Med-Surg Chapter 27

The nurse cares for an immunocompetent patient. Which clinical manifestation is most indicative of pulmonary tuberculosis?

A cough that progresses in frequency and produces mucoid or mucopurulent sputum is the most common symptom of pulmonary tuberculosis (TB). Diarrhea, hematuria, and dehydration are manifestations not directly associated with pulmonary TB. Fatigue and lymph node enlargement may be seen with TB but are not as indicative as is the production of mucopurulent sputum.

Which statement is true regarding a flutter valve?

A flutter valve or Heimlich valve allows patient mobility as the smaller drainage bag can be hidden under the clothes while the patient ambulates. The valve evacuates air from the pleural space. It is attached to the external end of the chest tube. A flutter valve opens whenever the pressure in the chest is greater than the atmospheric pressure.

The nurse is assessing a young male patient who came to the emergency department complaining of sudden shortness of breath. He has no other visible problems. The nurse notes that, upon auscultation, there are no breath sounds on the right upper lobe of the lung. The nurse suspects that the patient has which of these conditions?

A lack of breath sounds over a portion of the lung fields indicates the presence of a pneumothorax. A spontaneous pneumothorax typically occurs because of the rupture of small blebs (air-filled blisters) located on the apex of the lung. These blebs can occur in healthy, young individuals, especially tall, thin males. Tension pneumothorax occurs when air enters the pleural space but cannot escape. The continued accumulation of air in the pleural space causes increasingly elevated intrapleural pressures. Tension pneumothorax can occur with mechanical ventilation and resuscitative efforts. Iatrogenic pneumothorax can occur because of laceration or puncture of the lung during medical procedures. Traumatic pneumothorax can occur from either penetrating (open) or nonpenetrating (closed) chest trauma.

Which type of surgery involves the removal of one lobe of lung?

A lobectomy is a type of chest surgery that involves removal of one lobe of lung. A pneumonectomy is a type of chest surgery that involves removal of entire lung. A wedge resection is a type of surgery that involves removal of only a small, localized lesion. A segmental resection is a type of surgery that involves removal of one or more lung segments.

What modality of annual screening is recommended for those ages 55 to 80 years old with a history of a 30-pack per year smoking history, who currently smoke, or who quit less than 15 years ago?

A low-dose CT scan is typically used for screening high-risk patients. A chest x-ray is a diagnostic test, not a screening tool. Sputum cytologic studies can identify malignant cells but are rarely used in diagnosing because malignant cells are not always present. An MRI is done to evaluate the cancer and is not used as a screening tool.

The nurse is reviewing a chest x-ray for a client diagnosed with a mucous gland adenoma. Where does the nurse expect to find the tumor?

A mucous gland adenoma is a benign tumor that arises in the bronchi. Mesotheliomas may be either benign or malignant and develop in the visceral pleura. Hamartomas are benign tumors composed of fibrous tissue. A secondary metastasis is a malignancy associated with the spread of a tumor via the capillaries to the lungs.

A patient began taking antitubercular drugs a week ago. The nurse reviews the patient's medical record and learns that the patient has a 10-year history of consuming one standard drink of alcohol three times a week. The patient states, "In the last week, my urine turned orange and I am very worried about it." How should the nurse respond?

A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. It may also cause hepatitis. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. However, it is highly unlikely that tuberculosis has spread to the liver. The alcohol intake of the patient is within normal limits, and so it is not correct to say that alcohol may have damaged the liver. It is also inappropriate to advise the patient to stop taking antitubercular drugs.

The nurse who is caring for a patient with lung cancer anticipates that the tumor has spread to the mediastinum. Which finding helps the nurse to reach this conclusion?

A patient who has a malignant tumor that has spread to the mediastinum will have cardiac complications. Therefore pericardial effusion indicates that the patient has a tumor in the mediastinum. Dysphagia, superior vena cava obstruction, and unilateral paralysis of the diaphragm characterize intrathoracic spread of the malignancy.

A patient with dyspnea has partial pressure of carbon dioxide equal to 55 mm Hg and accentuation of the pulmonic heart sound. Which complication may be suspected in the patient?

A patient with dyspnea associated with low partial pressure of carbon dioxide and accentuation of the pulmonic heart sound may have a pulmonary embolism. The ongoing obstruction of blood flow in the lung vasculature leads to death of the lung tissue (pulmonary infraction). Intrapulmonary causes like pneumonia cause restrictive lung disorders. Pulmonary effusion is the accumulation of fluids in the pleural space and is not affected by the blockage of the pulmonary artery. Idiopathic pulmonary fibrosis, a chronic inflammatory disorder characterized by the formation of fibrosis in the lung's connective tissue, is caused by aging and smoking.

While assessing a patient with lung cancer, the nurse suspects that the patient has brain metastasis. Which finding in the patient supports the nurse's inference?

A patient with lung cancer who has brain metastasis may have neurologic problems such as an unsteady gait. Muscle wasting is related to musculoskeletal problems, which are a late manifestation of lung cancer. Pleural effusions are respiratory system manifestations of lung cancer. Edema of the face and neck is observed in patients with superior vena cava syndrome.

The nurse provides care to a trauma victim. Which clinical manifestation most suggests a pneumothorax?

A pneumothorax indicates that one of the lungs has collapsed and is not functioning. On auscultation no sounds of air movement will be heard. Because no air movement occurs with a pneumothorax, no breath sounds, including crackles, will be heard. Dullness may be a finding on percussion over the area of the pneumothorax, but an absence of breath sounds is the definitive finding.

A 48-year-old patient with sudden onset of respiratory distress is scheduled for a stat ventilation-perfusion scan. What explanations should the nurse provide to the patient about the procedure?

A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli. Sedation is not required; magnetic imaging is not a component of the examination, so the patient can have the test even if there is metal in the body. Chest pressure may indicate an adverse reaction and is not normal.

The nurse is assessing a patient with chest trauma who is on chest-tube gravity drainage. While assessing, the nurse finds that the fluid level in the chamber is very high. What is the best nursing intervention in this situation?

A very high fluid level in the water chamber indicates high negative pressure in the patient with chest trauma. Therefore the nurse should release the high negativity valve. Applying a clamp will stop the suction and decrease the risk of leakage but will not reduce negative pressure. Retaping the tube connections will reduce the leakage from the tube. The patient is on gravity drainage. Therefore lowering the water-seal column may cause complications for the patient.

The nurse is assessing a patient who was admitted from a nursing home with suspected tuberculosis (TB). Which of these are initial manifestations of tuberculosis? Select all that apply.

Active TB disease may manifest initially with constitutional symptoms such as fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, and night sweats. Dyspnea is a late symptom that may signify considerable pulmonary disease or a pleural effusion. Hemoptysis, which occurs in less than 10% of patients with TB, is also a late symptom.

The nurse is caring for a patient with adenocarcinoma. What statement made by the patient demonstrates an understanding of the condition?

Adenocarcinoma is a type of non-small cell lung cancer that is the most common lung cancer found in nonsmokers. Small cell carcinoma is the most malignant form of lung cancer. Unlike adenocarcinoma, small cell carcinoma is associated with endocrine disturbances. Squamous cell carcinoma does not have a widespread tendency to metastasize; however, adenocarcinoma is characterized by widespread metastasis.

Which ethnic group has the highest rate of lung cancer for men?

African American men have a higher rate of lung cancer than other ethnic groups. Whites, Hispanics, and Asian/Pacific Islanders do not have a higher rate than African Americans.

The nurse is providing a community program about lung cancer. What risk factor should the nurse be sure to include when discussing this topic?

Age of smoking onset is the directly related risk of lung cancer. Use of filtered cigarettes, number of cigarettes per day, and prolonged exposure to nickel may not be directly related.

When can airborne infection isolation for a patient with pulmonary tuberculosis (TB) be discontinued?

Airborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious (defined as effective drug therapy, clinical improvement, and three negative AFB smears). Therapy must be deemed effective. Teaching the patient to properly use the HEPA mask isn't a criterion for terminating isolation. Chest x-rays are not criteria to terminate isolation.

After assessing a patient with non-small cell lung cancer, the nurse finds that the patient has airway stenting. What outcome does the nurse expect for the patient after this treatment?

Airway stenting helps protect the airway wall against collapse or external compression, thereby delaying the extension of tumor into the airway lumen. The targeted therapy with crizotinib, a kinase inhibitor, helps reduce production of kinase protein produced by the ALK gene. Bronchoscopic laser therapy destroys tumor cells and causes thermal necrosis and shrinkage, which will clear the airway. Prophylactic radiation is a radiation therapy, which reduces the risk of cerebral metastasis in patients with lung cancer after receiving chemotherapy.

A patient with non-small cell lung cancer is having symptoms such as wheezing, dyspnea, and respiratory insufficiency. What are the most appropriate interventions for which the nurse should prepare the patient? Select all that apply.

Airway stenting is used to relieve coughing and dyspnea. Photodynamic therapy is used to remove lesions obstructing the airway and can relieve wheezing and dyspnea. Bronchoscopic laser surgery aims to remove the obstructing bronchial lesions, thereby relieving the symptoms of airway obstruction. Radiofrequency ablation is used to treat non-small cell lung tumors that are near the outer edge of the lungs. Chemotherapy is used to treat nonresectable tumors, or as an adjuvant therapy in patients with non-small cell lung cancer.

The nurse is caring for a patient with a diagnosis of active tuberculosis (TB). What does the nurse know is true?

Alcohol must be avoided because it increases the hepatotoxicity of INH. Directly observed therapy must be continued through both phases in patients who are at risk for noncompliance with drug therapy. Drug therapy includes a two-phase process, with an initial and continuation phase. Baseline LFTs are done before treatment is begun and then monitored monthly.

What is the priority nursing intervention in helping a patient expectorate thick lung secretions?

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 and administering cough suppressant are helpful but not the primary interventions. Teaching the patient to splint the affected area also may be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

A patient had an intradermal tuberculin skin test (Mantoux) administered 48 hours ago. The nurse assesses the injection site and identifies a 12-mm area of palpable induration. How should the nurse interpret this result?

An area of 12 mm of induration at the injection site 48 hours after a Mantoux test is considered significant for a past or current tuberculin infection. An induration of less than 5 mm is considered a negative result. The other answer options are incorrect conclusions related to the findings

A patient is diagnosed with intrathoracic metastasis from lung cancer. What clinical manifestation assessed by the nurse is related to this diagnosis?

An intrathoracic spread of malignancy in patients with lung cancer may cause dysphagia. Anorexia is a nonspecific systemic symptom of lung cancer. Laryngeal nerve involvement may cause hoarseness. A persistent cough is one of the most common and first symptoms of lung cancer.

What is the most evident symptom of flail chest in an unconscious patient?

An unconscious patient who has fractures of consecutive ribs will have rapid and shallow respirations. Cyanosis may occur in a patient with impaired respiration; however, it is not an evident symptom of flail chest. The patient with flail chest will not have edema, so distension of the neck is not apparent. The patient with flail chest will have asymmetric movement of the thorax due to poor air movement.

Which complication does the nurse expect when a patient with fractured ribs is wearing a binder on the chest?

Applying a binder on fractured ribs can reduce the chest expansion and retain secretions. Therefore the patient will have the risk of atelectasis. Chylothorax is complication of chest trauma, which results from disruption of the thoracic duct. Hemopneumothorax is the presence of blood in the pleural cavity due to chest trauma. Pulmonary embolism is a blockage of pulmonary a blood vessel due to thrombus formation; this complication is not associated with application of a binder.

A nurse preparing educational information about lung cancer notes that what is the primary risk factor related to the development of lung cancer?

As many as 90% of patients with lung cancer have a history of cigarette smoking. Cigarette smoke contains several organ-specific carcinogens. Genetics and occupational exposure are risks but not as high as cigarette smoking. Chewing tobacco is not associated with lung cancer; it is related to oral cancer.

Which condition may lead to intrapulmonary restrictive disease?

Atelectasis is a complete or partial closure of the lungs leading to a reduced exchange of gases that can cause intrapulmonary restrictive disease. Kyphoscoliosis, chest wall trauma, and Pickwickian syndrome cause extrapulmonary restrictive disease, in which the lung tissue is normal.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which most appropriate nursing diagnosis is based upon this assessment?

Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and the patient's breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient?

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 once the patient's acute respiratory distress is being managed.

A patient presents with a lung abscess. What treatment option would be the most appropriate?

Because there are mixed bacteria in a lung abscess, starting a broad spectrum antibiotic is the appropriate treatment option. Postural drainage and chest physiotherapy are not recommended because they may cause spillage of infection to other bronchi and spread the infection. Reducing fluid intake is not advisable; instead, adequate fluid intake is recommended.

A patient with lung cancer is being scheduled for chemotherapy. About what medication will the nurse educate the patient that is used for treatment?

Carboplatin is a chemotherapeutic agent used to treat lung cancer. Erlotinib, crizotinib, and bevacizumab are drugs used for targeted therapy. Erlotinib blocks the signal for growth in the cancer cells. Crizotinib is used to treat abnormal anaplastic lymphoma kinase gene. Bevacizumab inhibits the growth of new blood vessels.

Which are common causes of cancer? Select all that apply.

Coal dust, smoking, and high levels of pollution contribute to lung cancer. These carcinogens cause the development of mutations that alter the epithelial cells. Chewing tobacco is a precursor to oral cancer, not lung cancer. Bronchial asthma is a medical condition not associated with lung cancer, and genetic mutations are a predisposition for cancer overall, not specifically lung cancer.

A nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. The sputum, which is yellow, has been sent for laboratory testing, but the lab report is pending. What should be the next step in managing the patient?

Culture and Gram stain of sputum is required for prescribing specific antibiotics. However, if there is a delay in obtaining the lab reports, antibiotic administration should not be delayed. Deferring the antibiotics may lead to increased morbidity and mortality because the infection can worsen. Taking the sample again to send to a different lab would not be helpful because the lab will take a similar amount of time to provide the report. Chest physiotherapy can be advised later once the antibiotic therapy is started.

The nurse finds that a patient with chest trauma exhibits cyanosis, air hunger, distension of the neck vein, profuse diaphoresis, and an increase of intrathoracic pressure. What is the priority procedure in this situation?

Cyanosis, air hunger, distension of the neck vein, profuse diaphoresis, and an increase of intrathoracic pressure indicates tension pneumothorax in a patient with chest trauma. Tension pneumothorax is a complication associated with the presence of excess air in pleural thorax that cannot escape and is treated with needle decompression. Pericardiocentesis is helpful in aspirating fluid from the pleural space, which is more useful in cases of cardiac tamponade. Insertion of a chest tube with a flutter valve or a chest tube with drainage are techniques that help to drain air from the lung. However, these techniques are performed after needle decompression.

The nurse is caring for a patient who had a recent lung transplant. The nurse knows which statements are correct? Select all that apply.

Cytomegalovirus (CMV) is the most common opportunistic infection. Because acute rejection is common, higher levels of immunosuppressive therapy than what other organ recipients receive are given. Diagnosis of rejection is confirmed by transtracheal biopsy. Immunosuppressive therapy is usually a three-drug regimen, and acute rejection can occur in the first 5 to 10 postoperative days. If acute rejection is diagnosed, then high doses of corticosteroids are given for three days, followed by high doses of oral prednisone. If this does not work and rejection occurs, then antilymphocytic therapy may be useful. Bacterial pneumonia is the most common postoperative infection.

A patient is prescribed a medication that is used in targeted therapy and affects the epidermal growth factor. About what medication should the nurse educate the patient?

Erlotinib stops the growth in cancer cells by blocking the signals for epidermal growth factor receptors. Crizotinib and ifosfamide are used in chemotherapy to treat lung cancer. Bevacizumab is a drug that inhibits the growth of new blood vessels.

Which condition in a patient with chest trauma requires treatment of positive pressure ventilation?

Flail chest results in loss of chest stability due to fracture of the ribs. The patient with loss of chest stability requires positive pressure ventilation to ensure proper respiration. The nurse performs needle decompression to treat the cardiac tamponade effectively. The patient with hemopneumothorax or tension pneumothorax requires treatment with chest tube drainage, and positive pressure ventilation aggravates the patient's condition.

A patient is diagnosed with a hamartoma and asks the nurse what type of tumor it is. What is the best response by the nurse?

Hamartomas are slow-growing congenital tumors composed of fat, fibrous tissue, and blood vessels. Mucous gland adenomas are benign tumors arising in the bronchi. Mesotheliomas are tumors that arise from the visceral pleura. Mucous gland adenomas consist of columnar cystic spaces.

A patient presents with traumatic hemothorax. What action should the nurse perform immediately?

Hemothorax is an accumulation of blood in the pleural space resulting from injury to the chest wall, lung, blood vessels, diaphragm, or mediastinum. In the case of traumatic hemothorax, the nurse should assist in the immediate insertion of a chest tube, which is required for evacuation of blood. This blood can be recovered and reinfused for a short time after the injury. Further assessment can be done later. Hemothorax needs immediate intervention, and observing for 24 hours is not advisable. Keeping the patient lying down has no effect and is not the immediate action to be performed.

When the patient is diagnosed with a lung abscess, what should the nurse teach the patient?

IV antibiotics are used until the patient and x-ray show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Lobectomy surgery is needed only when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem. 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.

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 interventions?

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.

A patient with a spontaneous pneumothorax has a chest tube that is attached to a closed drainage system. The drainage unit is not attached to suction. The water level in the water-seal chamber is fluctuating. What action should the nurse take?

In a closed drainage system (not in a suction system) the fluid in the water-seal chamber rises when the patient inhales and falls when the patient exhales; this is a normal finding. The absence of fluctuations may indicate an obstruction in the system. The nurse must continually check the function of the closed drainage system and assess respiratory status at least every four hours. There is no need to notify the primary health care provider or decrease the amount of water in the water-seal chamber, because the chest tube system is functioning normally. The chest tube should not be clamped unless the nurse is directed to do so by the primary health care provider because doing so could cause a tension pneumothorax.

The diagnostic studies of a patient with primary lung cancer indicate that the tumor is peripherally located and has a moderate growth rate. What does the nurse interpret from these findings?

In adenocarcinoma, the tumor is peripherally located and will have a moderate growth rate. A small cell carcinoma is a malignant lung cancer, which spreads through the lymphatics to the brain. In squamous cell carcinoma, the tumor is located in the central part of the lung and the patient may have a nonproductive cough and hemoptysis. Undifferentiated carcinoma has a rapid growth rate and is composed of anaplastic large cells, which arise on the bronchi.

During the treatment of a patient with lung cancer, the primary health care provider asks the nurse to administer porfimer intravenously. For which procedure does the nurse prepare the patient?

In photodynamic therapy, porfimer is injected intravenously to concentrate in the tumor cells and destroy them when exposed to laser light. Airway stenting is a procedure where a stent is placed in the patient's airway to reduce respiratory distress. Bronchoscopic laser therapy is used to remove any obstructing bronchial lesions by transmitting thermal energy to the targeted tissue. Prophylactic cranial radiation is a radiation therapy used to destroy cancer cells in patients with small cell lung carcinoma to reduce the risk of cerebral metastasis.

A patient is scheduled to have photodynamic therapy, and the nurse is educating the patient regarding the procedure. How should the nurse discuss the steps in chronologic order?

In photodynamic therapy, porfirmer is injected intravenously. This drug concentrates in tumor cells. After some time, the tumor is exposed to laser light. This exposure activates the drug, which will subsequently destroy the tumor cells.

The nurse is educating the patient about radiofrequency ablation. What are the steps in chronologic order?

In radiofrequency ablation, local anesthesia is administered. Then, a needle-like probe is passed through the skin into the tumor. Next, a CT scan is used confirm the placement of the probe. After that, an electric current is passed through the probe to destroy the tumor cells.

The nurse is monitoring a patient who has pneumonia with thick secretions. The patient is having difficulty clearing the secretions. Which of these would be appropriate nursing interventions for this patient? Select all that apply.

Interventions for pneumonia include teaching the patient how to cough effectively to remove secretions, providing adequate hydration, and encouraging rest. Hydration is important in the supportive treatment of pneumonia to prevent dehydration and loosen secretions. Individualize and carefully monitor fluid intake if the patient has heart failure. It is not necessary to provide postural drainage every hour. Providing analgesics will not help the patient clear secretions.

A patient has an initial positive PPD (purified protein derivative) skin test result. A repeat PPD's result is also positive. No other signs or symptoms of tuberculosis or allergies are evident. Which medication(s) does the nurse anticipate will be prescribed?

Isoniazid (INH) is the most commonly initially prescribed medication to treat patients exposed to tuberculosis (TB). Penicillin and theophylline would not be prescribed for treatment of TB exposure. INH plus an antibiotic would not likely be prescribed for this scenario

A patient is diagnosed with a pneumothorax, and the health care provider has inserted a chest tube with chest drainage system. The nurse who is monitoring the system finds that there is no bubbling. The nurse checked all the connections and found no problems. What are the most probable reasons for the absence of bubbling? Select all that apply.

It is important for a nurse to keep the water at the appropriate level in a suction chamber. If there is no bubbling seen, it indicates that there is no suction, or suction pressure is not enough, or the pleural leak is too large to be drained by the given suction pressure. The nurse should therefore revise the suction pressure. Collection of blood in pleural space would be evident by the type of drainage.

What does the nurse infer from finding that a patient with a pneumothorax has limited fluid accumulated in the intrapleural space, with no other body parts affected?

Limited fluid accumulation in the intrapleural space in the patient with pneumothorax indicates that the patient is stable and does not require further treatment, because the resolution is spontaneous. Chest tube drainage is helpful to drain the fluid; however, this procedure is performed when the patient has severe complications. Aspiration with a large-bore needle is thoracentesis. This procedure is performed when the patient has fluid accumulation in the complete lung. Needle decompression helps to resolve pneumothorax when the patient has a medical emergency.

When teaching the patient about reducing the risks of lung cancer, what is the most important topic for the nurse to address?

Lung cancer and the risks associated with it can be reduced by smoking cessation, and the patient should be counseled to discontinue use of tobacco and avoid second-hand smoke as much as possible. Drinking more fluids, eating more grains, and using steam inhalation are general measures to promote health and do not have much impact on reducing risks of lung cancer.

A patient is suspected to have stage IIA lung cancer. About what diagnostic tests will the nurse educate the patient that will be used to confirm the diagnosis? Select all that apply.

Magnetic resonance imaging (MRI) and positron emission tomography (PET) are used to evaluate the stage of lung cancer. Computed tomography (CT) is used to identify the location and the extent of the tumor mass. So MRI, PET, and CT are appropriate diagnostic tests to determine the stage, location, and extent of lung cancer. A chest x-ray is the initial diagnostic test used to identify the lung mass; it does not show the extent of the involvement. Sputum cytologic studies are used to detect the malignant cells in sputum. Because malignant cells are not always present in the sputum, it is not a definitive diagnostic study.

Which intervention should the nurse perform to reduce dyspnea in a patient with lung cancer?

Maintaining a semi-Fowler's position allows gravity to enhance respirations and increase airflow into the lungs. This especially is helpful in reducing the amount of dyspnea that the patient experiences. Postural drainage positions are used in the setting of excess lung secretions. Morphine and pursed lip breathing may be used to reduce anxiety, which this patient is not experiencing.

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do? Select all that apply.

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.

A patient is receiving radiation therapy for treatment of lung cancer. About what side effects should the nurse educate the patient that might occur during treatment? Select all that apply

Nausea, anorexia, and vomiting are complications of radiation therapy. Fatigue and weight loss are not associated with radiation therapy. These are nonspecific systemic symptoms of lung cancer.

A nurse is assessing a patient in whom lung cancer is suspected. Which symptom is the patient most likely to report first?

Persistent cough and hoarseness are two of the earliest signs of lung cancer. Chest pain, diaphoresis, and fever may develop along with later symptoms of lung cancer.

A patient with lung cancer is undergoing photodynamic therapy. For what other technique will the nurse prepare the patient?

Photodynamic therapy is used to treat very early stages of lung cancer. A bronchoscopy is an endoscopic technique used to visualize the inside of the airways. During photodynamic therapy, the tumor is exposed to laser light via bronchoscopy. Thoracentesis is a procedure performed to relieve pleural diffusions; the fluid is collected and analyzed for malignant cells. Airway stenting helps relieve dyspnea and breathing problems and delays the growth of the tumor into the airway lumen. CT-guided needle aspiration is used to obtain cells for biopsy.

Which surgical procedure involves the removal of a part of pleura in the body?

Pleurectomy is a procedure that involves in the removal of a part of pleura that has tumor or is damaged. Pleurodesis is the surgical procedure that helps in adhesion of visceral and parietal pleura in the patient who has pneumothorax. Pleural biopsy is a procedure in which a sample of pleural cell is examined for tumors. Thoracentesis is a procedure that is performed to drain the fluid from the pleural space

To ease pleuritic pain caused by pneumonia, what nursing interventions should be performed?

Pleuritic chest pain is triggered by chest movement and is particularly severe during coughing and deep breathing. Splinting the chest wall will reduce movement and thus ease discomfort during coughing. Use of an incentive spirometer and practicing abdominal breathing may help increase respiratory efficiency, remove secretions, and increase oxygenation, but they will not ease pleuritic pain. The patient should not be encouraged to breathe shallowly because this will increase the risk for atelectasis and decrease oxygenation.

A patient with chest wall trauma has diminished breath sounds on the affected side, dyspnea, and bleeding in the chest wall. The primary health care provider inserts a chest tube immediately after the injury. Which type of injury does the nurse expect has occurred?

Pneumothorax in the patient with a chest wall injury is manifested by diminished breath sounds on the affected side and dyspnea and bleeding in the chest wall and results in hemopneumothorax. Flail chest is a thoracic injury associated with fracture of ribs, and the patient will require positive pressure ventilation and intubation for effective treatment. Chylothorax is a thoracic injury and is characterized by the presence of lymph in the pleural space. Surgery and pleurodesis treats chylothorax. Cardiac tamponade is associated with increased pleural fluid in the pericardium, which increases pressure on heart.

A patient is diagnosed with pulmonary embolism. What nursing actions are appropriate for this patient? Select all that apply.

Pulmonary embolism requires prompt therapy for a good prognosis. Oxygen therapy should be administered as prescribed. An IV line should be maintained for medications and fluid therapy. Anticoagulants and fibrinolytics may have adverse effects, and the nurse should monitor the patient for side effects. The patient should be placed in a semi-Fowler's position to assist in breathing. The patient should be encouraged to cough and perform deep breathing exercises for better pulmonary function.

The nurse is caring for a patient who will be treated with electric current to destroy tumor cells. For which treatment should the nurse prepare the patient?

Radiofrequency ablation is a technique in which a needle-like probe is inserted through the skin into the tumor to deliver an electric current and destroy the tumor cells. Photodynamic therapy is a treatment that uses laser light to destroy tumor cells. Prophylactic cranial radiation is used to decrease the incidence of cerebral metastasis. Stereotactic body radiotherapy uses high doses of radiation to destroy the tumor cells.

The nurse is caring for an older frail adult patient with stage II non-small cell lung cancer who may not be a candidate for a surgical procedure. About what alternative should the nurse educate the patient?

Radiofrequency ablation is a therapy that uses an electric current to destroy tumor cells that provides effective treatment to the patient with lung cancer. Patients who cannot undergo surgery can have radiofrequency ablation therapy as an alternative. Airway stenting is used in combination with other techniques to relieve dyspnea, cough, or respiratory distress. Chemotherapy is used as an adjuvant to surgery to treat non-small cell lung cancer. Photodynamic therapy is used to treat a very early stage of lung cancer that is confined to the outer layers of the airways.

The nurse is caring for a patient who has had a left pneumonectomy. What is an appropriate nursing intervention for a patient postpneumonectomy?

Range-of-motion exercises performed on the affected upper extremity will prevent edema and encourage circulation to the lung space to promote healing. A patient who has had a pneumonectomy may have a clamped chest tube postoperatively, so there will not be any drainage. Fluid will gradually fill the space where the lung has been removed. Position the patient on operative side to facilitate expansion of remaining lung. There will not be lung sounds on the operative side because the entire lung has been removed.

A patient who has tuberculosis (TB) is being treated with combination drug therapy. The nurse explains that combination drug therapy is essential because of what reason?

Recommendations for the initial treatment of tuberculosis (TB) include a four-drug regimen until drug susceptibility tests are available. After susceptibility is established, the regimen can be altered, but patients should still receive at least two drugs to prevent emergence of drug-resistance organisms. Dosage, side effects, and duration of the regimen are not reasons for combination drug therapy in a patient with TB.

A 72-year-old patient is in the emergency department with a temperature of 101.4° F and a productive cough with rust-colored sputum. The nurse notifies the health care provider, understanding these findings are indicative of which condition?

Rust-colored sputum is indicative of pneumococcal pneumonia. Tuberculosis frequently presents with a dry cough. Pink, frothy sputum would be present in CHF and pulmonary edema. A pulmonary embolus would produce hemoptysis.

Which nursing interventions will the nurse implement to help the patient expectorate mucus in a 72-year-old patient with bronchitis? Select all that apply.

Several interventions may help the patient expectorate mucus, including increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily, humidifying the oxygen to loosen secretions, and elevating the head of the bed to increase movement of mucous. Pursed lip breathing and a cough suppressant will not promote mucus production and expectoration.

Which type of primary lung cancer presents with a very rapid growth of cancer cells?

Small cell carcinoma has a very rapid growth rate and is the most malignant form of lung cancer. Adenocarcinoma has a moderate growth rate and is the most common form of lung cancer in people who have not smoked. Squamous cell carcinoma has a very slow growth rate and has a central location. Large cell carcinoma (undifferentiated carcinoma) is composed of highly metastatic large cells that arise from the bronchi.

Which lung cancer diagnosis is associated with the most rapid growth rate?

Small cell carcinoma is the most malignant form of lung cancer, with a very rapid growth rate. Squamous cell carcinoma has a slow growth rate, owing to its tendency to not metastasize. Large cell carcinoma is highly metastatic via the lymphatics and blood, but its growth rate is not as rapid as small cell. Adenocarcinoma is the most common type of lung cancer, a non-small cell lung cancer.

Which sized chest tube does the nurse use to drain air from the patient's chest?

Small tubes having the size in the range of 12F to 24F are used to drain air from the patient's chest. Medium tubes in the range of 24F to 36F are used for draining fluid from the patient's chest. Large tubes ranging from 36F to 40F are used for draining blood from the patient's chest.

What diagnostic information does a nurse relate to a patient with stage IV lung cancer?

Stage IV lung cancer is characterized by distant metastasis, whereby the tumor spreads to distant organs. A tumor that is 5 cm in size can be seen in stage IB and stage IIA. In stage II A, the tumor spreads to the regional lymph nodes and nearby structures such as the pleura and pericardium.

A patient with lung cancer is undergoing stereotactic body radiotherapy. What information should the nurse give to the patient before performing the test? Select all that apply.

Stereotactic body radiotherapy is a radiation therapy that treats lung cancer by reducing the tumor cells. The treatment is provided in an outpatient setting for one to three days. The patient will have side effects such as skin irritation and anorexia. Because this radiotherapy is performed in an outpatient setting, the patient will not be admitted for two days in the hospital after the treatment. In stereotactic body radiotherapy, the higher dose of radiation will target the tumor cells and only small part of the healthy lung is exposed. Airway stenting is a technique that alleviates a patient's dyspnea, cough, or respiratory insufficiency.

What does the nurse interpret from findings of swelling in the head and neck and compromised airways in a patient who has an iatrogenic pneumothorax and is going through the process of chest tube drainage?

Subcutaneous emphysema is characterized by edema in the head and neck in a patient with iatrogenic pneumothorax and who is on chest tube drainage. Subcutaneous emphysema increases leakage of tissue, resulting in head and neck edema and airway compromise. Pleurisy is characterized by an inflammation in the pleura due to infection, which results in rapid and shallow breathing. Atelectasis is associated with absence of breath sounds and collapsed lungs. Cor pulmonale is a disorder of the respiratory system associated with enlargement of the right ventricle.

A patient comes to the emergency room presenting with dyspnea, tachycardia, violent agitation, tracheal deviation, neck vein distension, and hyperresonance to percussion. Which condition should the nurse suspect?

Tension pneumothorax is the result of increased air in the pleural space; it causes shifting of bodily organs and an increase in intrathoracic pressure. The patient usually presents with cyanosis, air hunger, violent agitation, tracheal deviation, neck vein distension, and hyperresonance to percussion. Hemothorax is an accumulation of blood in the pleural space; the patient usually presents with dyspnea, diminished breath sounds, dullness to percussion, and shock, depending on blood loss. Flail chest is a fracture of two or more ribs; the patient presents with paradoxical movement of the chest wall and respiratory distress. Cardiac tamponade occurs when blood collects in the pericardial sac; the patient presents with muffled, distant heart sounds, hypotension, neck vein distension, and increased central venous pressure.

What is the characteristic feature of stage IIIA lung cancer?

The characteristic feature of stage IIIA lung cancer is a tumor that spreads to the nearby structures, such as the pleura. The heart is involved in stage IIIB lung cancer. Bronchus involvement is associated with stage IIB lung cancer. Contralateral lymph nodes are involved in stage IIIB lung cancer.

How will splinting the incision with a pillow benefit a patient who underwent surgery to repair chest trauma?

The patient will have difficulty breathing after surgery due to the incision on the chest. Splinting the incision facilitates deep breathing. The nurse administers analgesics to reduce pain. An occlusive dressing is applied over the site of surgery to reduce air leakage. The nurse instructs the patient to perform range-of-motion exercise to increase perfusion or oxygen supply to the injured site.

A patient has had lung cancer and is suspected to have metastasis. On what system should the nurse focus the assessment to determine this complication?

The liver is the most common site of metastasis in lung cancer, and the nurse should focus the assessment on symptoms of liver dysfunction. The lungs, spleen, and pancreas are not the most common sites of metastasis in lung cancer.

What is the reason that the nurse, while assisting with insertion of a chest tube, positions the patient with the arm raised above the head on the affected side?

The midaxillary area is the standard site for insertion of a chest tube. Therefore the nurse will position the patient with the arm raised above the head on the affected side to expose the midaxillary area. Analgesics will be given to the patient to minimize pain. The patient's head will be elevated to reduce the risk of injury. The chest tube will be advanced up over the over the top of the rib to avoid the intercostal nerves.

A patient has been admitted with a suspected lung abscess. During the assessment, the nurse is aware that the most common manifestation of a lung abscess is which of these?

The most common manifestation of a lung abscess is cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Hemoptysis is common, especially when an abscess ruptures into a bronchus. Other common manifestations are fever, chills, prostration, night sweats, pleuritic pain, dyspnea, anorexia, and weight loss. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of lung. Vomiting is not a manifestation of a lung abscess

Which finding in a patient who is on a chest drainage system requires attention of the primary health care provider immediately?

The normal flow of drainage is below 100 mL/hr. Fluid level drainage of 120 mL/hr indicates excessive drainage or/and increases the risk of further complications, and this requires the immediate attention of the primary health care provider. The presence of yellow or bloody fluid would indicate that the patient may have complications; however, the fluid is clear, indicating no risk of injury or infection. While adjusting the chest drainage tube, the nurse should ensure that the water level in the suction chamber is 20 cm and the water seal chamber is 2 cm. This will ensure that the suction is appropriate.

The nurse is performing complete assessment of a patient who has lung cancer. Which question does the nurse ask in the interview while assessing the cognitive-perceptual pattern in the patient?

The nurse asks the patient about chest, shoulder, arm, or bone pain while assessing the cognitive-perceptual health pattern in a patient with lung cancer. The nurse questions a patient's smoking habit while assessing the health perception-health management pattern. The nurse asks the patient about nausea, vomiting, and dysphagia while assessing the nutritional-metabolic pattern. While assessing the patient's activity-exercise health pattern, the nurse asks about persistent cough, fatigue, and dyspnea either at rest or with exertion.

The health care provider has prescribed intravenous (IV) vancomycin for a patient with pneumonia. Which action should the nurse perform first?

The nurse should ensure that the sputum for culture and sensitivity has been sent to the laboratory before administering the antibiotic. It is important that the organisms be correctly identified (in the culture) before their numbers are affected by the antibiotic; the test also will determine whether the proper antibiotic has been prescribed (sensitivity testing). Vital signs and white blood cell count measurement can be assessed following the obtainment of sputum cultures. Timing of antibiotic administration should be based upon the institution's policy.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, the nurse will verify that which health care provider prescriptions have been completed before administering a dose of cefuroxime to the patient?

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 identified correctly (by the culture) before the antibiotic takes effect. The test also will determine whether the proper antibiotic has been prescribed (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

A 46-year-old patient who has undergone total left knee arthroplasty complains of shortness of breath and slight chest pain. Temperature is 98° F, blood pressure 140/86 mmHg, respirations 30, and oxygen saturation 92% on room air. The nurse suspects that the patient is experiencing which condition?

The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain. Unstable angina would present with chest pain occurring at rest; COPD exacerbation would present with wheezing, cough, and shortness of breath. Pneumonia would be evident if the patient had a fever, elevated white blood cell count, and a productive cough with yellow, green, or rust-colored sputum.

Which factor places a conscious patient at risk for pneumonia?

The patient who has difficulty swallowing needs assistance in eating, drinking, and taking medication to prevent aspiration. Difficulty swallowing increases risk of aspiration. Treating postoperative pain effectively provides comfort, permitting the patient to cough and deep breathe and achieve optimum mobility. Lying supine for two consecutive hours alone does not place an otherwise healthy patient at risk for pneumonia, but for the altered consciousness patient, repositioning should occur at least every two hours. Turning, coughing, and deep breathing exercises promote optimal oxygenation or perfusion and help prevent atelectasis.

What does the nurse interpret from finding excessive bubbling in the water-seal chamber while monitoring a patient who is on chest tube drainage?

The patient with chest trauma is in need of chest tube drainage. Excess bubbling in the water-seal chamber may cause air leakage from the water-seal chamber and may result in bronchopleural leak. Lung expansion in the water-seal chamber is indicated by tidaling. An absence of bubbles in the chamber may indicate a large pleural air leak. The presence of inflammation, erythema at the site, and an increase in white blood cell count indicates infection.

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first?

The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse should take is 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 health care provider. 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 collaborates with the health care team to arrange for home care for a patient with pulmonary tuberculosis (TB). Of the family members that live with the patient, who is the one at greatest risk for contracting TB?

The patient's parent would be most susceptible to tuberculosis (TB) as a consequence of advanced age and immunosuppression by the corticosteroid. History of asthma, obesity, or pregnancy does not increase the risk of contracting TB.

Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?

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 support definitely the nursing diagnosis of ineffective airway clearance.

What instructions would the nurse give to the patient with a cervical spine injury who, during follow-up visits, shows improvement? Select all that apply.

The semi-Fowler's position facilitates lung expansion, so the patient will be able to breathe easily. The nurse tells the patient that he or she may sleep on the injured side when breathing is comfortable. Bathing will not complicate the improved condition of cervical spine injury. Applying a binder will reduce chest expansion, so the nurse does not instruct the patient to apply a binder over his or her chest. There is no need to wear the cervical collar throughout the day, because the cervical spine injury has improved.

While monitoring a patient who is on a wet chest drainage system, the nurse covers the suction control chamber with a muffler. What is the reason for this intervention?

The suction chamber is covered with a muffler because the continuous boiling is noisy and it may disturb the patient. The absence of bubbles in the chamber will reduce the pleural air leak but closing the chamber with a muffler will not. The muffler will reduce evaporation but will not increase the bubbling. The suction from the chamber is increased when slight bubbles form in the water.

Which alteration to the suction control system in a wet suction system requires immediate correction?

The suction control chamber should not be open; a muffler should be provided to cover the suction control chamber to prevent rapid evaporation of water. The suction control system should show the presence of bubbling; the absence of bubbling indicates that there is no suction. Sterile water is to be added to the suction control chamber to replace water lost from evaporation. The suction tubing should be connected to the wall section after filling the suction control chamber to the ordered suction amount.

A patient who was in a motor vehicle accident is brought to the emergency department unconscious, and cardiopulmonary resuscitation (CPR) is performed. The patient responds well, and the condition improves. After several hours, the patient experiences dyspnea and becomes cyanotic. On examination, the neck veins are distended and the patient is tachycardic. The nurse expects that the immediate plan for treatment will include what intervention?

The symptoms and signs indicate that the patient has tension pneumothorax. This is a medical emergency in which air enters into the pleural space and does not come out. This leads to compression of the surrounding organs like the lung, heart, and large vessels. If not treated promptly, the patient may die. Therefore the patient requires immediate needle decompression followed by chest tube insertion with chest drainage system. Oxygen administration will not help this patient. Pericardiocentesis is done for patients with cardiac tamponade. Repositioning the patient to his side is not required in this case.

A nurse is caring for a pediatric patient who has experienced a cough, clear and watery sputum, headache, and muscle aches for the past two weeks. The nurse auscultates wheezes during expiration. There is no other abnormality found. The patient's parent asks why an antibiotic has not been prescribed. How should the nurse respond?

The symptoms and signs indicate that the patient may have acute bronchitis, which is a viral disorder. Therefore the nurse should explain to the father that antibiotics will not help in viral infections. If they are prescribed, antibiotics may cause side effects and may also lead to antibiotic resistance. It is incorrect to advise the father to see another health care provider who will do the same. It is also inappropriate to tell him that his child needs anticancer treatment. Acute bronchitis is a self-limiting disorder, and cough may last up to three weeks. Informing the father that antibiotics will be prescribed if the cough persists for two more days is not correct.

Which wound is described as a penetrating trauma on the chest wall?

The wound caused by a gunshot is a penetrating trauma because it is an open injury into which a foreign object enters into the body. A wound caused by a motor vehicle accident, a crush injury, or a pedestrian accident are blunt injuries.

Which outcome does the nurse expect from administering patient-controlled analgesia (PCA) to the patient who has undergone thoracotomy? Select all that apply.

Thoracotomy is a painful procedure and involves cutting respiratory muscles during the surgery. Therefore the nurse administers patient-controlled analgesia (PCA) to alleviate pain. This will help the patient to cough effectively because there is a reduction in pain. Due to pain reduction, the strain on the lungs is reduced during breathing and the patient will be able to take deep breaths more easily. PCA will relieve pain and ease the movement of arm on the operative side. The chest tube placed on the chest after thoracotomy helps lung expansion. The nurse administers diuretics to relieve pulmonary edema.

A patient with pneumonia is being treated at home and has reported fatigue to the nurse. What instructions should the nurse include when teaching the patient about care and recovery at home? Select all that apply.

To ensure complete recovery after pneumonia, the patient should be advised to rest, avoid alcohol and smoking, and take every dose of the prescribed antibiotic. The patient should not resume work if feeling fatigued and should be encouraged to drink plenty of fluids during the recovery period.

A nurse is monitoring the chest drainage system of a patient and finds that bubbling has increased. The nurse then marks the whole tube with the numbers 1, 2, 3, 4, and 5 at increments and clamps the tube methodically. The nurse finds that the leak stopped when the clamps were between 3 and 4. What does this indicate?

Whenever the bubbling increases, the nurse should suspect an air leak. To look for the point of leak, the nurse should clamp the tube to the chest and see if it is from the patient's chest. Then the nurse should mark the tube and move the clamps methodically away from the chest. If the leak stops at a particular point, this indicates that the leak was between these two points. Therefore the air leak was from the tube between points 3 and 4.

Why does the primary health care provider, while managing a patient who is on chest drainage, clamp the chest tube a few hours before removal?

While planning to remove the chest drainage tube, the primary health care provider clamps the chest tube a few hours before removal to assess the patient's tolerance after removal. Adequate patient teaching is provided to minimize the risk of atelectasis and to reduce the risk of shoulder stiffness. Meticulous sterile technique during dressing changes is followed to reduce the incidence of infected sites.