ch10: lower resp tract

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

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

"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.

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? Aspiration Drug ingestion Chemical irritation Direct lung damage

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.

Class 1 with regard to TB indicates latent infection with no disease. disease that is not clinically active. exposure and no evidence of infection. no exposure and no infection.

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

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 after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately? "Client is becoming agitated and complains of pleuritic pain." "Client is drowsy and complains of headache." "Client has oxygen saturation of 93%." "Client has subcutaneous emphysema around needle insertion site."

"Client is becoming agitated and complains of pleuritic pain." After a thoracentesis, the nurse monitors the client for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.

A patient is postoperative day 3 following major bowel surgery and has been reluctant to ambulate since being admitted from postanesthetic recovery 2 days ago. As a result, the patient has developed atelectasis and is now being treated for this problem. When administering the patient's bronchodilator by nebulizer, what teaching should the nurse provide? "Try to avoid coughing until your nebulizer has finished." "If you can practice 'huffing' while your nebulizer is running, it will help the medication reach your lungs." "If possible, take slow, deep breaths while your nebulizer is running." "Try to breathe through your nose to ensure that you get as much benefit as possible from your medication."

"If possible, take slow, deep breaths while your nebulizer is running." During nebulizer therapy, the patient breathes through the mouth, taking slow, deep breaths, and then holds the breath for a few seconds. The patient is encouraged to cough during the treatment, which assists in increasing intrathoracic pressure and promoting secretion expectoration. Huffing may be of benefit, but slow deep breaths are a priority.

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? "It is all right if I drink a glass of red wine with my dinner." "It is fine if I eat sushi with a little bit of soy sauce." "It is all right if I have a grilled cheese sandwich with American cheese." "I am going to have a tuna fish sandwich for lunch."

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

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

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? Respiratory alkalosis Bradypnea Productive cough Blood-tinged sputum

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.

A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client? Angiotensin receptor blockers Calcium channel blockers Beta blockers Angiotensin converting enzyme inhibitor

Calcium channel blockers Clients with a positive vasoreactivity test may be prescribed calcium channel blockers. Calcium channel blockers have a significant advantage over other medications taken to treat PH in that they may be taken orally and are generally less costly; however, because calcium channel blockers are indicated in only a small percentage of clients, other treatment options, including prostanoids, are often necessary (Hopkins & Rubin, 2016).

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Crackles Rhonchi Decreased breath sounds Wheezes

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.

The nurse is aware that the clinical manifestations of atelectasis are correlated to the severity of the affected collapse. Which of the following indications are consistent with a smaller, affected area? Select all that apply. Trachea deviation toward the ateliotic area Egophony Asymmetry of the chest Decreased breath sounds Crackles Decreased tactile fremitus

Decreased breath sounds Crackles Decreased tactile fremitus For a small atelectatic area, findings include crackles, decreased breath sounds, and decreased tactile fremitus over the affected lung area(s). For a large atelectatic area, findings include trachea deviation toward the atelectatic area, decreased fremitus, bronchial breath sounds, egophony (secondary to lobar or lung collapse), and asymmetry of the chest.

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

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.

Which intervention does a nurse implement for clients with empyema? Do not allow visitors with respiratory infections Institute droplet precautions Place suspected clients together Encourage breathing exercises

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.

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

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote more efficient and controlled ventilation and to decrease the work of breathing Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote the strengthening of the client's diaphragm Promote the client's ability to take in oxygen

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

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: Ineffective breathing pattern. Risk for falls. Ineffective airway clearance. 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.

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? Notify the physician. Disconnect the system and get another. Milk the chest tube. Place the head of the patient's bed flat.

Notify the physician. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.

Which is a key characteristic of pleurisy? Blood-tinged secretions Anxiety Pain Dyspnea

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 has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? Bicarbonate (HCO3-) pH Partial pressure of arterial carbon dioxide (PaCO2) Partial pressure of arterial oxygen (PaO2)

Partial pressure of arterial oxygen (PaO2) In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A nurse assesses a client with pneumonia. Which assessments are diagnostic for pneumonia? Select all that apply. Percussion dullness Whispered pectoriloquy Friction rubs Wheezes Presence of crackles Egophony

Percussion dullness Whispered pectoriloquy Wheezes Presence of crackles Egophony Physical examination findings may reveal bronchial breath sounds over consolidated lung areas: soft, high-pitched crackles, inspiratory vesicular sounds that are longer than expired normal breath sounds, increased tactile fremitus (vocal vibration detected on palpation), percussion dullness, egophony, wheezing, and whispered pectoriloquy (whispered sounds are easily auscultated through the chest wall). Friction rubs are not common assessment findings for clients with pneumonia.

A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? Pulmonary hypertension Chronic obstructive pulmonary disease (COPD) Pulmonary tuberculosis Empyema

Pulmonary hypertension Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

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? Cyanosis Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing

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.

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 Staphylococcus aureus Pseudomonas aeruginosa Mycobacterium tuberculosis

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 had normal lung function Insidious onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had compromised lung function Insidious onset of lung impairment in a client who had normal lung function

Sudden onset of lung impairment in a client who had 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.

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? Avoid using a pillow while splinting. Use a heat or cold application. Turn onto the affected side. Use a prescribed analgesic.

Turn onto the affected side. Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

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

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.

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

continue to take 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.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: lobar pneumonia. infected chest tube wound site. Pneumocystis carinii pneumonia. empyema.

empyema Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as tertiary drug resistance. multidrug resistance. secondary drug resistance. primary drug resistance.

primary drug resistance. Primary drug resistance refers to resistance to one of the first-line antituberculotic agents in people who have not received previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in clients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.