Saunders Ch 54: Respiratory System
628. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select ALL that apply. 1. Activities should be resumed gradually 2. Avoid contact with other individuals, except family members, for at least 6 months 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated 4. Respiratory isolation is not necessary because family members already have been exposed 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags 6. When one sputum culture is negative, the client is no longer considered infectious and usually can return to former employment
1. Activities should be resumed gradually 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated 4. Respiratory isolation is not necessary because family members already have been exposed 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. Advise the client of the side effects of the medication and ways of minimizing them to ensure compliance. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.
641. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected findings? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia
1. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with acquired immunodeficiency syndrome (AIDS). The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.
643. The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection
1. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary.
640. A client who is human immunodeficiency virus (HIV)- positive has had a tuberculin skin test (TST). The nurse notes a 7mm area of induration at the site of the skin test and interprets the result as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Need for repeat testing
1. Positive Rationale: The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5mm. The client without HIV is positive with an induration larger than 10mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2,3, and 4 are incorrect interpretations.
634. A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse IMMEDIATELY assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome
1. Right pneumothorax Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.
625. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
2 Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are short- ness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and sub- cutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. Test-Taking Strategy: Focus on the subject, a blunt chest injury. Noting the word blunt will assist in eliminating option 4, which describes a sucking chest wound injury. Knowing that in a respiratory injury increased respirations will occur will assist you in eliminating option 1. Option 3 can be eliminated because a barrel chest is a characteristic finding in a client with chronic obstructive pulmonary disease. Review: The signs of pneumothorax Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Respiratory Priority Concepts: Gas Exchange; Perfusion Reference: Ignatavicius, Workman (2016), pp. 505, 623-624.
626. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select ALL that apply. 1. Hypocapnia - low PaCO2 level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity
2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity. Test-Taking Strategy: Focus on the subject, manifestations of COPD. Think about the pathophysiology associated with this disorder. Remember that hypercapnia, a hyperinflated chest, a flat diaphragm, oxygen desaturation on exercise, and decreased vital capacity are manifestations. Review: The manifestations associated with chronic obstructive pulmonary disease (COPD) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Respiratory Priority Concepts: Gas Exchange; Perfusion References: Lewis et al. (2014), pp. 586-587.
638. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear
2. Particulate respirator, gown, and gloves Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard respirator. The nurse wears a gown when the possibility exists that the clothing could be contaminated, such as when giving a bed bath.
636. The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow
2. Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus moving from smaller airway to larger ones to support expectoration of the mucus. Options 1, 3, or 4 are not actions that will loosen secretions.
644. An oxygen delivery system is prescribed for client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar
2. The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitations because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
630. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds
3. 10 seconds Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
629. The nurse is caring for a client after a bronchoscopy and biopsy. Which findings, if noted in the client, should be reported immediately to the HCP? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum
3. Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs/symptoms of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
639. A client has experienced pulmonary embolism. The nurse should assess for which symptoms, which is MOST commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken
3. Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
633. A client with a chest injury has suffered flail chest. The nurse assesses the client for which MOST distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation
3. Paradoxiacal chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
647. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin testk8
3. Sputum culture Rationale: 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.
631. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is MOST appropriate? 1. Continue to suction 2. Notify the HCP immediately 3.Stop the procedure and reoxygenate the client 4. Ensure that the suction is limited to 15 seconds
3. Stop the procedure and reoxygenate the client Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
648. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what INITIAL action? 1. Administer oxygen 2. Check the client's vital signs 3. Ventilate the client manually 4. Start cardiopulmonary resuscitation
3. Ventilate the client manually Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.
637. The nurse has conducted discharge teaching with a client diagnosed with tuberculosis, who has been receiving medication for two weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue drug therapy for one month" 2. "I can't shop at the mall for the next 6 months" 3. "I can return to work if a sputum culture comes back negative" 4. "I should not be contagious after 2-3 weeks of medication therapy
4. "I should not be contagious after 2-3 weeks of medication therapy Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.
646. The community health nurse is conducting an educational session with community members regarding the symptoms associated with tuberculosis. Which is one of the FIRST manifestations associated with tuberculosis? 1. Dyspnea 2. Headache 3. A bloody, productive cough 4. A cough with the expectoration of mucoid sputum
4. A cough with the expectoration of mucoid sputum Rationale: One of the first pulmonary manifestations of tuberculosis is a slight cough with the expectoration of mucoid sputum. Options 1,2, and 3 are late manifestations and signify cavitation and extensive lung involvement.
635. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which EARLIEST sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate
4. Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
632. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow deep respirations 2. Rapid deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration
4. Pain, especially with inspiration Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
627. The nurse instructs a 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 which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination
4. Promote carbon dioxide elimination Rationale: 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 1, 2, and 3 are not the purposes of this type of breathing.
642. The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which EARLY sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath
4. Shortness of breath Rationale: Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.
645. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed and leaning on an overbed table
4. Sitting on the side of the bed and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing includes sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees and standing and leaning against the wall.
