143 Module 2 - Lower Respiratory Tract Disorders (PRACTICE QUESTIONS)

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? A. 3 to 5 months B. 3 months C. 13 to 18 months D. 6 to 12 months

D. Pulmonary tuberculosis (TB) is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.

DELETE The nurse is planning care for a child with a pneumothorax. The nurse adds the nursing diagnosis, Risk for injury related to potential dislodgement of chest tube to the care plan. When writing the care plan, what should the nurse be sure to include as interventions? A. Ensure a pair of hemostats are at the bedside. B. Maintain chest tube bottle in an upright position and below the level of the chest. C. Assess lungs as directed by the physician or as the client's condition warrants. D. Mo

A, B, C, D. If the tube becomes dislodged from the child's chest, the nurse must apply Vaseline gauze and an occlusive dressing to prevent air leakage into the pleural space. A pair of hemostats should be kept at the bedside to clamp the tube should it become dislodged from the drainage container. Pulse oximetry and lung assessments help ensure proper placement of the chest tube. To maintain proper drainage, the bottle must be kept upright and below the level of the chest.

What is the reason for chest tubes after thoracic surgery? A. Draining secretions, air, and blood from the thoracic cavity is necessary. B. Chest tubes allow air into the pleural space. C. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. D. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

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

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? A. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. B. The client exhibits bronchial breath sounds over the affected area. C. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. D. The client exhibits restlessness and confusion.

A. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

A client has a nursing diagnosis of ineffective airway clearance as a result of excessive secretions. An appropriate outcome for this client would be which of the following? A. Lungs are clear on auscultation. B. Client can perform incentive spirometry. C. Client reports no chest pain. D. Respiratory rate is 12 to 18 breaths per minute.

A. Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A. To remove air from the pleural space B. To drain copious sputum secretions C. To assist with mechanical ventilation D. To monitor bleeding around the lungs

A. Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? A. Viruses like influenza are the most common cause of pneumonia. B. Getting the flu can complicate pneumonia. C. Influenza vaccine will prevent typical pneumonias. D. Influenza is the major cause of death in the United States.

A. Influenza type A is a common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.

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? A. The tube will drain air from the space around the lung. B. The tube will drain secretions from the lung. C. The tube will provide a route for medication instillation to the lung. D. The tube will allow air to be restored to the lung.

A. Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.

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? A. Pneumothorax B. Heart failure C. Pulmonary embolism D. Myocardial infarction (MI)

A. Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

Pink, frothy sputum may be an indication of A. pulmonary edema. B. a lung abscess. C. bronchiectasis. D. an infection.

A. Profuse frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as A. Atelectasis B. Pneumonia C. Emphysema D. Pleurisy

A. Retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? A. Initiate chest physiotherapy. B. Immobilize the ribs with an abdominal binder. C. Prepare the client for surgery. D. Immediately sedate and intubate the client.

ANS: A Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes chest physiotherapy and controlling pain. Intubation is required only for severe flail chest injuries, not small flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment. Immobilization of the ribs with an abdominal binder is not necessary for a small flail chest injury.

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration

ANS: A Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, and aspiration.

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax? A. Diminished or absent breath sounds on the affected side B. Paradoxical chest wall mov

ANS: A Rationale: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? A. Incentive spirometry B. Intermittent positive-pressure breathing (IPPB) C. Positive end-expiratory pressure (PEEP) D. Bronchoscopy

ANS: A Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize? A. The importance of adhering closely to the prescribed medication regimen B. The disease being a lifelong, chronic condition that will affect activities of daily living (ADLs) C. TB being self-limiting but taking up to 2 years to resolve D. The need to work closely with the occupational and physical therapists

ANS: A Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care? A. Administer an analgesic before coughing and deep breathing. B. Ambulate the client at least three times daily. C. Arrange for a soft-textured diet and increased fluid intake. D. Encourage the client to speak as little as possible.

ANS: A Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Because deep breathing and coughing prevent atelectasis, the client should be given an analgesic prior to performing these respiratory exercises. A soft diet is not necessarily indicated, and there is no need for the client to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.

The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes which type of impairment? A. Impaired gas exchange B. Collapsed bronchial structures C. Necrosis of the alveoli D. Closed bronchial tree

ANS: A Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? A. Increase oral fluids unless contraindicated. B. Call the nurse for oral suctioning, as needed. C. Lie in a low Fowler or supine position. D. Increase activity.

ANS: A Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

Which would be least likely to contribute to a case of hospital-acquired pneumonia? A. Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. B. Host defenses are impaired. C. A highly virulent organism is present. D. A nurse washes her hands before beginning client care.

