Sr Med Surg Prep U Ch 23: Mgmnt of Pts w/Chest & Lower Respiratory Tract Disorders

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?

0-4 mm

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

Because I had a previous reaction to the test, this time I need to get a chest X-ray

What is a pleural effusion?

Fluid accumulating within the pleural space

The nurse is caring for a client who has started therapy for tuberculosis. The client demonstrates understanding of tuberculosis transmission when stating:

I'll follow airborn precautions until I have 3 negative sputum specimens

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

a positive reaction indicates that the client has been exposed to the disease

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

hypercapnia, hypoxemia, hypoventilation

The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States?

pneumonia

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?

pneumothorax

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

progressive loss of lung function associated w/chronic disease

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?

receiving vaccinations

A mediastinal shift occurs in which type of chest disorder?

tension pneumothorax

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

tension pneumothorax

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

the tissues give a crackling sensation when palpated

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?

the tube will drain air from the space around the lung

Why is a prolonged treatment required for tuberculosis?

to ensure eradication of the organisms and to prevent relapse

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?

turn on to the affected side

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?

15-mm induration

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?

6-12 months

What dietary recommendations should a nurse provide a client with a lung abscess?

A diet rich in protein & calories

What is considered a significant finding for a mantoux test?

An induration of 10 mm or greater

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?

Classes at community centers to teach about smoking cessation strategies

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client'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 help the client breathe more easily?

Intubate the client and control breathing with mechanical ventilation

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?

It is all right if I have a grilled cheese sandwich with American cheese

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

See if there are leaks in the system

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?

Shortness of breath

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

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 disease process is present

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

acute respiratory distress syndrome

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

acute respiratory distress syndrome (ARDS)

What is a simple pneumothorax?

air enters the pleural space through the rupture of a bleb or a bronchopleural fistula

What is a pneumothorax?

air in the pleural space

What are the generalized symptoms of pulmonary sarcoidosis?

anorexia, fatigue, and weight loss

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

aspiration pneumonia

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

What is a hemothorax?

blood within the pleural space

What type of diet is not recommended for the patient with a lung abscess?

carbohydrate-dense diet or diets with limited fat

A nurse should include what instruction for the client during postural drainage?

change positions frequently & cough up secretions

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

chemical irritation

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?

chemical irritation

What are the signs and symptoms of a pneumothorax?

chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds

Why is a diet rich in protein and calories integral for the patient with a lung abscess?

chronic infection is associated with a catabolic state

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

client w/a nasogastric tube

What is a cardiac tamponade?

compression of the heart resulting from fluid or blood within the pericardial sac

What are some risk factors for developing a pulmonary embolus?

constrictive, tight fitting clothes & estrogen replacement

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

continue to take antibiotics for the entire 10 days

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

cough or change in chronic cough

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

coughing, deep breathing, frequent repositioning, using an incentive spirometer

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?

crackles in the lung bases

In acute respiratory failure (ARF), what is expected to happen to the patient's arterial oxygen (PaO2)?

decrease to less than 60 mm Hg (hypoxemia)

Class 4 with regard to TB indicates

disease, but not clinically active

What is the reason for chest tubes after thoracic surgery?

draining secretions, air, and blood from the thoracic cavity is necessary to allow lungs to expand

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

dyspnea and wheezing

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

encourage increased fluid intake

In acute respiratory failure (ARF), what is expected to happen to the patient's arterial pH?

expected to be less than 7.35

Class 1 with regard to TB indicates

exposure & no evidence of infection

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

few early symptoms

The nurse is caring for a client with tuberculosis. Why should the nurse always encourage a client with tuberculosis to perform active range-of-motion (ROM) exercises three times a day?

for maintaining muscle strength

Why is increased fluid intake important for the patient with viral pneumonia?

helps to loosen secretions and replace fluids lost through fever and increased respiratory rate

What are the common contributors to a case of hospital-acquired pneumonia?

host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present

What are the cardinal physiologic abnormalities of acute respiratory failure?

hypercapnia, hypoventilation, and hypoxemia

In acute respiratory failure (ARF), what is expected to happen to the patient's arterial carbon dioxide tension (PaCO2)?

increase to >50 mm Hg (hypercapnia)

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

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:

ineffective airway clearance

Class 2 with regard to TB indicates

latent infection with no disease

What is a mediastinal shift?

lung collapse and the heart, the great vessels, and the trachea shift towards the unaffected side of the chest

What is consolidation?

lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process

What are the early signs and symptoms of pulmonary sarcoidosis?

may include dyspnea, cough, hemoptysis, and congestion

What might occur if a patient taking isoniazid (INH) therapy eats food containing tyramine and histamine?

may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis

Class 0 with regard to TB indicates

no exposure and no infection

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

oxygen supports combustion

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis?

pain in the calf

What does a positive purified protein derivative (PPD) test consist of?

palpable swelling and induration of 5 to 15 mm

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?

paradoxical chest movement

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

pleural effusion

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

pulmonary hypertension

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

rapid onset of severe dyspnea

Why do nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia?

risk of aspiration from improperly placed tubes

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

significant

The most diagnostic clinical symptom of pleurisy is:

stabbing pain during respiratory movements

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

streptococcus pneumoniae

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?

sudden onset of lung impairment in a client who had normal lung function

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

tense and relax muscles of lower extremities

A patient taking isoniazid (INH) therapy should avoid foods that contain?

tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts)

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?

using strict hand hygiene

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?

viruses like the flu are the most common cause of pneumonia

A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan?

wearing a disposable respirator that fits snugly around the face

What is a traumatic pneumothorax?

when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall

When is a client with nonresistant tuberculosis no longer considered contagious?

when they show clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears

When does flail chest occur?

when two or more adjacent ribs fracture and results in impairment of chest wall movement