Ch 23 Chest and Lower Respiratory Tract Disorders

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) test stimulates a reddened response in some clients and requires a second test in 3 months. c) presence of a wheal at the injection site in 2 days indicates active tuberculosis. d) skin test doesn't differentiate between active and dormant tuberculosis infection.

skin test doesn't 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.

What dietary recommendations should a nurse provide a patient with a lung abscess? a) A carbohydrate-dense diet b) A diet with limited fat c) A diet low in calories d) A diet rich in protein

A diet rich in protein For a patient with pleural effusion, a diet rich in protein and calories is pivotal. A carbohydrate-dense diet or diets with limited fat are not advisable for a patient with lung abscess.

A positive Mantoux test indicates that a client: a) has an active case of tuberculosis. b) will develop full-blown tuberculosis. c) is actively immune to tuberculosis. d) has produced an immune response.

has produced an immune response. The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis.

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a 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) 20 - 30 ml b) 5 - 15 ml c) 15 - 25 ml d) No fluid normally is present

5 - 15 ml Under normal conditions, approximately 5 to 15 mL of fluid between the pleurae prevent friction during pleural surface movement.

Which of the following is a potential complication of a low pressure in the endotracheal cuff? a) Pressure necrosis b) Aspiration pneumonia c) Tracheal ischemia d) Tracheal bleeding

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? a) Syncope b) Hypertension c) Ascites d) Dyspnea

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 rightsided 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.

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? a) Negative Homan's sign b) Pain in the calf c) Inability to dorsiflex d) Pain in the feet

Pain in the calf When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis.

The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? a) Shortness of breath b) Headache c) Weight loss d) Fever

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.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.35, PaCO2 48 mm Hg b) pH 7.28, PaO2 50 mm Hg c) pH 7.46, PaO2 80 mm Hg d) pH 7.36, PaCO2 32 mm Hg

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

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago b) A client who is receiving acetaminophen (Tylenol) for pain c) A client with a nasogastric tube d) A client who ambulates in the hallway every 4 hours

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 client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Paradoxical chest movement b) Chest pain on inspiration c) Respiratory acidosis d) Clubbing of fingers and toes

Paradoxical chest movement Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall 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 patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? a) "It is fine if I eat sushi with a little bit of soy sauce." b) "It is all right if I have a grilled cheese sandwich with American cheese." c) "I am going to have a tuna fish sandwich for lunch." d) "It is all right if I drink a glass of red wine with my dinner."

"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.

A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a) "You must consume a diet rich in protein, such as chicken, fish, and beans." b) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." c) "You must consume a diet low in fat by limiting dairy products and concentrated sweets." d) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta."

"You must consume a diet rich in protein, such as chicken, fish, and beans." For a patient with a lung abscess the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess.

A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient? a) "The physician can give you eye drops to prevent any problems." b) "You should switch to wearing your glasses while taking this medication." c) "Only wear your contact lenses during the day and take them out in the evening before bed." d) "There are no significant problems with wearing contact lenses."

"You should switch to wearing 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 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? a) 5 to 6 mm b) 7 to 8 mm c) 0 to 4 mm d) 9 mm

0 to 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.

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). a) 50 and 50 b) 75 and75 c) 80 and 80 d) 60 and 60

50 and 50 Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to <50 mm Hg on room air) and or hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to >50 mm Hg with an arterial pH of <7.35).

You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Bronchitis b) Tracheobronchitis c) Lung cancer d) Acute respiratory distress syndrome

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.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis

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. Options A, C and D are incorrect.

A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? a) Silica b) Coal dust c) Pollen d) Asbestos

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? a) Blood-tinged sputum b) Respiratory alkalosis c) Bradypnea d) Productive cough

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.

You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a) Chemical irritation b) Drug ingestion c) Direct lung damage d) Aspiration

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.

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? a) Coughing b) Copious sputum production c) Severe pain d) Dyspnea

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 client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer b) Administering oxygen, coughing, breathing deeply, and maintaining bed rest c) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer d) Administering pain medications, frequent repositioning, and limiting fluid intake

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? a) Daily doses of isoniazid, 300 mg for 6 months to 1 year b) Nothing, until signs of active disease arise c) Isolation until 24 hours after antitubercular therapy begins d) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years

Daily doses of isoniazid, 300 mg for 6 months to 1 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.

An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion? a) Wheezing upon auscultation b) Resonance upon percussion c) Decreased chest wall excursion upon palpation d) Mottling of the skin upon inspection

Decreased chest wall excursion upon palpation Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area.

A Class 1 with regards to TB indicates a) disease that is not clinically active. b) no exposure and no infection. c) exposure and no evidence of infection. d) latent infection with no disease.

exposure and no 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.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? a) Client teaching about the cause of TB b) Developing a list of people with whom the client has had contact c) Client teaching about the importance of TB testing d) Reviewing the risk factors for TB

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.

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.

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.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions. b) Do not allow visitors with respiratory infection. c) Encourage breathing exercises. d) Place suspected patients together.

Encourage breathing exercises. The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.

You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? a) Lung contusion b) Hemorrhage c) Fibrotic changes in lungs d) Damage to surrounding tissues

Fibrotic changes in lungs 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.

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? a) Provide employees with smoking cessation materials. b) Give workshops on disease prevention. c) Fit all employees with protective masks. d) Insist on adequate breaks for each employee.

Fit all employees with protective masks. The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases.

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? a) Pneumothorax b) Flail chest c) Tension pneumothorax d) ARDS

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? a) Hyperventilation, hypertension, and hypocapnia b) Hyperoxemia, hypocapnia, and hyperventilation c) Hypotension, hyperoxemia, and hypercapnia d) Hypercapnia, hypoventilation, and hypoxemia

Hypercapnia, hypoventilation, and 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? a) Ineffective tissue perfusion (cardiopulmonary) b) Decreased cardiac output c) Impaired gas exchange d) Anxiety

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 who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Ineffective airway clearance. b) Ineffective breathing pattern. c) Risk for falls. d) Impaired tissue integrity.

Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? a) Constipation usually develops b) It is spread by fecal contamination c) It is the most contagious during the second week of illness d) Hypothermia will occur

It is the most contagious during the second week of illness Based on available information, SARS is most likely to be contagious only when symptoms are present, and patients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.

The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Adenocarcinoma b) Squamous cell carcinoma c) Large cell carcinoma d) Bronchoalveolar carcinoma

Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.

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) Heart failure b) Pneumothorax c) Myocardial infarction (MI) d) Pulmonary embolism

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? a) Progressive loss of lung function associated with chronic disease b) Sudden loss of lung function associated with chronic disease c) Progressive loss of lung function with history of normal lung function d) Sudden loss of lung function with history of normal lung function

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.

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Measure the patient's pulse oximetry b) Record the observation c) Apply a compression dressing to the area d) Report the finding to the physician immediately

Record the observation 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 a typical postoperative finding in the patient after chest surgery. 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.

The most diagnostic clinical symptom of pleurisy is: a) Dyspnea and coughing. b) Stabbing pain during respiratory movements. c) Dullness or flatness on percussion over areas of collected fluid. d) Fever and chills.

Stabbing pain during respiratory movements. 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; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.

A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following? a) Wear tight-fitting clothing. b) Consume majority of fluid intake prior to bed. c) Begin estrogen replacement. d) Tense and relax muscles in lower extremities.

Tense and relax muscles in lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent the development of 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 mediastinal shift occurs in which type of chest disorder? a) Tension pneumothorax b) Cardiac tamponade c) Simple pneumothorax d) Traumatic pneumothorax

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 patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a) Pulmonary contusion b) Tension pneumothorax c) Cardiac tamponade d) Flail chest

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

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

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

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? a) Keeping the head of the bed at 15 degrees or less b) Providing oral hygiene daily c) Turning the client every 4 hours to prevent fatigue d) Using strict hand hygiene

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.

The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin B6 b) Vitamin D c) Vitamin C d) Vitamin E

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 client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) test stimulates a reddened response in some clients and requires a second test in 3 months. c) skin test doesn't differentiate between active and dormant tuberculosis infection. d) presence of a wheal at the injection site in 2 days indicates active tuberculosis.

skin test doesn't 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.

What are the conditions that make up Virchow's triad? Select all that apply. a) Hypocoagulability b) Disruption of the vessel lining c) Hypercoagulability d) Venostasis e) Edema

• Hypercoagulability • Disruption of the vessel lining • Venostasis Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad.