Test 2 Respiratory Disorders 2

A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions? A. Auscultation of breath sounds B. Chest x-ray C. Echocardiogram D. Electrocardiogram (ECG)

Correct Answer: A. Auscultation of breath sounds Because the client is short of breath, listening to breath sounds is a good idea. He may need a chest x-ray and an ECG, but a physician must order these tests. Option B: A chest x-ray is one of the first diagnostic tests that should be utilized in evaluating dyspnea. If abnormal the disease process is likely cardiac or a primary pulmonary process. If the chest x-ray is normal, then spirometry is needed to determine lung function. Option C: Unless a cardiac source for the client's pain is identified, he won't need an echocardiogram. An echocardiogram is needed to evaluate cardiac function and valvular function. Option D: Additionally, an electrocardiogram should be obtained to evaluate for myocardial infarction or right-sided heart pattern strain. Elevated proBNP levels can further a congestive heart disease diagnosis.

When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? A. Bronchial B. Bronchovesicular C. Tubular D. Vesicular

Correct Answer: A. Bronchial Chest auscultation reveals bronchial breath sounds over areas of consolidation. When bronchial sounds are heard in areas distant from where they normally occur, the patient may have consolidation (as occurs with pneumonia) or compression of the lung. These conditions cause the lung tissue to be dense. Option B: Bronchovesicular is normal over mid lobe lung regions. Bronchovesicular sounds can be heard during inspiration and expiration and have a mid-range pitch and intensity. They are commonly heard over the upper third of the anterior chest. Option C: Tubular sounds are commonly heard over large airways. Bronchial sounds (also called tubular sounds) normally arise from the tracheobronchial tree and vesicular sounds normally arise from the finer lung parenchyma. Loud, harsh, and high-pitched bronchial sounds are typically heard over the trachea or at the right apex. Option D: Vesicular breath sounds are commonly heard in the bases of the lung fields. Vesicular breath sounds are soft, low-pitched, predominantly inspiratory, and appreciated especially well at the posterior lung bases.

Nurse Lei, caring for a client with a pneumothorax and who has had a chest tube inserted, continues gentle bubbling in the suction control chamber. What action is appropriate? A. Do nothing, because this is an expected finding. B. Immediately clamp the chest tube and notify the physician. C. Check for an air leak because the bubbling should be intermittent. D. Increase the suction pressure so that the bubbling becomes vigorous.

Correct Answer: A. Do nothing, because this is an expected finding. Continuous gentle bubbling should be noted in the suction control chamber. Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes. Option B: Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Clamp tubing in stepwise fashion downward toward the drainage unit if air leak continues. Isolates location of a system-centered air leak.Note: Information indicates that clamping for a suspected leak may be the only time that the chest tube should be clamped. Option C: Bubbling should be continuous and not intermittent. Seal drainage tubing connection sites securely with lengthwise tape or bands according to established policy.Prevents and corrects air leaks at connector sites. Option D: Bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. Position drainage system tubing for an optimal function like shorten tubing or coil extra tubing on the bed, making sure tubing is not kinked or hanging below the entrance to the drainage container. Drain accumulated fluid as necessary.

A male adult client is suspected of having a pulmonary embolism. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A. Dyspnea B. Bradypnea C. Bradycardia D. Decreased respirations

Correct Answer: A. Dyspnea The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. PE leads to impaired gas exchange due to obstruction of the pulmonary vascular bed leading to a mismatch in the ventilation to perfusion ratio because alveolar ventilation remains the same, but pulmonary capillary blood flow decreases, effectively leading to dead space ventilation and hypoxemia. Option B: The most common symptoms of PE include the following: dyspnea, pleuritic chest pain, cough, hemoptysis, presyncope, or syncope. Dyspnea may be acute and severe in central PE, whereas it is often mild and transient in small peripheral PE. Option C: If a patient with PE who has tachycardia on presentation develops sudden bradycardia or develops a new broad complex tachycardia (with right bundle branch block), providers should look for signs of right ventricular strain and possible impending shock. Option D: On examination, patients with PE might have tachypnea and tachycardia, which are common but nonspecific findings. Other examination findings include calf swelling, tenderness, erythema, palpable cords, pedal edema, rales, decreased breath sounds, signs of pulmonary hypertension such as elevated neck veins, loud P2 component of second heart sound, a right-sided gallop, and a right ventricular parasternal lift might be present on examination

A male client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects Legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating Legionnaires' disease? A. erythromycin (Erythrocin) B. rifampin (Rifadin) C. amantadine (Symmetrel) D. amphotericin B (Fungizone)

Correct Answer: A. Erythromycin (Erythrocin) Erythromycin is the drug of choice for treating Legionnaires' disease. Erythromycin has traditionally; it has been used for various respiratory infections (i.e., community-acquired pneumonia, Legionnaires disease), prophylaxis of neonatal conjunctivitis, and chlamydia. Erythromycin is a bacteriostatic antibiotic, which means it prevents the further growth of bacteria rather than directly destroying it. This action occurs by inhibiting protein synthesis. Option B: Rifampin may be added to the regimen if erythromycin alone is ineffective; however, it isn't administered first. Clinically, rifampin is recommended for infections where the disease-causing organisms are identified, their drug susceptibility determined, and it is used in combination with other antimicrobial agents to prevent the drug resistance. Option C: Amantadine, an antiviral agent, is ineffective against Legionnaires' disease, which is caused by bacterial infection. Amantadine is now used mostly for Parkinson disease. Clinical trials have shown that amantadine decreases symptoms of bradykinesia, rigidity, and tremor. Amantadine is an antiviral agent with mild antiparkinsonian activity. Amantadine was used in the early 2000s for Influenza A treatment. A 2006 meta-analysis showed that the drug decreased influenza symptoms by one day and decreased the severity of fever and other symptoms. Option D: Amphotericin B, an antifungal agent, is ineffective against Legionnaires disease because it is caused by bacteria. Amphotericin B deoxycholate belongs to the polyene class of antifungals. It is also known by the name conventional amphotericin B and has been in use for the treatment of invasive fungal infections for more than 50 years. It was first isolated as a natural product of a soil actinomycete.

A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. Which action should the nurse take? A. Remove the airway and insert a shorter one. B. Reposition the airway. C. Leave the airway in place until the client gets used to it. D. Remove the airway and attempt suctioning without it.

