302 Hinkle Chapter 23: Management of Patients with Chest and Lower Respiratory Tract Disorders PrepU

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

"Because I had a previous reaction to the test, this time I need to get a chest x-ray" A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.

On auscultation, which finding suggests a right pneumothorax?

absence of breath sounds in the right thorax 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.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?

"You should switch to using your glasses while taking this medication" The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.

A mediastinal shift occurs in which type of chest disorder?

tension pneumothorax 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 nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

crackles in the lung bases When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

Class 1 with regard to TB indicates

exposure and not evidence of infection Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection with no disease. Class 4 is disease, but not clinically active.

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

increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

Which type of pneumonia has the highest incidence in clients with AIDS and clients receiving immunosuppressive therapy for cancer?

pneumocytis Pneumocystis pneumonia incidence is greatest in clients with AIDS and clients receiving immunosuppressive therapy for cancer, organ transplantation, and other disorders.

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

rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

Which comfort technique does a nurse teach to a client with pleurisy to assist with splinting the chest wall?

turn unto the affected side The nurse teaches the client to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain.

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

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

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

"It is all right if I have a grilled cheese sandwich with American cheese." Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?

"The tube will drain the air from the space around the lung" 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.

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?

"the mucus secreting glands and abnormal" Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.

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

a diet rich in protein For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.

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

change positions frequently and cough up secretions Clients who lie supine will have secretions accumulate in the posterior lung sections, whereas upright patients will pool secretions in their lower lobes. By changing positions, secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

daily doses of isoniazid, 300 mg from 6 months to a year All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

developing a list of people with whom the client has had contact To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

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

few early symptoms Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

Which community-acquired pneumonia demonstrates the highest occurrence during summer and fall?

legionaries disease Legionnaires disease accounts for 15% of community-acquired pneumonias; it occurs mainly in summer and fall. Streptococcal and viral pneumonias demonstrate the highest occurrence during the winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter.

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

pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

using strict hand hygiene The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

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

"viruses like influenza are the most common causes of pneumonia" Influenza type A is the most 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 ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?

acute respiratory distress syndrome (ARDS) Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

dyspnea Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15 mm induration A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6-12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse?

the employee enters the room wearing gown, gloves, and mask The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. To prevent the spread of infection, a stethoscope, blood pressure cuff, and thermometer for single client use should be kept in the room of a client who requires isolation. Removing all personal protective equipment and washing hands before leaving the client's room are correct procedures.

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

the skin test does not differentiate between active and dormant tuberculosis infection The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply.

wear appropriate protective equipment when around airborne irritants and dust do not smoke, or stop smoking if currently smoking

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:

"I;ll stop being contagious when I have a negative acid-fast bacilli test A client with drug-resistant tuberculosis isn't contagious when he's had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce negative acid-fast test results for several days. The client won't have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they don't indicate whether the client is contagious.

Arterial blood gas analysis would reveal which value related to acute respiratory failure?

pH 7.26 Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

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

0-4 mm The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

Which intervention does a nurse implement for clients with empyema?

encourage breathing exercises Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.

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

6-12 months 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.

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

a client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

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

a positive reaction indicated that the client has been exposed to the disease 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.

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

acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

Which action should the nurse take first in caring for a client during an acute asthma attack?

administer bronchodilator as ordered Administering bronchodilator will dilate the airway and allow oxygen to reach the lungs. Although ABGs and chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

airborne and contact precautions SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:

asbestos Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

blood tinged sputum The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.

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

chemical irritation Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

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

continue to take the antibiotics for the entire 10 days 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.

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session?

coughing The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

decreased breath sounds In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis.

What is the reason for chest tubes after thoracic surgery?

draining secretions, air, and blood from the thoracic cavity is necessary After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.

For a client with pleural effusion, what does chest percussion over the involved area reveal?

dullness over the involved area Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.

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

dyspnea and wheezing 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.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

fibrotic changes in lung For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) 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 exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

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

hypercapnia, hypoventilation, hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?

ineffective airway clearance related to an obstruction by a tumor or secretions Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, Ineffective airway clearance related to obstruction by a tumor or secretions takes highest priority. Although a client with bronchogenic carcinoma is likely to have Disturbed body image, Anxiety, and Imbalanced nutrition: Less than body requirements, these nursing diagnoses have a lower priority.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

initiate oxygen therapy The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

institute isolation precautions SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?

intubate the client and control breathing with mechanical ventilator

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?

negative The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.

The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis?

pH 7.25, PaCO2 48, HCO3 24 pH less than 7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2 38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30 indicate respiratory alkalosis; and pH 7.49, PaCO2 34, HCO3 25 indicate respiratory alkalosis.

Which is a key characteristic of pleurisy?

pain The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.

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

paradoxical chest movement Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

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

pleural effusion Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

pneumothorax 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.

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

progressive loss of lung function associated with chronic disease In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.

A client continues to report dyspnea on exertion and overall weakness. A pulmonary artery catheter is placed and the mean pulmonary arterial pressure is 35 mm Hg. What condition is the client experiencing?

pulmonary arterial hypertension Pulmonary hypertension (PH) is confirmed with a mean pulmonary artery pressure *greater than 25 mm* Hg. The main symptom of PH is dyspnea. Client with restrictive lung disease, asthma, and atelectasis should not have PH.

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?

record the observation The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.

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

see if there are leaks in the system Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

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

shortness of breath Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.

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

significant An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

stabbing pain during respiratory movement When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

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

streptococcus pneumoniae Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.

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

sudden onset of lung impairment in a client who has normal lung function In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

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

tense and relax muscles in the lower extremities Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

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

the client has a partial pressure of arterial oxygen (Pa02) value of 90 mmHg or higher 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.

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

the tissues give a crackling sound when palpated Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

unresponsive arterial hypoxemia Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?

venous thromboemboli Neuromuscular blockers predispose the client to venous thromboemboli (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The client may have discomfort or pain but be unable to communicate these sensations.