a, b, c, f. For the first 2 months, a four-drug regimen consists of isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol (Myambutol). Rifabutin (Mycobutin) and levofloxacin (Levaquin) may be used if the patient develops toxicity to the primary drugs. Rifabutin (Mycobutin) may be used as first-line treatment for patients receiving medications that interact with rifampin.
19. During a health promotion program, why should the nurse plan to target women in a discussion of lung cancer prevention (select all that apply)? a. Women develop lung cancer at a younger age than men. b. More women die of lung cancer than die from breast cancer. c. Women have a worse prognosis from lung cancer than do men. d. Women are more likely to develop small cell carcinoma than men. e. Nonsmoking women are at greater risk for developing lung cancer than men.
a, b, d, e. Smoking by women is taking a great toll, as reflected by the increasing incidence and deaths from lung cancer in women, who develop lung cancer at a younger age than men. Nonsmoking women are at greater risk of developing lung cancer. The incidence of small cell carcinoma is higher in women than in men. Men still have a worse prognosis than women from lung cancer
4. Which of the following microorganisms are associated with both CAP and MCAP (select all that apply)? a. Klebsiella b. Staphylococcus aureus c. Haemophilus influenzae d. Mycoplasma pneumonia e. Pseudomonas aeruginosa f. Streptococcus pneumonia
a, b, f. Community-acquired pneumonia (CAP) and medical care-associated pneumonia (MCAP) are both associated with Klebsiella, Staphylococcus aureus, and Streptococcus pneumonia. Haemophilus influenzae and Mycoplasma pneumonia are only associated with CAP. Pseudomonas aeruginosa is only associated with MCAP
1. How do microorganisms reach the lungs and cause pneumonia (select all that apply)? a. Aspiration b. Lymphatic spread c. Inhalation of microbes in the air d. Touch contact with the infectious microbes e. Hematogenous spread from infections elsewhere in the body
a, c, e. Microorganisms that cause pneumonia reach the lungs by aspiration from the nasopharynx or oropharynx, inhalation of microbes in the air, and hematogenous spread from infections elsewhere in the body. The other causes of infection do not contribute to pneumonia.
5. Place the most common pathophysiologic stages of pneumonia in order. Number the first stage with 1 and the last stage with 4. a. Macrophages lyse the debris and normal lung tissue and function is restored. b. Mucus production increases and can obstruct airflow and further decrease gas exchange. c. Inflammatory response in the lungs with neutrophils is activated to engulf and kill the offending organism. d. Increased capillary permeability contributes to alveolar filling with organisms and neutrophils interrupt normal oxygen transportation.
a. 4; b. 3; c. 1; d. 2. With most pneumonia-causing organisms the inflammatory response sends increased blood flow and neutrophils to engulf the offending organisms. The alveoli are filled with extra fluid from increased blood flow and capillary permeability from surrounding vessels, which leads to hypoxia. Mucus production is increased and can further obstruct airflow. With bacterial pneumonia the alveoli fill with fluid and debris. Macrophages lyse and process the debris so that normal gas exchange returns.
35. Priority Decision: Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. What is the first action that the nurse should take? a. Raise the head of the bed. b. Notify the health care provider. c. Take the patient's pulse and blood pressure. d. Determine the patient's SpO2 with an oximeter
a. All of the activities are correct but the first thing to do is to raise the head of the bed to promote respiration in the patient who is dyspneic. The health care provider would not be called until the nurse has assessment data relating to vital signs, pulse oximetry, and any other patient complaints
37. Which condition contributes to secondary pulmonary arterial hypertension by causing pulmonary capillary and alveolar damage? a. COPD b. Sarcoidosis c. Pulmonary fibrosis d. Pulmonary embolism
a. Chronic obstructive pulmonary disease (COPD) causes pulmonary capillary and alveolar damage. Sarcoidosis is a granulomatous disease. Pulmonary fibrosis stiffens the pulmonary vasculature and pulmonary embolism obstructs pulmonary blood flow.
