Chapter 27 Evolve

C. Oral antibiotics will be used until there is evidence of improvement. IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? A. Lobectomy surgery is usually needed to drain the abscess. B. IV antibiotic therapy will be used for a 6-month period of time. C. Oral antibiotics will be used until there is evidence of improvement. D. Culture and sensitivity tests are needed for 1 year after resolving the abscess

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

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

A. Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? A. Antibiotic B. Corticosteroid C. Bronchodilator D. Cough suppressant

D. Bronchitis obliterans (BOS) BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? A. Pulmonary infarction B. Pulmonary hypertension C. Cytomegalovirus (CMV) D. Bronchiolitis obliterans (BOS)

B. Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for AM

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

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? A. Perform a comprehensive health history with the patient to review prior respiratory problems. B. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

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

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? A. Sudden onset of confusion B. Oral temperature of 102.3oF C. Coarse crackles in lung bases D. Clutching chest on inspiration

A. Asbestos exposure B. Exposure to uranium D. History of cigarette smoking Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? A. Asbestos exposure B. Exposure to uranium C. Chronic interstitial fibrosis D. History of cigarette smoking E. Geographic area in which he was born

A. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.

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? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guérin (BCG)

C. Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

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? A. Water-seal chamber has 5 cm of water. B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

B. "The medicine will be prescribed for 10 days." Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? A. "I need to take this medicine with meals." B. "The medicine will be prescribed for 10 days." C. "I will inject this medicine into my upper arm." D. "The medicine will dissolve the clot in my lung."

A. Obesity C. Malignancy D. Cigarette smoking E. Prolonged air travel An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? A. Obesity B. Pneumonia C. Malignancy D. Cigarette smoking E. Prolonged air travel

C. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

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

A. A temperature of 101.4°F B. Heart rate of 120 beats/min D. A productive cough with yellow sputum A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? A. A temperature of 101.4°F B. Heart rate of 120 beats/min C. Respiratory rate of 20 breaths/min D. A productive cough with yellow sputum E. Reports of unable to have a bowel movement for 2 days

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

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? A. Maintain adequate fluid intake. B. Maintain a 30-degree elevation. C. Splint the chest when coughing. D. Maintain a semi-Fowler's position. E. Instruct patient to cough at end of exhalation.

D. Increase fluid intake to 3 L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

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

C. Obtain a sputum specimen for culture and Gram stain. A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.

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? A. Teach the patient to cough and deep breathe. B. Take the temperature, pulse, and respiratory rate. C. Obtain a sputum specimen for culture and Gram stain. D. Check the patient's oxygen saturation by pulse oximetry.

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

The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? A. Positioning patient on right side B. Maintaining adequate fluid intake C. Positioning patient with "good lung" down D. Performing postural drainage every 4 hours

D. Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

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? A. Notify the health care provider. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen.

B. mucociliary clearance. Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? A. Cough reflex B. Mucociliary clearance C. Reflex bronchoconstriction D. Ability to filter particles from the air

C. Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation

A. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? A. Basilar crackles B. Oxygen saturation of 85% C. Presence of greenish sputum D. Respiratory rate of 28 breaths/min

C. "I need to be isolated from my family and friends so they won't get it. " The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? A. "I will be given amphotericin B to treat the fungus." B. "I got this fungus because I am immunocompromised." C. "I need to be isolated from my family and friends so they won't get it." D. "The effectiveness of my therapy can be monitored with fungal serology titers."

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

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

C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

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