Lower Respiration Questions

What are common signs of pneumonia? (select all that apply) -Fever -Confusion -Nausea/Vomiting -SOA -Chest pain -Dry cough

Fever, confusion, SOA, and chest pain

A male client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? -Inflamed lung tissue -Sudden onset -Responsiveness to penicillin -Elevated white blood cell (WBC) count

The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Although most types of pneumonia have a sudden onset, a few (such as anaerobic bacterial pneumonia and mycoplasmal pneumonia) have an insidious onset.

What is normal for COPD patients? -They have high levels of O2, their drive to breathe is low CO2 -They have low levels of O2, their drive to breathe is high CO2 -They have high levels of CO2, their drive to breathe is low O2 -They have low levels of CO2, their drive to breathe is high O2

-They have high levels of CO2, their drive to breathe is low O2

What's the main difference between an incentive spirometer and a flutter valve? -A flutter valve focuses on exhalation rather than inhalation -A flutter valve only needs to be used once an hour instead of continuously -The patient should quickly inhale into a flutter valve vs. taking long inhales with an incentive spirometer -The incentive spirometer will promote coughing, the flutter valve will not

A flutter valve focuses on exhalation rather than inhalation

A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? -Activity intolerance related to fatigue -Anxiety related to actual threat to health status -Risk for infection related to retained secretions -Impaired gas exchange related to airflow obstruction

A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.

What is a common result of a pleural effusion? -Pneumonia and third spacing -Third spacing and empyema -Congestive heart failure

A pleural effusion is when there is fluid built up in the pleural cavity. Third spacing and empyema are generally results of a pleural effusion, while CHF usually causes pleural effusion

For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? -Restricting fluid intake to 1,000 ml per day -Enforcing absolute bed rest -Teaching the patient how to perform controlled coughing -Administering prescribe sedatives regularly and in large amounts

Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.

While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to: -Call the physician to reinsert the tube -Grasp the retention sutures to spread the opening -Call the respiratory therapy department to reinsert the tracheotomy -Cover the tracheostomy site with a sterile dressing to prevent infection

If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation.

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: -Pleural effusion -Pulmonary edema -Atelectasis -Oxygen toxicity

In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis.

A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: -Dyspnea -Chest pain -A bloody, productive cough -A cough with the expectoration of mucoid sputum

One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

What is an important teaching point for a patient with TB? -Patient needs a negative pressure room instilled in their home -Patient will need to get 2 sputum tests within the next month after discharge -Patient needs to be fitted for a HEPA mask -Patient needs to cover their mouth and nose while in public

Patient needs to cover their mouth and nose while in public

What procedure injects an irritant into the pleural cavity to cause the pleural to inflame and become "sticky"? -Thoracentesis -Pleurodesis -Bronchoscopy -VAT

Pleurodesis

Which of the following are lower respiratory diseases? -Pneumonia -Sinusitis -TB -COPD -Pharyngitis

Pneumonia, TB, and COPD

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: -Promote oxygen intake -Strengthen the diaphragm -Strengthen the intercostal muscles -Promote carbon dioxide elimination

Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.

What is a main side effect of Rifampin? -Nephrotoxicity -Hepatotoxicity -An in crease in urine output -Decreased visual acuity -Red/orange urine

Red/orange urine

The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? -Diaphragmatic breathing -Use of accessory muscles -Pursed-lip breathing -Controlled breathing

The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen? -Limiting fluid -Having the client take deep breaths -Asking the client to spit into the collection container -Asking the client to obtain the specimen after eating

To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis? -Bronchoscopy -Sputum culture -Chest x-ray -Tuberculin skin test

Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

What is O2 toxicity? -Due to patients retaining high levels of CO2 and breathing because of low O2 -When a patient has been deprived of oxygen or isn't receiving adequate amounts of oxygen for a period of time -A prolonged exposure to oxygen that leads to irritation of the eyes, nose, and throat -When a patient receives prolonged exposure to supplemental oxygen

When a patient received prolonged exposure to supplemental oxygen

Which of the following is not an expected finding if a patient has 180mL of fluid in the pleural cavity? -Wherever the fluid is it will appear "whited out/opaque" on the CXR -Patient will have decreased bilateral breath sounds -Patient's oxygen saturation may be lower than normal -Patient may be ordered a thoracentesis

Wherever the fluid is it will appear "whited out/opaque" on the CXR