Correct Answer: A. Remove the airway and insert a shorter one. If the client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse should remove it and insert a shorter one. A nasopharyngeal airway device (NPA) is a hollow plastic or soft rubber tube that a healthcare provider can utilize to assist with patient oxygenation and ventilation in patients who are difficult to oxygenate or ventilate via bag mask ventilation, for example. Option B: Simply repositioning the airway won't solve the problem. NPAs are passed into the nose and through to the posterior pharynx. NPAs do not cause patients to gag and are, therefore, the best airway adjunct in an awake patient and a better choice in a semiconscious patient that may not tolerate an oropharyngeal airway due to the gag reflex. Option C: The client won't get used to the tube because it's the wrong size. When placing an NPA, the healthcare provider should be knowledgeable regarding the sizing of the NPA. Adult sizes range from 6 to 9 cm. Sizes 6 to 7 cm should be considered in the small adult, 7 to 8 cm in the medium size adult, and 8 to 9 cm in the large adult. Option D: Suctioning without a nasopharyngeal airway causes trauma to the natural airway. When the NPA is too long for the patient, it can create a direct route of ventilation of the stomach, causing gastric distention, increasing vomiting risk, and decreasing oxygenation and ventilation of the lungs.

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: A. Resonant sounds. B. Hyperresonant sounds. C. Dull sounds. D. Flat sounds.

Correct Answer: A. Resonant sounds. When percussing the chest wall, the nurse expects to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Percussion over normal, healthy lung tissue should produce a resonant note. With the patient in an upright seated position, with the scapula protracted; percuss on the posterior chest wall; either side of the midclavicular line in the interspaces at 5cm intervals. Option B: Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Option C: Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Dull percussive sounds are indicative of abnormal lung density. Likely indicating: atelectasis, tumour, pleural effusion, lobar pneumonia Option D: Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure. Percussion produces sounds on a spectrum from flat to dull depending on the density of the underlying tissue.

Which of the following antituberculous drugs can cause damage to the eighth cranial nerve? A. Streptomycin B. Isoniazid C. Para-aminosalicylic acid D. Ethambutol hydrochloride

Correct Answer: A. Streptomycin Streptomycin is an aminoglycoside, and eighth cranial nerve damage (ototoxicity) is a common side effect from aminoglycosides. Ototoxicity and vestibular impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be exercised when combining streptomycin with other potentially ototoxic drugs. Option B: Mild liver injury will occur in up to 20% of patients taking isoniazid. Clinical manifestations of hepatotoxicity include fever, fatigue, nausea, and vomiting. However, most patients experiencing isoniazid-induced liver injury are asymptomatic. Option C: In one retrospective study of 7492 patients on rapidly absorbed aminosalicylic acid preparations, drug-induced hepatitis occurred in 38 patients (0.5%); in these 38 the first symptom usually appeared within three months of the start of therapy with a rash as the most common event followed by fever and much less frequently by GI disturbances of anorexia, nausea or diarrhea. Option D: The manifestation of EMB-induced optic neuropathy appears to be from EMB's chelation of copper. A study with 60 patients undergoing treatment with ethambutol monitored their serum copper levels. Statistical analysis confirmed there was a significant change in copper concentration, supporting the copper chelation effect by EMB.

The client experiencing eighth cranial nerve damage will most likely report which of the following symptoms? A. Vertigo B. Facial paralysis C. Impaired vision D. Difficulty swallowing

Correct Answer: A. Vertigo The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve. Ototoxicity and vestibular impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be exercised when combining streptomycin with other potentially ototoxic drugs. Vestibular impairment usually manifests during the course of treatment and is typically permanent. Option B: Isoniazid can cause pyridoxine deficiency that may lead to peripheral neuropathy in patients. The patient can supplement vitamin B6 to prevent this from happening. Neuropathy symptoms are usually sensory which include numbness, tingling, burning sensation in all the extremities. Rarely seen are central features like ataxia, nystagmus. Option C: The manifestation of EMB-induced optic neuropathy appears to be from EMB's chelation of copper. A study with 60 patients undergoing treatment with ethambutol monitored their serum copper levels. Statistical analysis confirmed there was a significant change in copper concentration, supporting the copper chelation effect by EMB. Option D: Aminoglycoside-induced nephrotoxicity is reversible when stopping the medication. Renal toxicity depends on the patient if any underlying renal disease is present, and on the dose of the medication being administered. Renal insufficiency is avoidable in most patients.

A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if any of the following were noted in the laboratory report? A. 5 mcg/mL B. 15 mcg/mL C. 25 mcg/mL D. 30 mcg/mL

Correct Answer: B. 15 mcg/mL Therapeutic theophylline blood levels range from 10-20 mcg/mL. Patients can be administered IV theophylline for acute bronchospasm. Those who are not currently taking theophylline should be given a loading dose of 5 to 7 mg/kg intravenously, followed by a maintenance dose of 0.4 to 0.6 mg/kg per hour intravenously to maintain serum concentrations at 10 to 15 mg/L. Option A: In patients with cardiac decompensation, cor pulmonale, older patients or those on medications that are known to decrease theophylline clearance, the infusion rate of theophylline should not be increased above 17 mg per hour unless the patient remains symptomatic, their steady-state serum concentrations are consistently below 10 mcg/mL, and their serum concentrations are observable at 24-hour intervals. Option C: The serum theophylline concentrations require monitoring directly to avoid toxicity as the adverse effects of theophylline are related to its plasma concentration and have been observed when plasma concentrations exceed 20 mg/L. Option D: Serum concentration of theophylline should be measured to one expected half-life (approximately 4 hours in young children [ages 1 to 9 years], or around 8 hours in otherwise healthy adults, who do not smoke) after administering a continuous infusion, then checked every 12 to 24 hours to establish if any further adjustments are required, and then at 24-hour intervals for the remainder of the infusion.

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: A. 1 L/min B. 2 L/min C. 6 L/min D. 10 L/min

Correct Answer: B. 2 L/min Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. Supplemental oxygen can successfully reach the alveoli in these lungs, which prevents this vasoconstriction and thereby increases perfusion and improves gas exchange, thus resulting in improvement of hypoxemia. Option A: Routine supplemental oxygen does not improve the quality of life or clinical outcomes in stable patients. Continuous long-term, i.e., longer than 15 hours of supplemental oxygen is recommended in patients with COPD with PaO2 less than 55 mmHg (or oxygen saturation less than 88%) or PaO2 less than 59 mm Hg in case of cor pulmonale. Option C: Oxygen therapy has shown to increase the survival of these patients with severe resting hypoxemia. For those who desaturate with exercise, intermittent oxygen will help. The goal is to maintain oxygen saturation greater than 90%. Option D: Excessive correction of hypoxia in a patient with longstanding COPD can sometimes lead to hypercapnia. This is due to the loss of compensatory vasoconstriction with an ineffective gas exchange as there is a loss of hypoxic drive for ventilation. Also, increased oxyhemoglobin decreases the uptake of carbon dioxide due to the Haldane effect.