D. HAP occurs when at least one of three conditions exists: 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.

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? A. Acute respiratory distress syndrome (ARDS) B. Atelectasis C. Aspiration D. Pulmonary embolism

ANS: B Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A. Administration of prophylactic antibiotics B. Administration of pneumococcal vaccine to vulnerable individuals C. Obtaining culture and sensitivity swabs from all newly admitted clients D. Administration of antiretroviral medications to clients over age 65

ANS: B Rationale: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A one-time vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.

A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care? A. Facilitation of long-term intubation B. Restoration of adequate gas exchange C. Attainment of effective coping D. Self-management of oxygen therapy

ANS: B Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.

A client is undergoing testing to assess for a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? A. Increased tactile fremitus, egophony, and the chest wall dull on percussion B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on percussion C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on p

ANS: C Rationale: Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present. The other listed signs are not typically associated with a pleural effusion.

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid

ANS: D Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.

An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care? A. Nasogastric intubation B. Administration of probiotic supplements C. Bed rest D. Cautious hydration

ANS: D Rationale: Supportive treatment of pneumonia in the older adults includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the older adults); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the client.

A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection, the nurse notes that the patient's trachea is slight displaced toward the left. Which nursing intervention is priority? 1. Have the patient release his arm and sit up straight for reassessment. 2. Notify the emergency room physician immediately. 3. Auscultate the patient's lung fields. 4

Answer: 2 Explanation: 1. Reassessment is not the priority in this situation. 2. Deviation of the trachea away from the injured side indicates pressure on the affected side, which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient's condition. 3. The nurse will auscultate the lungs, but another intervention is the priority. 4. This position is not indicated for this patient. Positioning is not the immediate priority.

A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology? 1. Prolonged expiratory time 2. Increased lung compliance 3. Reduced tidal volume 4. Hyper-inflated lungs

Answer: 3 Explanation: 1. Expiratory time is dependent upon airflow, which remains normal in the patient with a restrictive lung disorder such as pneumothorax. 2. With restrictive lung disorders such as pneumothorax, the air cannot move into the alveoli because of decreased lung compliance. 3. Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient's tidal volume will be reduced. 4. Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.

A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses tidaling in the water-seal chamber. What nursing action is indicated? 1. Collaborate with the healthcare provider regarding need to reinstitute the external suction. 2. Check the connections between the chest tube and the drainage system. 3. No action is necessary as this is an expected occurrence. 4. Have the patient cough forcefully.

Answer: 3 Explanation: 1. There is no need for external suction. 2. The nurse should always check these connections, but there is no special need for that action related to this assessment. 3. The tidaling in this patient likely indicates successful reinflation of the lung, which is the desired outcome. 4. This assessment does not indicate that coughing is necessary.

A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs? 1. Decreased work of breathing 2. Reduced muscle activity 3. Dehydration of lung tissues 4. Decreased compliance

Answer: 4 Explanation: 1. A respiratory rate of 28 is evidence of increased work of breathing. 2. It requires more muscle activity to breathe at a rate of 28. 3. Pulmonary edema results from retention of fluid in the lung tissues. 4. Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema.

A patient diagnosed with acute respiratory distress syndrome (ARDS) is being mechanically ventilated with 12 cm of positive end-expiratory pressure (PEEP). On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication? 1. Obstructed endotracheal tube 2. Increased severity of ARDS 3. Decreased cardiac output 4. Pneumothorax

Answer: 4 Explanation: 1. An obstructed endotracheal tube would affect both lung fields. 2. If the disease process was worsening, it would be likely that both lung fields would be involved. 3. Decreased cardiac output would affect vital signs but not breath sounds. 4. A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.

An older adult presents to the emergency department in septic shock. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic? 1. Whenever the drug is received from the pharmacy 2. After the preliminary results of the sputum specimen are obtained 3. Within 30 minutes of the order being received 4. Within 1 hour of diagnosis

Answer: 4 Explanation: 1. There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient's diagnosis and need to start the antibiotic quickly. 2. The nurse should not wait for sputum specimen results. 3. There is no standard by which the antibiotic must be started within 30 minutes of the order being received. 4. Standards indicate that antibiotic therapy for pneumonia should be started within 1 hour of diagnosis if the patient is also in shock.

DELETE The nurse working in an intensive care unit is alert to the development of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). The nurse would monitor which patients most closely for this complication? Select all that apply. 1. A patient who sustained a severe chest contusion. 2. A patient hospitalized for treatment of drug overdose. 3. A patient who sustained severe head trauma. 4. A patient hospitalized for treatment of pneumonia. 5. A patient diagnosed with sepsis.

Answer: 4, 5 Explanation: 1. Chest contusion can result in ALI/ARDS, but this is not the patient of most concern. 2. Drug overdose can result in ALI/ARDS, but this is not the patient of most concern. 3. Head trauma can result in ALI/ARDS, but this is not the patient of most concern. 4. Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS. 5. Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.