6. When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report? a. Confusion b. A recent loss of consciousness c. An abrupt onset of fever and chills d. A gradual onset of headache and sore throat
a. Confusion possibly related to hypoxia may be the only finding in older adults. Although CAP is most commonly caused by Staphylococcus aureus pneumonia and is associated with an acute onset with fever, chills, productive cough with purulent or bloody sputum, and pleuritic chest pain, the older patient may not have classic symptoms. Other causes of pneumonia have a more gradual onset with dry, hacking cough; headache; and sore throat. A recent loss of consciousness or altered consciousness is common in those pneumonias associated with aspiration, such as anaerobic bacterial pneumonias
19. A nurse knows to assess a patient with pulmonary arterial hypertension for the primary symptom of: a. ascites. b. dyspnea. c. hypertension. d. syncope.
b
2. After Mr. Carrera has undergone a series of additional tests, the diagnosis is confirmed by: a. a chest radiograph. b. the ELISA test. c. a positive multiple-puncture skin test. d. repeated Mantoux tests that yield indurations of 10 mm or greater.
b
2. All of the following are manifestations of bacterial pneumonia except: a. fever. b. bradycardia. c. stabbing or pleuritic chest pain. d. tachypnea.
b
20. Clinical manifestations directly related to cor pulmonale include all of the following except: a. dyspnea and cough. b. diminished peripheral pulses. c. distended neck veins. d. edema of the feet and legs.
b
28. The most frequent symptom of lung cancer is: a. copious sputum production. b. coughing. c. dyspnea. d. severe pain.
b
30. Paradoxical chest movement is associated with which chest disorder? a. Pneumothorax b. Flail chest c. ARDS d. Tension pneumothorax
b
5. Theresa is expected to respond to antibiotic therapy: a. within 6 hours. b. between 1 and 2 days. c. by the fourth day. d. after 7 days.
b
Mr. Carrera, a 67-year-old retired baker and pastry chef, is admitted to the clinical area for confirmation of suspected tuberculosis. He is anorexic and fatigued and suffers from "indigestion." His temperature is slightly elevated every afternoon. 1. Mr. Carrera's Mantoux tuberculin test yields an induration area of 6 to 10 mm. This result is interpreted as indicating that: a. active disease is present. b. he has been exposed to M. tuberculosis or has been vaccinated with BCG. c. preventive treatment should be initiated. d. the reaction is doubtful and should be repeated.
b
12. During an annual health assessment of a 65-year-old patient at the clinic, the patient tells the nurse he had the pneumonia vaccine when he was age 58. What should the nurse advise him about the best way for him to prevent pneumonia? a. Seek medical care and antibiotic therapy for all upper respiratory infections b. Obtain the pneumococcal vaccine this year with an annual influenza vaccine c. Obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia d. Obtain only the influenza vaccine every year because he has immunity to the pneumococcus
b. A second dose of the pneumococcal vaccine should be provided to all persons 65 years of age or older who have not received the vaccine within 5 years and were younger than 65 years of age at the time of vaccination. Influenza vaccine should be taken each year by those older than 65 years of age. Antibiotic therapy is not appropriate for all upper respiratory infections unless secondary bacterial infections develop.
36. A pulmonary embolus is suspected in a patient with a deep vein thrombosis who develops hemoptysis, tachycardia, and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? a. Chest x-rays b. Spiral (helical) CT scan c. Take the patient's pulse and blood pressure. d. Ventilation-perfusion lung scan
b. A spiral (helical) CT scan is the most frequently used test to diagnose pulmonary emboli because it allows illumination of all anatomic structures and produces a 3-D picture. If a patient cannot have contrast media, a ventilation-perfusion scan is done. Although pulmonary angiography is most sensitive, it is invasive, expensive, and carries more risk for complications. Chest x-rays do not detect pulmonary emboli until necrosis or abscesses occur.
