Complex Ch 23: Resp II

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? a) Crackles in the lung bases b) Pleural friction rub c) Low-pitched rhonchi during expiration d) Sibilant wheezes

Answer: A 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. (page 570)

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

Answer: B 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. (page 596)

The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Cyanosis b) Rapid onset of severe dyspnea c) Inspiratory crackles d) Bilateral wheezing

Answer: B 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 (page 596)

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range? a) 3.0 to 3.5 b) 1.5 to 2.5 c) 2.0 to 2.5 d) 0.5 to 1.0

Answer: C Low-molecular- weight heparin and fondaparinux (Arixtra) are the cornerstones of therapy, but IV unfractionated heparin may be used during the initial phase (ACCP, 2012). The early maintenance phase of anticoagulation typically consists of overlapping regimens of heparins or fondaparinux for at least 5 days with an oral vitamin K antagonist (e.g., warfarin [Coumadin]). A 3- to 6-month regimen of long-term maintenance with warfarin is typical but depends on the risks of recurrence and bleeding (ACCP, 2012). Heparin must be continued until the INR is within a therapeutic range, typically 2.0 to 3 (Kearon, Kahn, Agnelli, et al., 2008). (page 602)

A Class 1 with regards to TB indicates a) no exposure and no infection. b) disease that is not clinically active. c) latent infection with no disease. d) exposure and no evidence of infection.

Answer: D 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. (page 588)

Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? a) Pneumocystis b) TB c) Streptococcal d) Fungal

Answer: A Pneumocystis pneumonia incidence is greatest in patient with AIDS and patients receiving immunosuppressive therapy for cancer. (page 574)

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

Answer: B 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. (page 595)

The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Risk for Infection b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Impaired Gas Exchange

Answer: B The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis. (page 582)

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: a) "I'll stop being contagious when I have a negative acid-fast bacilli test." b) "I'm contagious as long as I have night sweats." c) "I'm clear when my chest X-ray is negative." d) "My tuberculosis isn't contagious after I take the medication for 24 hours."

Answer: A A client with drug-resistant tuberculosis isn't contagious when he's had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce negative acid-fast test results for several days. The client won't have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they don't indicate whether the client is contagious. (page 588)

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? a) Placing the client in respiratory isolation b) Monitoring the client's fluid intake and output c) Wearing gloves during all client contact d) Assessing the client's temperature every 8 hours

Answer: A Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances. (page 587)

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Dyspnea and wheezing b) Hemoptysis and dysuria c) Nonproductive cough and normal temperature d) Sore throat and abdominal pain

Answer: A In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia. (page 577)

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

Answer: A 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 pressure ulcers but wouldn't help with the 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. (page 528)

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? a) "The tube will drain air from the space around the lung." b) "Chest tubes provide a route for medication instillation to the lung." c) "Chest tube will allow air to be restored to the lung." d) "The tube will drain secretions from the lung."

Answer: A 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. (page 614)

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? a) Using strict hand hygiene b) Turning the client every 4 hours to prevent fatigue c) Keeping the head of the bed at 15 degrees or less d) Providing oral hygiene daily

Answer: A The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia. (page 577)

A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient'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 assist the patient to breathe easier? a) Increase oxygen administration b) Intubate the patient and control breathing with mechanical ventilation c) Schedule the patient for pulmonary surgery d) Administer a large dose of furosemide (Lasix) IVP stat

Answer: B A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate. (page 597)

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

Answer: B 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. (page 605)

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? a) Myocardial infarction (MI) b) Pneumothorax c) Heart failure d) Pulmonary embolism

Answer: B Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure. (page 613)

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? a) Productive cough b) Blood-tinged sputum c) Respiratory alkalosis d) Bradypnea

Answer: B 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. (page 613)

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? a) A blister b) Reddened area c) 15-mm induration d) 5-mm induration

Answer: C A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation. (page 588)

Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? a) PaO 80 mm Hg b) PaCO 32 mm Hg c) pH 7.28 d) pH 7.35

Answer: C Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. (page 597)

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

Answer: C 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. (page 584)

For a patient with pleural effusion, what does chest percussion over the involved area reveal? a) Absent breath sounds b) Fluid presence c) Dullness over the involved area d) Friction rub

Answer: C Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area. (page 594)

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

Answer: C Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation. (page 614)

The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema? a) Elevated troponin levels b) Elevated myoglobin levels c) Elevated B-type natriuretic peptide (BNP) levels d) Elevated white blood count

Answer: C Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. (page 597)

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? a) "Early treatment can stop the progression of the disease." b) "Allergic reactions cause inflammation in the lungs." c) "The mucus-secreting glands are abnormal." d) "There are fibrous cysts in the lungs."

Answer: C Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis. (page 648)

Which of the following is a potential complication of a low pressure in the endotracheal cuff? a) Pressure necrosis b) Tracheal bleeding c) Aspiration pneumonia d) Tracheal ischemia

Answer: C Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis. (page 576)

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

Answer: C 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. (page 577)

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? a) Dyspnea b) Severe pain c) Coughing d) Copious sputum production

Answer: C The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection. (page 607)

Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall? a) Use a prescribed analgesic b) Use a heat or cold application c) Turn onto the affected side d) Avoid using a pillow while splinting

Answer: C The nurse teaches the patient to splint the chest wall by turning onto the affected side. The nurse also instructs the patient to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The patient can also splint the chest wall with a pillow when coughing. (page 593)

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? a) The ET tube must be advanced. b) The ET tube must be pulled back. c) A disease process is present. d) The X-ray is inconclusive.

Answer: C This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back. (page 588)

A nurse is caring for a patient after a thoracentesis. Which of the following signs if noted in the patient should be reported to the physician immediately? a) "Patient has subcutaneous emphysema around needle insertion site." b) "Patient is drowsy and complains of headache." c) "Patient has an oxygen saturation level of 93%." d) "Patient is becoming agitated and complains of pleuritic pain."

Answer: D After a thoracentesis, the nurse monitors the patient for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the patient may become anxious and develop dyspnea with increased use of the accessory muscles. (page 583)

Approximately what percentage of people who are initially infected with TB develop active disease? a) 40% b) 20% c) 10% d) 30%

Answer: C Approximately 10% of people who are initially infected develop active disease. The other percentages are inaccurate. (page 587)

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? a) Bloody drainage is seemed in the collection chamber. b) Skin around tube is pink. c) Absence of bloody drainage in the anterior/upper tube d) Crackling is heard when skin around tube is touched.

Answer: D Subcutaneous emphysema is the result of air leaking between the subcutaneous layers not 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. (page 616)

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? a) Aspiration b) Chemical irritation c) Drug ingestion d) Direct lung damage

Answer: B Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. 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. (page 573)

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

Answer: A Acute respiratory failure occurs suddenly in a client who previously had normal lung function. (page 595)

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: a) Ineffective airway clearance. b) Risk for falls. c) Impaired tissue integrity. d) Ineffective breathing pattern.

Answer: A 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. (page 582)

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

Answer: A 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. (page 595)