A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing: A. Carbon monoxide poisoning B. Carbon dioxide narcosis C. Respiratory alkalosis D. Metabolic acidosis

Correct Answer: B. Carbon dioxide narcosis Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possible coma. The delineating feature of CO2 narcosis is a depressed level of consciousness. It is essential to recognize impending or current CO2 narcosis; if left untreated, it can result in coma or death. Option A: Carbon monoxide toxicity occurs after breathing in excessive levels of carbon monoxide. This is a tasteless, odorless, and colorless gas and victims are usually unconscious before they realize they are being poisoned. Option C: Respiratory alkalosis is 1 of the 4 basic classifications of blood pH imbalances. Normal human physiological pH is 7.35 to 7.45. A decrease in pH below this range is acidosis, an increase above this range is alkalosis. Respiratory alkalosis is by definition a disease state where the body's pH is elevated to greater than 7.45 secondary to some respiratory or pulmonary process. Option D: Metabolic acidosis is characterized by an increase in the hydrogen ion concentration in the systemic circulation resulting in a serum HCO3 less than 24 mEq/L. Metabolic acidosis is not a benign condition and signifies an underlying disorder that needs to be corrected to minimize morbidity and mortality.

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A. Inform the physician. B. Continue to monitor the client. C. Reinforce the occlusive dressing. D. Encourage the client to deep breathe.

Correct Answer: B. Continue to monitor the client. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded. Option A: Monitor water-seal chamber "tidaling." Note whether the change is transient or permanent. The water-seal chamber serves as an intrapleural manometer (gauges intrapleural pressure); therefore, fluctuation (tidaling) reflects pressure differences between inspiration and expiration. Option C: If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify the physician at once. Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment. Option D: Assist the patient with splinting painful areas when coughing, deep breathing. Supporting chest and abdominal muscles makes coughing more effective and less traumatic.

When caring for a male patient who has just had a total laryngectomy, the nurse should plan to: A. Encourage oral feeding as soon as possible. B. Develop an alternative communication method. C. Keep the tracheostomy cuff fully inflated. D. Keep the patient flat in bed.

Correct Answer: B. Develop an alternative communication method. A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. Assess the effectiveness of nonverbal communication methods. The client may use hand signals, facial expressions, and changes in body posture to communicate with others. However, others may have difficulty in interpreting these nonverbal techniques. Each new method needs to be assessed for effectiveness and altered as necessary. Option A: After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. Typically most patients wait a minimum of 7 days following total laryngectomy before oral feeding is started. 84% of 141 American surgeons reported that they waited until after the seventh postoperative day in a questionnaire survey by Boyce and Meyers in 1989. However, periods of up to three weeks were reported. The choice often depends on the surgeon's experience and preference and on the patient's comorbidities and tumor characteristics. Option C: To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. Cuff should be deflated if the patient uses a speaking valve. Cuff should be inflated just enough to allow minimal air leak. Option D: To decrease edema, the nurse should place the patient in semi-Fowler's position. Early complications after total laryngectomy include bleeding, postoperative edema, and airway compromise. These, especially in the immediate postoperative, should be carefully monitored. Administration of corticosteroids is recommended to minimize postoperative edema and airway compromise.

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory rate. B. Diminished breath sounds. C. The presence of a barrel chest. D. A sucking sound at the site of injury.

Correct Answer: B. Diminished breath sounds. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A pneumothorax is defined as a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse. Option A: An increase in central venous pressure can result in distended neck veins, hypotension. Patients may have tachypnea, dyspnea, tachycardia, and hypoxia. Clinical presentation of a pneumothorax can range anywhere from asymptomatic to chest pain and shortness of breath. Option C: Barrel chest could also be present which consists in increased anterior-posterior diameter of the chest wall and is a normal finding in children, but it is suggestive of hyperinflation with chronic obstructive pulmonary disease (COPD) in adults. Option D: A sucking sound at the site of injury would be noted with an open chest injury. Open "sucking" chest wounds are treated initially with a three-sided occlusive dressing. Further treatment may require tube thoracostomy and/or chest wall defect repair.

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

Correct Answer: B. Grasp the retention sutures to spread the opening. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary. If agency policy permits, the nurse then attempts immediately to replace the tube. Options A and C will delay treatment in this emergency situation. Option A: When a tube is dislodged, a nurse is generally the first responder. At the first sign of a possible dislodged tube, another caregiver should send another individual to urgently summon a physician. Option C: If the tracheostomy is new, only a physician should reinsert the tube, and a nurse or respiratory therapist should never attempt to reposition the tube. This is because it takes time for the tract to form, and repositioning before the tract has formed can lead to complications as severe as those caused by the failure to act. Option D: Covering the tracheostomy site will block the airway. A dislodged tube also calls for immediate attempts at manual ventilation, and suction with a solution of sodium chloride. This will rule out a mucus plug. Once this is done, to prevent brain damage the nurse should immediately deflate the tracheostomy cuff and take out the tracheostomy tube.

Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? A. Dehydration B. Group living C. Malnutrition D. Severe periodontal disease

Correct Answer: B. Group living Clients with chronic illnesses generally have poor immune systems. Often, residing in group living situations increases the chance of disease transmission. Pneumonia is a fairly prevalent disease and carries a heavy burden in all populations. A study carried out by the US Centers for Disease Control and Prevention (CDC) aimed at estimating its burden in North America found that CAP accounted for the eighth leading cause of mortality in the United States and the seventh leading cause of mortality in Canada after adjusting for various gender and age differences. Option A: Pneumonia can also cause dehydration from fever and decreased thirst and appetite, which may require treatment with extra fluids intravenously. Potential benefits of fluids are replacing fluid lost because of fever or rapid breathing, treating dehydration, and reducing the viscosity of mucus. Option C: Pneumonia is common in malnourished children and is frequently associated with fatal outcomes, especially in children younger than 24 months of age. Studies consistently reported a two- to threefold greater risk of mortality in cases with pneumonia associated with malnutrition. Therefore, pneumonia and malnutrition are two of the biggest killers in childhood diseases. Option D: Various pathogenic bacteria have been found in patients with deep periodontal pockets. The association between periodontal disease and pneumonia may be due to colonization by pathogenic bacteria in the periodontal pocket, as inhalation of a pathogen is considered a risk factor for pneumonia.

A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean that the client has: A. Active TB B. Had contact with Mycobacterium tuberculosis. C. Developed a resistance to tubercle bacilli. D. Developed passive immunity to TB.

Correct Answer: B. Had contact with Mycobacterium tuberculosis. A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. If the infection risk is very high, the PPD test need not be repeated. The positive PPD test is usually followed by TB symptom assessment, physical exam, and chest radiograph. If there are no TB symptoms and no evidence of active tuberculosis infection on physical exam and chest radiograph, the patient most likely has latent TB. The treatment of latent TB should be encouraged once detected. Option A: A person with active infection usually presents with symptoms of the part affected and constitutional symptoms such as unexplained weight loss, fever, fatigue, loss of appetite, and night sweats. The latent TB, however, is asymptomatic and non-infectious. Early diagnosis of active TB is crucial to managing the disease in time and preventing its spread. The latent TB infection is non-infectious and asymptomatic, with a significant worldwide prevalence (33%). Option C: The benefit to the PPD test is the rapid identification of the presence of TB infection and, thus, the rapid diagnosis of TB. Although sometimes the infection may not be active, the detection of latent TB allows for treatment and decreases the risk of progression to active TB. It is a very simple and inexpensive skin test (not routinely recommended). Option D: Some individual's ability to react to tuberculin antigen wanes over time, which results in a false-negative reaction. In individuals with very old tuberculosis infection (many years), sensitization to tuberculin is weak, and the PPD test may be a false negative. However, if a subsequent test is administered, the tuberculin PPD may stimulate the immune system.

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A. Pallor B. Low arterial PaO2 C. Elevated arterial PaO2 D. Decreased respiratory rate

Correct Answer: B. Low arterial PaO2 The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg. Despite 100% oxygen, patients have low oxygen saturation. Option A: Systemic signs may also be evident depending on the severity of illness, such as central or peripheral cyanosis resulting from hypoxemia, tachycardia, and altered mental status. Chest auscultation usually reveals rales, especially bibasilar, but are often auscultated throughout the chest. Option C: ARDS is defined by the patient's oxygen in arterial blood (PaO2) to the fraction of the oxygen in the inspired air (FiO2). These patients have a PaO2/FiO2 ratio of less than 300. When interviewing patients that are able to communicate, they often start to complain of mild dyspnea initially, but within 12 to 24 hours, the respiratory distress escalates, becoming severe and requiring mechanical ventilation to prevent hypoxia. Option D: The syndrome is characterized by the development of dyspnea and hypoxemia, which progressively worsens within hours to days, frequently requiring mechanical ventilation and intensive care unit-level care. The physical examination will include findings associated with the respiratory system, such as tachypnea and increased effort to breathe.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: A. Lips B. Mucous membranes C. Nail beds D. Earlobes

Correct Answer: B. Mucous membranes Skin color doesn't affect the mucous membranes. When the oxygen level has dropped only a small amount, cyanosis may be hard to detect. In dark-skinned people, cyanosis may be easier to see in the mucous membranes (lips, gums, around the eyes) and nails. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color. Option A: Red blood cells provide oxygen to body tissues. Most of the time, nearly all red blood cells in the arteries carry a full supply of oxygen. These blood cells are bright red and the skin is pinkish or red. Blood that has lost its oxygen is dark bluish-red. People whose blood is low in oxygen tend to have a bluish color to their skin. This condition is called cyanosis. Option C: But in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish. When assessing a patient's skin, use natural light or a halogen lamp rather than fluorescent light, which may alter the skin's true color and give the illusion of a bluish tint. Option D: Skin color is particularly important in detecting cyanosis and staging pressure ulcers. Cyanosis occurs when a person has 5 g/dL of unoxygenated hemoglobin in the arterial blood. Central cyanosis (cyanosis of the lips, mucous membranes, and tongue) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels.

Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A. Call the physician. B. Place the tube in a bottle of sterile water. C. Immediately replace the chest tube system. D. Place a sterile dressing over the disconnection site.

Correct Answer: B. Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. Anchor thoracic catheter to the chest wall and provide an extra length of tubing before turning or moving the patient. Prevents thoracic catheter dislodgement or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing. Option A: The physician may need to be notified, but this is not the initial action. Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing or suction, using clean technique. Option C: The system is replaced if it breaks or cracks or if the collection chamber is full. Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment. Option D: Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. If the catheter is dislodged from the chest, cover the insertion site immediately with petrolatum dressing and apply firm pressure. Notify the physician at once.

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

Correct Answer: B. Sputum culture Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. Mycobacterial culture is the gold standard for diagnosis. Mycobacterial culture should be performed on both the solid and liquid medium. Liquid media culture can detect very low bacterial load and is considered a gold standard. Culture essential for drug susceptibility testing. 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. Active tuberculosis is diagnosed by isolating Mycobacterium tuberculosis complex bacilli from bodily secretions. Option A: If all measures fail to obtain a sputum sample, a fiberoptic bronchoscopy with bronchoalveolar lavage can be performed with or without a transbronchial biopsy. Bronchoscopy can also be performed in high clinical suspicion with negative sputum studies and to rule out an alternative diagnosis. Option C: Primary tuberculosis often causes middle and lower lung field opacities associated with mediastinal adenopathy. Whereas secondary tuberculosis commonly involves upper lobes, causing opacities, cavities, or fibrotic scar tissue. Option D: The Mantoux test is a two-part test consisting of an intradermal injection of .1ml purified protein derivative and observing for induration 48-72 hours. The patient's risk of exposure is taken into consideration when interpreting the result. Patients are then classified into three groups based on the size of the induration and the risk of exposure.

INH treatment is associated with the development of peripheral neuropathies. Which of the following interventions would the nurse teach the client to help prevent this complication? A. Adhere to a low cholesterol diet. B. Supplement the diet with pyridoxine (vitamin B6). C. Get extra rest. D. Avoid excessive sun exposure.

Correct Answer: B. Supplement the diet with pyridoxine (vitamin B6). INH competes with the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Peripheral neuropathy is avoided and treated with daily pyridoxine administration along with INH. Though there are no specific therapies for INH-induced liver damage, some studies have shown a mortality benefit in using corticosteroids and N-acetylcysteine early in the course of liver injury. Option A: The treatment is generally supportive with hydration and monitoring. If there is evidence of liver damage, small case studies suggest the use of N-acetyl cysteine and corticosteroids. In rare cases, a liver transplant may be required. Today, peripheral neuropathy is rarely seen because most patients are prescribed pyridoxine at the initiation of isoniazid therapy. Option C: The patient should be instructed properly on consumption of an adequate dose of the drug at the appropriate time. If the patient is not able to remember properly, the task can be assigned to a family member to dispense the medicine. Option D: Acute toxicity is approached by strict airway management, activated charcoal if the patient presents early, seizure management with the use of benzodiazepines, and pyridoxine administration. This helps with the rapid restoration of GABA stores.

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: A. Monitor fluctuations in the water-seal chamber. B. Clamp the chest tube once every shift. C. Encourage coughing and deep breathing. D. Milk the chest tube every 2 hours.

Correct Answer: C. Encourage coughing and deep breathing When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Assist the patient with splinting painful areas when coughing, deep breathing. Supporting chest and abdominal muscles makes coughing more effective and less traumatic. Option A: Because the lung has been removed, the water-seal chamber should display no fluctuations. Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes. The absence of bubbling may indicate complete lung re-expansion (normal) or represent complications such as an obstruction in the tube. Option B: Reinflation is not the purpose of a chest tube. Know the location of air leak (patient- or system-centered) by clamping thoracic catheter just distal to exit from the chest. If bubbling stops when the catheter is clamped at the insertion site, leak is patient-centered (at the insertion site or within the patient). Option D: Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage. Although routine stripping is not recommended, it may be necessary occasionally to maintain drainage in the presence of fresh bleeding, large blood clots, or purulent exudate (empyema).

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A. Cardiogenic pulmonary edema B. Respiratory alkalosis C. Increased pulmonary capillary permeability D. Renal failure

Correct Answer: C. Increased pulmonary capillary permeability ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. ARDS is defined as an acute disorder that starts within 7 days of the inciting event and is characterized by bilateral lung infiltrates and severe progressive hypoxemia in the absence of any evidence of cardiogenic pulmonary edema. ARDS is defined by the patient's oxygen in arterial blood (PaO2) to the fraction of the oxygen in the inspired air (FiO2). These patients have a PaO2/FiO2 ratio of less than 300. Option A: In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. The pulmonary epithelial and endothelial cellular damage is characterized by inflammation, apoptosis, necrosis, and increased alveolar-capillary permeability, which leads to the development of alveolar edema and proteinosis. Alveolar edema, in turn, reduces gas exchange, leading to hypoxemia. Option B: In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Segments of the lung may be more severely affected, resulting in decreased regional lung compliance, which classically involves the bases more than the apices. This intrapulmonary differential in pathology results in a variant response to oxygenation strategies. Option D: Renal failure does not cause ARDS, either. ARDS has many risk factors. Besides pulmonary infection or aspiration, extra-pulmonary sources include sepsis, trauma, massive transfusion, drowning, drug overdose, fat embolism, inhalation of toxic fumes, and pancreatitis. These extra-thoracic illnesses and/or injuries trigger an inflammatory cascade culminating in pulmonary injury.

Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? A. Coma B. Apathy C. Irritability D. Depression

Correct Answer: C. Irritability Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Apathy and depression are not symptoms of hypoxia. Option A: Coma is a late clinical manifestation of hypoxia. Pneumonia is a common cause of mortality and morbidity. It can have a myriad of clinical presentations and can pose a diagnostic dilemma especially in the setting of severely ill patients with several comorbidities and underlying lung pathologies. Option B: Apathy is not a symptom of pneumonia. Historically, the chief complaints in case of pneumonia include systemic signs like fever with chills, malaise, loss of appetite, and myalgias. These findings are more common in viral pneumonia as compared to bacterial pneumonia. A small fraction of patients may have an altered mental status, abdominal pain, chest pain, and other systemic findings. Option D: Depression is not a symptom of pneumonia. Pulmonary findings include cough with or without sputum production. Bacterial pneumonia is associated with purulent or rarely blood-tinged sputum. Viral pneumonia is associated with watery or occasionally mucopurulent sputum production.

What effect does hemoglobin amount have on oxygenation status? A. No effect B. More hemoglobin reduces the client's respiratory rate. C. Low hemoglobin levels cause reduced oxygen-carrying capacity. D. Low hemoglobin levels cause increased oxygen-carrying capacity.

Correct Answer: C. Low hemoglobin levels cause reduces oxygen-carrying capacity Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. If the client has been tachypneic during exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an increase in hemoglobin may decrease the respiratory rate to normal levels. Option A: Hemoglobin behavior is concerted in that hemoglobin with three sites occupied by oxygen is in the quaternary structure associated with the R state. The remaining open binding site has an affinity for oxygen more than 20-fold as great as that of fully deoxygenated hemoglobin binding its first oxygen. Option B: The vast majority of oxygen transported in the blood is bound to hemoglobin within red blood cells, while a small amount is carried in blood in the dissolved form. The unloading of oxygen from hemoglobin at target tissues is regulated by a number of factors including oxygen concentration gradient, temperature, pH, and concentration of the compound 2,3-Bisphosphoglycerate. Option D: The most important measures of effective oxygen transportation are hemoglobin concentration and the oxygen saturation level, the latter often measured clinically using pulse oximetry. Insults to oxygen-carrying capacity or oxygen delivery must be rapidly corrected to prevent irreversible damage to tissues.

The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results? A. Indeterminate B. Needs to be redone C. Negative D. Positive

Correct Answer: C. Negative This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. If the patient is at a high risk of developing an active infection, a repeat test is recommended after an initial negative test to rule out the possibility of missing a case. However, a decision is made based on the risk factors. Option A: Indeterminate isn't a term used to describe results of a PPD test. It is a time-sensitive test. Tests that are read late are not accurate as they tend to under-estimate the size of the skin reaction. Therefore, the reliability of the test is compromised, and the results are doubtful. Option B: To avoid this, repeat testing is recommended if the reaction is not read on time. The second test can be administered as soon as possible. However, if repeated, the test should preferably be performed within 7 days of the initial test to avoid boosting effect. Option D: If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC. If the infection risk is very high, the PPD test need not be repeated. The positive PPD test is usually followed by TB symptom assessment, physical exam, and chest radiograph.

A pulse oximetry gives what type of information about the client? A. Amount of carbon dioxide in the blood B. Amount of oxygen in the blood C. Percentage of hemoglobin carrying oxygen D. Respiratory rate

Correct Answer: C. Percentage of hemoglobin carrying oxygen. The pulse oximeter determines the percentage of hemoglobin carrying oxygen. This doesn't ensure that the oxygen being carried through the bloodstream is actually being taken up by the tissue. Pulse oximetry is a non-invasive monitor that measures the oxygen saturation in the blood by shining light at specific wavelengths through tissue (most commonly the fingernail bed). Option A: A CO2 blood test measures the amount of carbon dioxide in the blood. Too much or too little carbon dioxide in the blood can indicate a health problem. A CO2 blood test is often part of a series of tests called an electrolyte panel. Electrocytes help balance the levels of acids and bases in the body. Most of the carbon dioxide in the body is in the form of bicarbonate, which is a type of electrolyte. An electrolyte panel may be part of a regular exam. Option B: A blood oxygen level test is used to check how well the lungs are working and measure the acid-base balance in the blood. A blood oxygen level test also checks the balance of acids and bases, known as pH balance, in the blood. Too much or too little acid in the blood can mean there is a problem with the lungs or kidneys. Option D: The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises

Which of the following methods is the best way to confirm the diagnosis of a pneumothorax? A. Auscultate breath sounds. B. Have the client use an incentive spirometer. C. Take a chest x-ray. D. Stick a needle in the area of decreased breath sounds.

Correct Answer: C. Take a chest x-ray A chest x-ray will show the area of collapsed lung if pneumothorax is present as well as the volume of air in the pleural space. Chest radiography, ultrasonography, or CT can be used for diagnosis, although diagnosis from a chest x-ray is more common. Radiographic findings of 2.5 cm air space are equivalent to a 30% pneumothorax. Option A: Listening to breath sounds won't confirm a diagnosis. Clinical presentation of a pneumothorax can range anywhere from asymptomatic to chest pain and shortness of breath. A tension pneumothorax can cause severe hypotension (obstructive shock) and even death. Option B: An IS is used to encourage deep breathing. Do not let a chest radiograph or CT scan delay treatment with needle decompression or thoracostomy tube if the patient is clinically unstable, i.e., tension pneumothorax. Option D: A needle thoracostomy is done only in an emergency and only by someone trained to do it. If a patient is hemodynamically unstable with suspected tension pneumothorax, intervention is not withheld to await imaging. Needle decompression can be performed if the patient is hemodynamically unstable with a convincing history and physical exam, indicating tension pneumothorax.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

Correct Answer: C. The system has an air leak. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (system-centered). Option A: Clients without a pneumothorax should have no evidence of bubbling in the chamber. Absence of bubbling may indicate complete lung re-expansion (normal) or represent complications such as obstruction in the tube. Option B: The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes. Option D: If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. Monitor water-seal chamber "tidaling." Note whether the change is transient or permanent. Tidaling of 2-6 cm during inspiration is normal and may increase briefly during coughing episodes. Continuation of excessive tidal fluctuations may indicate the existence of airway obstruction or the presence of a large pneumothorax.

Which phrase is used to describe the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

Correct Answer: C. Tidal volume Tidal volume refers to the volume of air inspired and expired with a normal breath. Tidal volume is the amount of air that moves in or out of the lungs with each respiratory cycle. It measures around 500 mL in an average healthy adult male and approximately 400 mL in a healthy female. It is a vital clinical parameter that allows for proper ventilation to take place. Option A: Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Among healthy adults, the average lung capacity is about 6 liters. Age, gender, body composition, and ethnicity are factors affecting the different ranges of lung capacity among individuals. TLC rapid increases from birth to adolescence and plateaus at around 25 years old. Option B: Forced vital capacity is the vital capacity performed with a maximally forced expiration. Vital capacity may be measured as inspiratory vital capacity (IVC), slow vital capacity (SVC), or forced vital capacity (FVC). The FVC is similar to VC, but it is measured as the patient exhales with maximum speed and effort. Option D: Residual volume is the maximal amount of air left in the lung after a maximal expiration. In other words, it is the volume of air that cannot be expelled, thus causing the alveoli to remain open at all times. The residual volume remains unchanged regardless of the lung volume at which expiration was started.

An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct? A. Using intermittent suction while advancing the catheter. B. Using continuous suction while withdrawing the catheter. C. Using intermittent suction while withdrawing the catheter. D. Using continuous suction while advancing the catheter.

Correct Answer: C. Using intermittent suction while withdrawing the catheter. Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia, suctioning shouldn't last more than 10-seconds at a time. Suction shouldn't be applied while the catheter is being advanced. Ensure preoxygenation with 100% FiO2 was done with adequate pulse oximetry measurements. Preoxygenation is required because airway suctioning procedure may be associated with significant hypoxemia. Option A: Suctioning of the lower airways should be done in a sterile manner with single-use gloves and suction catheters to prevent contamination and secondary infection. The catheter should be introduced to a depth no more than the tip of the artificial airway to prevent trauma and bleeding from airway mucosa. Option B: Suction pressure should be kept less than 200 mmHg in adults. It should be set at 80 mmHg to 120 mmHg in neonates. The catheter size used for suction should be less than 50% of the internal diameter of the endotracheal tube. A common conversion is that a 1 mm diameter is equal to a 3 French. Option D: The duration of suctioning should be less than 15 seconds per suction attempt. Following airway suction, the patient should be allowed to recover for at least 10 to 15 seconds and re-oxygenate as needed before re-suctioning occurs. Standard precautions should be followed while suctioning by the care provider.

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

Correct Answer: D. A cough with the expectoration of mucoid sputum One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. A chronic cough, hemoptysis, weight loss, low-grade fever, and night sweats are some of the most common physical findings in pulmonary tuberculosis. Other options are late symptoms and signify cavitation and extensive lung involvement. Option A: Secondary tuberculosis differs in clinical presentation from the primary progressive disease. In secondary disease, the tissue reaction and hypersensitivity is more severe, and patients usually form cavities in the upper portion of the lungs Option B: Pulmonary or systemic dissemination of the tubercles may be seen in active disease, and this may manifest as miliary tuberculosis characterized by millet-shaped lesions on chest x-ray. Disseminated tuberculosis may also be seen in the spine, the central nervous system, or the bowel. Option C: As the bacterium begins multiplying in the body and destroying tissue, it causes symptoms such as a bad, persistent cough, fatigue/loss of energy, weight loss, loss of appetite, chills, fever, drenching night sweats, chest pain, and coughing up or spitting up bright red blood, a symptom that occurs when the blood vessels inside the lungs become eroded and begin to bleed.

A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: A. Lung vibrations B. Vocal sounds C. Breath sounds D. Chest movements.

Correct Answer: D. Chest movements The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolism, or a rib or sternum fracture. During the inspection, the examiner should pay attention to the pattern of breathing: thoracic breathing, thoracoabdominal breathing, coastal markings, and use of accessory breathing muscles. The use of accessory breathing muscles (i.e., scalenes, sternocleidomastoid muscle, intercostal muscles) could point to excessive breathing effort caused by pathologies. Option A: After asking the client to say "99," the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. An increase in the tactile fremitus points towards an increased intraparenchymal density and a decreased fremitus hints towards a pleural process that separates the pleura from the parenchyma (pleural effusion, pneumothorax). Option B: The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus. Palpation should focus on detecting abnormalities like masses or bony crepitus. Of note, the fremitus can also be auscultated and can be referred to as vocal fremitus. Option C: The nurse assesses breath sounds during auscultation. The movement of air generates normal breath sounds through the large and small airways. Normal breath sounds have a frequency of approximately 100 Hz. The absence of breath sounds should prompt the health care provider to consider shallow breath, abnormal anatomy, or pathologic entities such as airway obstruction, bulla, hyperinflation, pneumothorax, pleural effusion or thickening, and obesity.