25. To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. Dull percussion sounds on the injured side b. Severe respiratory distress and tracheal deviation c. Muffled and distant heart sounds with decreasing blood pressure d. Decreased movement and diminished breath sounds on the affected side
b. A tension pneumothorax causes many of the same manifestations as other types of pneumothoraces but severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures and trachea to the unaffected side is present in a tension pneumothorax. Percussion dullness on the injured site indicates the presence of blood or fluid and decreased movement and diminished breath sounds are characteristic of a pneumothorax. Muffled and distant heart sounds indicate a cardiac tamponade.
23. A patient with advanced lung cancer refuses pain medication, saying, "I deserve everything this cancer can give me." What is the nurse's best response to this patient? a. "Would talking to a counselor help you?" b. "Can you tell me what the pain means to you?" c. "Are you using the pain as a punishment for your smoking?" d. "Pain control will help you to deal more effectively with your feelings."
b. Before making any judgments about the patient's statement, it is important to explore what meaning he or she finds in the pain. It may be that the patient feels it is deserved punishment for smoking but further information needs to be obtained from the patient. Immediate referral to a counselor negates the nurse's responsibility in helping the patient and there is no indication that the patient is not dealing effectively with his or her feelings.
11. A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. What is an expected outcome for this patient? a. SpO2 is 90% b. Lungs clear to auscultation c. Patient tolerates walking in hallway d. Patient takes three or four shallow breaths before coughing to minimize pain
b. Clear lung sounds indicate that the airways are clear. SpO2 of 90% to 100% indicates appropriate gas exchange. Tolerating walking in the hallway also indicates appropriate gas exchange, not improved airway clearance. Deep breaths are necessary to move mucus from distal airways but this is not an outcome.
31. Which chest surgery is used for the stripping of a fibrous membrane? a. Lobectomy c. Thoracotomy b. Decortication d. Wedge resection
b. Decortication is the stripping of a thick fibrous membrane. A lobectomy is the removal of one lung lobe. A thoracotomy is the incision into the thorax. A wedge resection is used to remove a small lesion.
13. What was the resurgence in tuberculosis (TB) resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis related to? a. A lack of effective means to diagnose TB b. Poor compliance with drug therapy in patients with TB c. Indiscriminate use of antitubercular drugs in treatment of other infections d. Increased population of immunosuppressed individuals with acquired immunodeficiency syndrome (AIDS)
b. Drug-resistant strains of TB have developed because TB patients' compliance with drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of TB treatment. TB can be diagnosed effectively with sputum cultures. Antitubercular drugs are almost exclusively used for TB infections. The incidence of TB is at epidemic proportions in patients with HIV but this does not account for drug-resistant strains of TB.
38. While caring for a patient with idiopathic pulmonary arterial hypertension (IPAH), the nurse observes that the patient has exertional dyspnea and chest pain in addition to fatigue. What are these symptoms related to? a. Decreased left ventricular output b. Right ventricular hypertrophy and dilation c. Increased systemic arterial blood pressure d. Development of alveolar interstitial edema
b. High pressure in the pulmonary arteries increases the workload of the right ventricle and eventually causes right ventricular hypertrophy and dilation, known as cor pulmonale. Eventually, decreased left ventricular output may occur because of decreased return to the left atrium but it is not the primary effect of pulmonary hypertension. Alveolar interstitial edema is pulmonary edema associated with left ventricular failure. Pulmonary hypertension does not cause systemic hypertension
18. A 154-lb, 60-year-old woman is being treated for ARDS. The nurse knows that the minimum daily caloric requirement to meet normal requirements is: a. 1,200 to 1,800 calories. b. 1,800 to 2,200 calories. c. 2,000 to 2,400 calories. d. 2,500 to 3,000 calories.
d
3. The microorganisms Pneumocystis jiroveci (PCP) and cytomegalovirus (CMV) are associated with which type of pneumonia? a. Bronchial pneumonia b. Opportunistic pneumonia c. Hospital-associated pneumonia d. Community-acquired pneumonia
b. People at risk for opportunistic pneumonia include those with altered immune responses. Pneumocystis jiroveci rarely causes pneumonia in healthy individuals but is the most common cause of pneumonia in persons with HIV disease. Cytomegalovirus (CMV) occurs in people with an impaired immune response. Medical care-associated pneumonia is frequently caused by Pseudomonas aeruginosa, Escherichia coli, Klebsiella, and Acinetobacter species. Communityacquired pneumonia is most commonly caused by Streptococcus pneumonia.
15. When obtaining a health history from a patient suspected of having early TB, what manifestations should the nurse ask the patient about? a. Chest pain, hemoptysis, and weight loss b. Fatigue, low-grade fever, and night sweats c. Cough with purulent mucus and fever with chills d. Pleuritic pain, nonproductive cough, and temperature elevation at night
b. TB usually develops insidiously with fatigue, malaise, anorexia, low-grade fevers, and night sweats. Pleuritic pain, flu-like symptoms, and a productive cough may occur with an acute sudden presentation but dyspnea and hemoptysis are late symptoms
29. When should the nurse check for leaks in the chest tube and pleural drainage system? a. There is continuous bubbling in the water-seal chamber. b. There is constant bubbling of water in the suction control chamber. c. Fluid in the water-seal chamber fluctuates with the patient's breathing. d. The water levels in the water-seal and suction control chambers are decreased.
b. The water-seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing patient. Continuous bubbling indicates a leak. The water in the suction control chamber will bubble continuously and the fluid in the water-seal chamber fluctuates with the patient's breathing. Water in the suction control chamber, and perhaps in the waterseal chamber, evaporates and may need to be replaced periodically
16. Neuromuscular blockers are given to patients who are on ventilators in ARF to accomplish all of the following except: a. maintain positive end-expiratory pressure (PEEP). b. maintain better ventilation. c. increase the respiratory rate. d. keep the patient from fighting the ventilator.
c
22. Anticoagulant therapy with heparin is administered in an attempt to maintain the International Normalized Ratio (INR) in a therapeutic range of: a. 0.5 to 1.0. b. 1.5 to 2.5. c. 2.0 to 2.5. d. 3.0 to 3.5.
c
23. Nursing measures to assist in the prevention of pulmonary embolism in a hospitalized patient include all of the following except: a. a liberal fluid intake. b. assisting the patient to do leg elevations above the level of the heart. c. encouraging the patient to dangle his or her legs over the side of the bed for 30 minutes, four times a day. d. the use of elastic stockings, especially when decreased mobility would promote venous stasis.
c
3. In the United States, the most common causes of death from infectious diseases are influenza and: a. atelectasis. b. pulmonary embolus. c. pneumonia. d. tracheobronchitis.
c
31. An initial characteristic symptom of a simple pneumothorax is: a. ARDS. b. severe respiratory distress. c. sudden onset of chest pain. d. tachypnea and hypoxemia
c
6. It is estimated that Mycobacterium tuberculosis infects about what percentage of the world's population? a. 10% b. 25% c. 35% d. 50%
c
9. Prophylactic isoniazid (INH) drug treatment is necessary for about how many months? a. 3 months b. 3 to 5 months c. 6 to 12 months d. 13 to 18 months
c
40. Six days after a heart-lung transplant, the patient develops a low-grade fever, dyspnea, and decreased SpO2 . What should the nurse recognize that this may indicate? a. A normal response to extensive surgery b. A frequently fatal cytomegalovirus infection c. Acute rejection that may be treated with corticosteroids d. Obliterative bronchiolitis that plugs terminal bronchioles
c. Acute rejection may occur as early as 5 to 7 days after surgery and is manifested by low-grade fever, fatigue, and oxygen desaturation with exertion. Complete remission of symptoms can be accomplished with bolus corticosteroids. Cytomegalovirus and other infections can be fatal but usually occur weeks after surgery and manifest with symptoms of pneumonia. Obliterative bronchiolitis is a late complication of lung transplantation, reflecting chronic rejection.
21. A patient with a lung mass found on chest x-ray is undergoing further testing. The nurse explains that a diagnosis of lung cancer can be confirmed using which diagnostic test? a. Lung tomograms b. Pulmonary angiography c. Biopsy done via bronchoscopy d. Computed tomography (CT) scans
c. Although chest x-rays, lung tomograms, CT scans, MRI, and positron emission tomography (PET) can identify tumors and masses, a definitive diagnosis of a lung cancer requires identification of malignant cells in either sputum specimens or biopsies.
30. An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed. b. securing the drainage container in an upright position. c. stripping or milking the chest tube to promote drainage. d. reminding the patient to cough and deep breathe every 2 hours.
c. If chest tubes are to be milked or stripped, this procedure should be done only by the professional nurse. This procedure is no longer recommended, as it may dangerously increase pleural pressure, but there is no indication to milk the tubes when there is no bloody drainage, as in a pneumothorax. The UAP can loop the chest tubing on the bed to promote drainage and patients should be reminded to cough and deep breathe at least every 2 hours to aid in lung reexpansion. Securing the drainage container in an upright position is also a necessary activity that can be completed by UAP.
2. Why is the classification of pneumonia as community-acquired pneumonia (CAP) or medical care-associated pneumonia (MCAP) clinically useful? a. Atypical pneumonia syndrome is more likely to occur in MCAP. b. Diagnostic testing does not have to be used to identify causative agents. c. Causative agents can be predicted and empiric treatment is often effective. d. IV antibiotic therapy is necessary for MCAP but oral therapy is adequate for CAP.
c. Pneumonia that has its onset in the community is usually caused by different microorganisms than pneumonia that develops related to hospitalization and treatment can be empiric—based on observations and experience without knowing the exact causative organism. Frequently a causative organism cannot be identified from cultures and treatment is based on experience
4. The nurse is aware that Theresa may develop arterial hypoxemia, because: a. bronchospasm causes alveolar collapse, which decreases the surface area necessary for perfusion. b. mucosal edema occludes the alveoli, thereby producing a drop in alveolar oxygen. c. venous blood is shunted from the right to the left side of the heart. d. all of the above are true.
d
5. Characteristics of the Mycobacterium tuberculosis include all of the following except: a. it can be transmitted only by droplet nuclei. b. it is acid-fast. c. it is able to lie dormant within the body for years. d. it survives in anaerobic conditions.
d
6. Nursing management includes assessment for complications such as: a. atelectasis. b. hypotension and shock. c. pleural effusion. d. all of the above.
d
Theresa, a 20-year-old college student, lives in a small dormitory with 30 other students. Four weeks into the spring semester, she was diagnosed as having bacterial pneumonia and was admitted to the hospital. 1. The nurse is informed that Theresa has the strain of bacteria most frequently found in community-acquired pneumonia. The nurse suspects that the infecting agent is: a. Haemophilus influenza. b. Klebsiella. c. Pseudomonas aeruginosa. d. Streptococcus pneumoniae.
d
33. Following a thoracotomy, the patient has a nursing diagnosis of ineffective airway clearance related to inability to cough as a result of pain and positioning. What is the best nursing intervention for this patient? a. Have the patient drink 16 oz of water before attempting to deep breathe. b. Auscultate the lungs before and after deep-breathing and coughing regimens. c. Place the patient in the Trendelenburg position for 30 minutes before the coughing exercises. d. Medicate the patient with analgesics 20 to 30 minutes before assisting to cough and deep breathe.
d. A thoracotomy incision is large and involves cutting into bone, muscle, and cartilage, resulting in significant postoperative pain. The patient has difficulty deep breathing and coughing because of the pain and analgesics should be provided before attempting these activities. Water intake is important to liquefy secretions but is not indicated in this case, nor should a patient with chest trauma or surgery be placed in Trendelenburg position, because it increases intrathoracic pressure.
