ch 23 PrepU lower airway

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

b. Pain in the calf Explanation: 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.

A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Sucking sound at the site of injury b) Bloody, productive cough c) Decreased respiratory rate d) Diminished breath sounds

a. Sucking sound at the site of injury Explanation: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds

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

b. Encourage breathing exercises. Explanation: 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.

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) Begin estrogen replacement. b) Tense and relax muscles in lower extremities. c) Consume majority of fluid intake prior to bed. d) Wear tight-fitting clothing.

b. Tense and relax muscles in lower extremities. Explanation: 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.

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

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

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? a) Wearing gloves during all client contact b) Assessing the client's temperature every 8 hours c) Placing the client in respiratory isolation d) Monitoring the client's fluid intake and output

c. Placing the client in respiratory isolation Explanation: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances

A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following? a) Pneumothorax b) Hemothorax c) Pleural effusion d) Consolidation

c. Pleural effusion Explanation: 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 due to collapse of alveoli or 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? a) Myocardial infarction (MI) b) Pulmonary embolism c) Pneumothorax d) Heart failure

c. Pneumothorax Explanation: 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.

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? a) "If the test area turns red that means I have tuberculosis." b) "I will avoid contact with my family until I am done with the test." c) "I will come back in 1 week to have the test read." d) "Because I had a previous reaction to the test, this time I need to get a chest X-ray."

d. "Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: 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.

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? a) 6 to 12 months b) 3 to 5 days c) 2 to 4 months d) 1 to 3 weeks

a. 6 to 12 months Explanation: 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.

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. Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: 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.

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) Pulmonary contusion c) Tension pneumothorax d) Cardiac tamponade

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

A nurse recognizes that a client with tuberculosis needs further teaching when the client states: a) "The people I have contact with at work should be checked regularly." b) "It won't be necessary for the people I work with to take medication." c) "I'll need to have scheduled laboratory tests while I'm on the medication." d) "I'll have to take these medications for 9 to 12 months."

a. "The people I have contact with at work should be checked regularly." Explanation: The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Impaired gas exchange b) Anxiety c) Decreased cardiac output d) Ineffective tissue perfusion (cardiopulmonary)

a. Impaired gas exchange Explanation: 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 patient admitted to the hospital following a motor vehicle crash has suffered a flail chest. A nurse assesses the patient for what most common clinical manifestation of flail chest? a) Paradoxical chest movement b) Wheezing c) Cyanosis d) Hypertension

a. Paradoxical chest movement Explanation: 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. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

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."

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

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) The PPD can be read within 12 hours after the injection. d) A negative reaction always excludes the diagnosis of TB.

b. A positive reaction indicates that the client has been exposed to the disease. Explanation: 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.

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. Absence of breath sounds in the right thorax Explanation: 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 client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer? a) "I've had a low-grade fever for 2 weeks." b) "I've lost 10 pounds in the last month." c) "My cough has changed from a dry cough to one with lots of sputum production." d) "My voice is hoarser than it used to be."

c. "My cough has changed from a dry cough to one with lots of sputum production." Explanation: A cough that changes in character is one of the hallmark signs of lung cancer. Low-grade fever, hoarseness, and weight loss may be attributed to other disease processes and don't necessarily indicate lung cancer.

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

c. Coughing Explanation: 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.

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? a) Low-pitched rhonchi during expiration b) Pleural friction rub c) Crackles in the lung bases d) Sibilant wheezes

c. Crackles in the lung bases Explanation: 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.

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? a) See if the wall suction unit has malfunctioned. b) See if the chest tube is clogged. c) See if a kink has developed in the tubing. d) See if there are leaks in the system.

d. See if there are leaks in the system. Explanation: 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.