A nurse is giving a speech addressing Communicable Diseases of Winter to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. A. incentive spirometry B. vaccinations C. hand antisepsis D. prescribed opioids

B, C. A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? A. A positive reaction indicates that the client has active tuberculosis (TB). B. A positive reaction indicates that the client has been exposed to the disease. C. A negative reaction always excludes the diagnosis of TB. D. The PPD can be read within 12 hours after the injection.

B. A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? A. Impaired spontaneous ventilation B. Impaired gas exchange C. Ineffective airway clearance D. Decreased cardiac output

B. Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue. If there is an obstruction, there is limited or no gas exchange in this area. Impaired gas exchange is thus the most likely nursing diagnosis with atelectasis.

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? A. Keeping the door to the client's room open to observe the client B. Wearing a disposable particulate respirator that fits snugly around the face C. Instructing the client to wear a mask at all times D. Wearing a gown and gloves when providing direct care

B. Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

On auscultation, which finding suggests a right pneumothorax? A. Bilateral pleural friction rub B. Absence of breath sounds in the right thorax C. Bilateral inspiratory and expiratory crackles D. Inspiratory wheezes in the right thorax

B. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum? A. Bronchitis B. An infection with pneumococcal pneumonia C. A lung abscess D. Bronchiectasis

B. Sputum that is rust colored suggests infection with pneumococcal pneumonia. Bronchiectasis and a lung abscess usually are associated with purulent thick and yellow-green sputum. Bronchitis usually yields a small amount of purulent sputum.

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was tapped to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? A. No fluid is normally present B. 20 mL or less C. 20-40 mL D. More than 40 mL

B. The pleural space, located between the visceral and parietal pleura, normally contains 20 mL of fluid or less. The fluid helps lubricate the visceral and parietal pleura.

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? A. Cardiac tamponade B. Flail chest C. Simple pneumothorax D. Pulmonary contusion

B. When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.

A client has a sucking stab wound to the chest. Which action should the nurse take first? A. Prepare a chest tube insertion tray. B. Draw blood for a hematocrit and hemoglobin level. C. Apply a dressing over the wound and tape it on three sides. D. Prepare to start an I.V. line.

C. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

What does purulent fluid indicate? A. Heart failure B. Cancer C. Infection D. Inflammation

C. A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

A mediastinal shift occurs in which type of chest disorder? A. Simple pneumothorax B. Traumatic pneumothorax C. Tension pneumothorax D. Cardiac tamponade

C. A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs 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. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? A. Flail chest B. Cardiac tamponade C. Tension pneumothorax D. Pulmonary contusion

C. Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? A Hemoptysis and dysuria B. Nonproductive cough and normal temperature C. Sore throat and abdominal pain D. Dyspnea and wheezing

D. In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

The nurse is assessing the site of a client's Mantoux skin test. The client is HIV positive. The nurse notes the induration to be 10 mm. Which action will the nurse take next? A. Document the finding in the client's medical record B. Place the client on droplet precaution. C. Determine if the client has been exposed to tuberculosis. D. Schedule the client for a chest x-ray.

D. Diagnosis of tuberculosis (TB) is confirmed with a positive Mantoux test. An induration of 5 mm is considered positive for clients with HIV. If a client's Mantoux test is positive, the client is next scheduled for a chest x-ray to look for lung changes related to TB, or for a sputum smear test. These tests are done to determine if a client has latent or active TB, which will then determine the course of action for the client. The nurse will document the results; however, documentation is not priority. There is no need to ask about exposure since the test results indicate exposure. The client with active TB will be placed on airborne precautions.

The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the A. nose. B. stomach. C. rectum. D. lungs.

D. Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as coffee ground emesis. This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.

A client seeks medical attention for new-onset cough and sputum production. The client is producing sputum that is yellowish-green in color and thick in consistency. The nurse anticipates which action for these types of symptoms? A. administration of a cough suppressant B. preparation for a CT scan C. placement of client in prone position D. increased hydration

D. Cough results from irritation or inflammation of the mucous membranes anywhere in the respiratory tract and is associated with multiple pulmonary disorders. Of the choices provided, the nurse would anticipate that increased hydration would be recommended for this client. Cough suppressants should be used with caution as they do not address the etiology of the cough. CT scans are used to distinguish fine-tissue density and are used to help diagnose pulmonary embolism. This client is not experiencing symptoms of a pulmonary embolism. Prone positioning is used for clients experiencing acute respiratory distress syndrome (ARDS), not a cough with sputum production.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: A. maintain fluid intake of 40 oz (1,200 ml) per day. B. follow up with the physician in 2 weeks. C. turn and reposition himself every 2 hours. D. continue to take antibiotics for the entire 10 days.

D. The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.