32. What is the purpose of video-assisted thoracic surgery (VATS)? a. Removal of a lung b. Removal of one or more lung segments c. Removal of lung tissue by multiple wedge excisions d. Used to inspect, diagnose, and manage intrathoracic injuries
d. During video-assisted thoracic surgery (VATS), a video scope is inserted into the thorax to assess, diagnose, and treat intrathoracic injuries. A pneumonectomy is the removal of a lung. A wedge resection is the removal of a lung segment. Lung volume-reduction surgery is the removal of lung tissue by excising multiple wedges.
39. What is a primary treatment goal for cor pulmonale? a. Controlling dysrhythmias b. Dilating the pulmonary arteries c. Strengthening the cardiac muscle d. Treating the underlying pulmonary condition
d. If possible, the primary management of cor pulmonale is treatment of the underlying pulmonary problem that caused the heart problem. Low-flow oxygen therapy will help to prevent hypoxemia and hypercapnia, which cause pulmonary vasoconstriction.
17. A patient with active TB continues to have positive sputum cultures after 6 months of treatment. She says she cannot remember to take the medication all the time. What is the best action for the nurse to take? a. Schedule the patient to come to the clinic every day to take the medication. b. Have a patient who has recovered from TB tell the patient about his successful treatment. c. Schedule more teaching sessions so the patient will understand the risks of noncompliance. d. Arrange for directly observed therapy by a responsible family member or a public health nurse
d. Notification of the public health department is required. If drug compliance is questionable, follow-up of patients can be made by directly observed therapy by a public health nurse or a responsible family member. A patient who cannot remember to take the medication usually will not remember to come to the clinic daily or will find it too inconvenient. Additional teaching or support from others is not usually effective for this type of patient.
7. What is the initial antibiotic treatment for pneumonia based on? a. The severity of symptoms b. The presence of characteristic leukocytes c. Gram stains and cultures of sputum specimens d. History and physical examination and characteristic chest x-ray findings
d. Prompt treatment of pneumonia with appropriate antibiotics is important in treating bacterial and mycoplasma pneumonia and antibiotics are often administered on the basis of the history, physical examination, and a chest x-ray indicating a typical pattern characteristic of a particular organism without further testing. Sputum and blood cultures take 24 to 72 hours for results and microorganisms often cannot be identified with either Gram stains or cultures. Whether the pneumonia is community acquired or medical-care associated is more significant than the severity of symptoms
24. A male patient has chronic obstructive pulmonary disease (COPD) and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring? a. Tension pneumothorax b. Iatrogenic pneumothorax c. Traumatic pneumothorax d. Spontaneous pneumothorax
d. Spontaneous pneumothorax is seen from the rupture of small blebs on the apex of the lung in patients with lung disease or smoking, as well as in tall, thin males with a family history of or a previous spontaneous pneumothorax. Tension pneumothorax occurs with mechanical ventilation and with blocked chest tubes. Iatrogenic pneumothorax occurs due to the laceration or puncture of the lung during medical procedures. Traumatic pneumothorax can occur with penetrating or blunt chest trauma
20. A patient with a 40 pack-year smoking history has recently stopped smoking because of the fear of developing lung cancer. The patient asks the nurse what he can do to learn about whether he develops lung cancer. What is the best response from the nurse? a. "You should get a chest x-ray every 6 months to screen for any new growths." b. "It would be very rare for you to develop lung cancer now that you have stopped smoking." c. "You should monitor for any persistent cough, wheezing, or difficulty breathing, which could indicate tumor growth." d. "Screening measures for lung cancers are controversial, but we can discuss the advantages and disadvantages of various measures."
d. The use of radiology, computed tomography (CT), and sputum cytology has been shown to detect lung cancer at earlier stages. Low-dose spiral CT scanning has been shown to decrease lung cancer mortality compared with those who had chest x-rays. To be considered for screening for lung cancer, patients must be 55 to 74 years old, current smokers with at least a 30 pack-year smoking history or former smokers who quit within the past 15 years, have no history of lung cancer, and not be on home oxygen A patient who has a smoking history always has an increased risk for lung cancer compared with an individual who has never smoked but the risk decreases as the period of nonsmoking increases.