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A. Contralateral side in a simple pneumothorax. B. Affected side in a hemothorax. C. Affected side in a tension pneumothorax. D. Contralateral side in hemothorax.

Correct Answer: D. Contralateral side in hemothorax. The trachea will shift according to the pressure gradients within the thoracic cavity. If there is no significant air or fluid accumulation, the trachea will not shift. The pressure gradient inside the thorax changes with a pneumothorax. Normally the pressure of the pleural space is negative when compared to atmospheric pressure. When the chest wall expands outwards, the lung also expands outwards due to surface tension between parietal and visceral pleura. Option A: Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side. When there is communication between the alveoli and the pleural space, air fills this space changing the gradient, lung collapse unit equilibrium is achieved, or the rupture is sealed. Pneumothorax enlarges, and the lung gets smaller due to this vital capacity, and oxygen partial pressure decreases. Option B: In hemothorax, accumulation of air or fluid causes a shift away from the injured side. Traumatic pneumothorax can result from blunt or penetrating trauma, these often create a one-way valve in the pleural space (letting the airflow in but not to flow out) and hence hemodynamic compromise. Option C: A tension pneumothorax can cause severe hypotension (obstructive shock) and even death. An increase in central venous pressure can result in distended neck veins, hypotension. Patients may have tachypnea, dyspnea, tachycardia, and hypoxia

A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. Which of the following is a normal physiologic change related to aging? A. Increased elastic recoil of the lungs. B. Increased number of functional capillaries in the alveoli. C. Decreased residual volume. D. Decreased vital capacity.

Correct Answer: D. Decreased vital capacity. Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase is residual volume. Lung volumes depend on body size, especially height. Total lung capacity (TLC) corrected for age remains unchanged throughout life. Functional residual capacity and residual volume increase with age, resulting in a lower vital capacity. Option A: There is marked variation in the effect of aging on lung function. Aging is associated with reduction in chest wall compliance and increased air trapping. The decline in FEV1 with age likely has a nonlinear phase with acceleration in rate of decline after age 70 years. Option B: Additionally, decreased strength and function of respiratory muscles is observable. All of these changes drop an aging patient's threshold in compensating for an acute illness or respiratory failure. Reduction in supporting tissue results in premature closure of small airways during normal breathing and can potentially cause air trapping and hyperinflation, hence "senile emphysema". Option C: Subjects with lower chest wall compliance had higher residual volume (RV), suggesting an impediment to complete emptying of the lungs from a stiff chest wall. Age-related changes in the respiratory system primarily center upon the loss of elasticity and decrease in chest wall compliance leading to increased work of breathing, as well as increased residual volume and functional residual capacity.

Which of the following statements best explains how opening up collapsed alveoli improves oxygenation? A. Alveoli need oxygen to live. B. Alveoli have no effect on oxygenation. C. Collapsed alveoli increase oxygen demand. D. Gaseous exchange occurs in the alveolar membrane.

Correct Answer: D. Gaseous exchange occurs in the alveolar membrane. Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, though by decreasing the surface area available for gas exchange, they decreased oxygenation of the blood. Option A: Ventilation is 50% greater at the base of the lung than at the apex. The weight of fluid in the pleural cavity increases the intrapleural pressure at the base to a less negative value. As a result, alveoli are less expanded and have higher compliance at the base, resulting in a more substantial increase in volume on inspiration for increased ventilation. Option B: The exchange of both oxygen and carbon dioxide is perfusion limited. Diffusion of gases reaches equilibrium one-third of the way through the capillary/alveolar interface. Deoxygenated blood from the pulmonary arteries has a PVO2 of 40 mmHg, and alveolar air has a PAO2 of 100 mmHg, resulting in a movement of oxygen into capillaries until arterial blood equilibrates at 100 mmHg (PaO2). Option C: Gas exchange in the alveoli occurs primarily by diffusion. Traveling from the alveoli to capillary blood, gases must pass through alveolar surfactant, alveolar epithelium, basement membrane, and capillary endothelium.

A chest x-ray showed a client's lungs to be clear. His Mantoux test is positive, with a 10mm of induration. His previous test was negative. These test results are possible because: A. He had TB in the past and no longer has it. B. He was successfully treated for TB, but skin tests always stay positive. C. He's a "seroconverter", meaning the TB has gotten to his bloodstream. D. He's a "tuberculin converter," which means he has been infected with TB since his last skin test.

Correct Answer: D. He's a "tuberculin converter," which means he has been infected with TB since his last skin test. A tuberculin converter's skin test will be positive, meaning he has been exposed to an infection with TB and now has a cell-mediated immune response to the skin test. Induration of 10 mm or greater indicates positivity in persons with above baseline risk of reactivation. Option A: The client's blood and x-ray results may stay negative. It doesn't mean the infection has advanced to the active stage. If the chest radiograph or clinical evaluation are suggestive of tuberculosis, then active infection needs to be excluded with further testing. Option B: Because his x-ray is negative, he should be monitored every 6 months to see if he develops changes in his x-ray or pulmonary examination. If there is no evidence of active disease is noted by history, physical or radiograph, the patient is deemed to have LTBI and should be treated. Option C: Being a seroconverter doesn't mean the TB has gotten into his bloodstream; it means it can be detected by a blood test. If there is a high risk of infection and progression, the test should not be repeated.

Which of the following pathophysiological mechanisms that occur in the lung parenchyma allow pneumonia to develop? A. Atelectasis B. Bronchiectasis C. Effusion D. Inflammation

Correct Answer: D. Inflammation The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. The resident macrophages serve to protect the lung from foreign pathogens. Ironically, the inflammatory reaction triggered by these very macrophages is what is responsible for the histopathological and clinical findings seen in pneumonia. Option A: Atelectasis and bronchiectasis indicate a collapse of a portion of the airway that doesn't occur in pneumonia. It is caused by the partial or complete, reversible collapse of the small airways resulting in an impaired exchange of CO2 and O2 - i.e., intrapulmonary shunt. The incidence of atelectasis in patients undergoing general anesthesia is 90%. Option B: Bronchiectasis is a chronic lung disease characterized by persistent and lifelong widening of the bronchial airways and weakening of the function mucociliary transport mechanism owing to repeated infection contributing to bacterial invasion and mucus pooling throughout the bronchial tree. Option C: An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia. Accumulation of excess fluid can occur if there is excessive production or decreased absorption or both overwhelming the normal homeostatic mechanism. If pleural effusion is mainly due to mechanisms that lead to pleural effusion mainly due to increased hydrostatic pressure are usually transudative, and leading to pleural effusion have altered the balance between hydrostatic and oncotic pressures (usually transudates), increased mesothelial and capillary permeability (usually exudates) or impaired lymphatic drainage.

A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and symptoms would the client show if therapy is inadequate? A. Decreased shortness of breath. B. Improved chest x-ray. C. Nonproductive cough. D. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.

Correct Answer: D. Positive acid-fast bacilli in a sputum sample after 2 months of treatment. Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection. One of the most important aspects of tuberculosis treatment is close follow up and monitoring for these side effects. Most of these side effects can be managed by either close monitoring or adjusting dose. In some cases, the medication needs to be discontinued and second-line therapy should be considered if other alternatives are not available. Option A: Majority of patients with a diagnosis of TB have a good outcome. This is mainly because of effective treatment. Without treatment mortality rate for tuberculosis is more than 50%. Tuberculosis is a preventable and treatable infectious disease. Having said that, it's still one of the major contributors of morbidity and mortality in developing countries where we are still struggling to provide adequate access to care. Option B: DOTS (Direct Observed Therapy) proposed by WHO has been very effective in recent years to improve adherence to the treatment in tuberculosis patients. Also, Vaccination drive in developing countries has played a bigger role in decreasing the prevalence of this infection. Option C: Preventive effect of BCG vaccination is controversial but many studies have identified vaccination as a very important tool in the fight against tuberculosis and we need to keep our focus on childhood vaccination especially in developing countries.

A high level of oxygen exerts which of the following effects on the lung? A. Improves oxygen uptake. B. Increases carbon dioxide levels. C. Stabilizes carbon dioxide levels. D. Reduces amount of functional alveolar surface area.

Correct Answer: D. Reduces amount of functional alveolar surface area. Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake. Continued exposure to high concentrations of oxygen results in heightened free radical production. This may damage the pulmonary epithelium, inactivate the surfactant, form intra-alveolar edema, interstitial thickening, fibrosis, and ultimately lead to pulmonary atelectasis. Option A: Oxygen-derived free radicals have been proposed as being the probable etiological cause in the development of oxygen toxicity. Free radicals are generated due to the mitochondrial oxidoreductive processes and also induced by the function of enzymes such as xanthine/urate oxidase at extra-mitochondrial sites, from auto-oxidative reactions, and by phagocytes during the bacterial killing. Option B: 100% oxygen can be tolerated at sea level for about 24-48 hours without any severe tissue damage. Lengthy exposures produce definite tissue injury. There is moderate carinal irritation on deep inspiration after 3-6 hours of exposure of 2 ATA, extreme carinal irritation with uncontrolled coughing after 10 hours, and finally, chest pain and dyspnea ensue. Option C: Extended exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes leading to the collapse of the alveoli in the lungs. CNS toxicity is expedited by factors such as raised PCO2, stress, fatigue, and cold.

A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? A. Acute asthma B. Chronic bronchitis C. Pneumonia D. Spontaneous pneumothorax

Correct Answer: D. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. For patients with larger spontaneous pneumothorax (more than 15%), there may be reduced movement of the chest wall, ipsilateral decreased or absent breath sounds, jugular venous distension, pulsus paradoxus, hyperresonance on percussion, and decreased tactile fremitus. Option A: An asthma attack would show wheezing breath sounds. Patients will show some respiratory distress, often sitting forward to splint open their airways. On auscultation, a bilateral, expiratory wheeze will be heard. Option B: Bronchitis would have rhonchi. Uncomplicated chronic bronchitis presents with a cough, and there is no evidence of airway obstruction physiologically. When patients have chronic asthmatic bronchitis, there is usually a wheeze present due to a hyperactive airway leading to intermittent bronchospasm. Option C: Pneumonia would have bronchial breath sounds over the area of consolidation. When bronchial sounds are heard in areas distant from where they normally occur, the patient may have consolidation (as occurs with pneumonia) or compression of the lung. These conditions cause the lung tissue to be dense.

A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? A. ABG analysis B. Chest x-ray C. Blood cultures D. Sputum culture and sensitivity

Correct Answer: D. Sputum culture and sensitivity Sputum C & S is the best way to identify the organism causing the pneumonia. If good quality, sputum evaluation may reveal more than 25 WBC per low-power field and less than 10 squamous epithelial cells. Some bacterial causes present with specific biochemical evidence, such as Legionella, may present with hyponatremia and microhematuria. Option A: ABG analysis will determine the extent of hypoxia present due to the pneumonia. An arterial blood gas may reveal hypoxia and respiratory acidosis. Pulse oximetry of less than 92% indicates severe hypoxia, and elevated CRP predicts a serious infection. Option B: Chest x-ray will show the area of lung consolidation. Findings may vary from lobar to interstitial infiltrate, to occasionally cavitary lesions with air-fluid levels suggestive of a more severe disease process. Option C: Blood cultures will help determine if the infection is systemic. These include a series of tests like blood culture, sputum culture and microscopy, routine blood counts, and lymphocyte count. Special tests such as urinary antigen testing, bronchial aspirate, or induced sputum may be used for certain pathogens.

Which of the following best describes pleural effusion? A. The collapse of alveoli. B. The collapse of bronchiole. C. The fluid in the alveolar space. D. The accumulation of fluid between the linings of the pleural space.

Correct Answer: D. The accumulation of fluid between the linings of the pleural space. The pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion. Option A: The word "atelectasis" is Greek in origin; It is a combination of the Greek words atelez (ateles) and ektasiz (ektasis) meaning "imperfect" and "expansion" respectively. It results from the partial or complete, reversible collapse of the small airways leading to an impaired exchange of CO2 and O2 - i.e., intrapulmonary shunt. Option B: Bronchomalacia is a term for weak cartilage in the walls of the bronchial tubes, often occurring in children under a day. Bronchomalacia means 'floppiness' of some part of the bronchi. Patients present with noisy breathing and/or wheezing. There is collapse of a main stem bronchus on exhalation. Option C: The fluid within the alveoli, often referred to as alveolar fluid, is part of the alveolar surface network (Scarpelli, 2003). This network within the alveoli can be envisaged as a foam made of surfactant and water. The foam forms a network within the alveoli and has a gas: fluid volume ratio of 900:1 (Scarpelli, 2003).

A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? A. Continued dyspnea B. Fever of 102*F C. Respiratory rate of 32 breaths/minute. D. Vesicular breath sounds in the right base

Correct Answer: D. Vesicular breath sounds in right base If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should be examined by the physician before discharge because he may have another source of infection or still have pneumonia. Option A: Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles. Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of the discomfort of moving chest wall and/or fluid in the lung due to a compensatory response to airway obstruction. Altered breathing pattern may occur together with the use of accessory muscles to increase chest excursion to facilitate effective breathing. Option B: Investigate sudden change in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics. Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Option C: Assess and record respiratory rate and depth at least every 4 hours. The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise.