Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "You need to start using the incentive spirometer 2 days after surgery." "Before you do the exercise, I'll give you pain medication if you need it." "Breathe in and out quickly." "Don't use the incentive spirometer more than 5 times every hour."
"Before you do the exercise, I'll give you pain medication if you need it." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily and hold the breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.
The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated. "I just finished eating my lunch, I'm ready for my CPT now." "I received my pain medication 10 minutes ago, let's do my CPT now." "I just changed into my running suit; we can do my CPT now." "I have been coughing all morning and am barely bringing anything up."
"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the client is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration, splints any incision, and provides pillows for support, as needed. A goal of CPT is for the client to be able to mobilize secretions; the client who has an unproductive cough is a candidate for CPT.
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? "If you can practice 'huffing' while your nebulizer is running, it will help the medication reach your lungs." "Try to breathe through your nose to ensure that you get as much benefit as possible from your medication." "Try to avoid coughing until your nebulizer has finished." "If possible, take slow, deep breaths while your nebulizer is running."
"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.
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 provide a route for medication instillation to the lung." "The tube will allow air to be restored to the lung." "The tube will drain secretions from the lung." "The tube will drain air from the space around the lung."
"The tube will drain 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.
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." "Getting the flu can complicate pneumonia." "Viruses like influenza are the most common cause of 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.
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 to 12 months 1 to 3 weeks 2 to 4 months 3 to 5 days
6 to 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 is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client who is receiving acetaminophen (Tylenol) for pain A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago A client with a nasogastric tube 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.
What dietary recommendations should a nurse provide a client with a lung abscess? A diet with limited fat A diet low in calories A carbohydrate-dense diet A diet rich in protein
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 is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? A positive reaction indicates that the client has been exposed to the disease. The PPD can be read within 12 hours after the injection. A positive reaction indicates that the client has active tuberculosis (TB). A negative reaction always excludes the diagnosis of TB.
A positive reaction indicates 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 caring for a 2-year-old near drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis 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.
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? Bronchitis Tracheobronchitis Acute respiratory distress syndrome Lung cancer
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.
Constant bubbling in the water seal of a chest drainage system indicates which problem? Increased drainage Tension pneumothorax Air leak Tidaling
Air leak The nurse needs to 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. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
The nurse knows that a sputum culture is necessary to identify the causative organism for acute tracheobronchitis. What causative fungal organism would the nurse suspect? Streptococcus pneumoniae Mycoplasma pneumoniae Aspergillus Hemophilus
Aspergillus In acute tracheobronchitis, the inflamed mucosa of the bronchi produces mucopurulent sputum, often in response to infection by Streptococcus pneumoniae, Hemophilus influenzae, or Mycoplasma pneumoniae. In addition, a fungal infection (e.g., Aspergillus) may also cause tracheobronchitis. A sputum culture is essential to identify the specific causative organism.
The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated? PaO2 greater than 60 mm Hg with an FiO2 less than 40% Heart rate less than100 bpm Blood pressure increase of 20 mm Hg from baseline Vital capacity of 12 mL/kg
Blood pressure increase of 20 mm Hg from baseline In collaboration with the primary provider, the nurse would terminate the weaning process if adverse reactions occur, including a heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement. A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume of 7 to -9 mL/kg, minute ventilation of 6 L/min, and a rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria that indicate a client is ready to be weaned from the ventilator. A normal vital capacity is 10 to 15 mL/kg.
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? Direct lung damage Aspiration Chemical irritation Drug ingestion
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 caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? Moderate amounts of colorless sputum Chest tube drainage, 190 mL/hr Heart rate, 112 bpm Pain of 5 on a 1-to-10 scale
Chest tube drainage, 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required.
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Hypoxemic hypoxia Circulatory hypoxia Anemic hypoxia Histotoxic hypoxia
Circulatory hypoxia Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective? Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays Legislation that requires homes and apartments be checked for asbestos leakage Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes Classes at community centers to teach about smoking cessation strategies
Classes at community centers to teach about smoking cessation strategies Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.
A 72-year-old patient who was admitted to the hospital for a total hip arthroplasty has developed increasing dyspnea and leukocytosis over the past 48 hours and has been diagnosed with hospital-acquired pneumonia (HAP). The choice of antibiotic therapy for this patient will be primarily based on which of the nurse's assessments? Assessment of the patient's activities of daily living Analysis of the patient's leukocytosis and the white blood cell (WBC) differential Collection of a sputum sample for submission to the hospital laboratory Auscultation and percussion of the patient's thorax
Collection of a sputum sample for submission to the hospital laboratory Choice of antibiotic therapy is based primarily on the patient's history and the results of sputum cultures. Blood work and chest auscultation confirm the diagnosis of pneumonia but do not typically inform the choice of antibiotic.
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Continuous positive airway pressure (CPAP) Medications to assist the patient with sleep at night Bi-level positive airway pressure (BiPAP) Surgery to remove the tonsils and adenoids
Continuous positive airway pressure (CPAP) CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? Shortness of breath Cough or change in chronic cough Obvious trauma Pain on inspiration
Cough or change in chronic cough A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Administering oxygen, coughing, breathing deeply, and maintaining bed rest 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 patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Ascites Hypertension Dyspnea Syncope
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 a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Dyspnea and wheezing Nonproductive cough and normal temperature Sore throat and abdominal pain Hemoptysis and dysuria
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 nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Incentive spirometry and deep breathing and coughing exercises Maintenance of SpO2 levels ≥90% using supplementary oxygen Early ambulation and the use of compression stockings Passive range of motion exercises for the upper and lower extremities
Early ambulation and the use of compression stockings For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.
A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Maintenance of SpO2 levels ≥90% using supplementary oxygen Passive range of motion exercises for the upper and lower extremities Early ambulation and the use of compression stockings Incentive spirometry and deep breathing and coughing exercises
Early ambulation and the use of compression stockings For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.
Which intervention does a nurse implement for clients with empyema? Do not allow visitors with respiratory infections Place suspected clients together Encourage breathing exercises Institute droplet precautions
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 client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? Restrict intravenous fluids for at least 24 hours. Assist with positioning the client on the right side. Encourage coughing to mobilize secretions. Make sure that a thoracotomy tube is linked to open chest drainage.
Encourage coughing to mobilize secretions. The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. The chest tube is always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration.
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Encourage increased fluid intake. Give antibiotics as ordered. Offer nutritious snacks 2 times a day. Place client on bed rest.
Encourage increased fluid intake. The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Turning the client every 2 hours Elevating the head of the bed 30 degrees Maintaining a cool room temperature Encouraging increased fluid intake
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 nurse knows the mortality rate is high in lung cancer clients due to which factor? Few early symptoms Increased exposure to industrial pollutants Increased incidence among the elderly Increase in women smokers
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.
The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? Fibrotic changes in lungs Lung contusion Damage to surrounding tissues Hemorrhage
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? Insist on adequate breaks for each employee. Fit all employees with protective masks. Give workshops on disease prevention. Provide employees with smoking cessation materials.
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? ARDS Flail chest Tension pneumothorax Pneumothorax
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.
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? Flail chest Pulmonary contusion Cardiac tamponade Simple pneumothorax
Flail chest When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? Impaired physical mobility related to being on a ventilator Risk for trauma related to endotracheal intubation and cuff pressure Risk for infection related to endotracheal intubation and suctioning Impaired gas exchange related to ventilator setting adjustments
Impaired gas exchange related to ventilator setting adjustments All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.
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 the strengthening of the client's diaphragm Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote more efficient and controlled ventilation and to decrease the work of breathing 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 client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A disconnected ventilator circuit A change in the oxygen concentration without resetting the oxygen level alarm An ET cuff leak Kinking of the ventilator tubing
Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? Decreased urinary output Localized calf tenderness Coolness to lower extremities Pain in the feet
Localized calf tenderness If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen? Nasal cannula Nonrebreather mask Simple mask Face tent
Nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
Which oxygen administration device has the advantage of providing a high oxygen concentration? Face tent Venturi mask Nonrebreathing mask Catheter
Nonrebreathing mask The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? pH HCO3 PaO2 PCO2
PaO2 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.
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 Sudden loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function 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.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Deflating the cuff before removing the tube Ensuring that humidified oxygen is always introduced through the tube Routinely deflating the cuff Checking the cuff pressure every 6 to 8 hours
Routinely deflating the cuff Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth. The nurse instructs the client, when using the incentive spirometer, the proper use of it. First, the client is to sit in an upright position. The client is then to place the mouthpiece of the spirometer in the client's mouth. Next, the client breathes air in through the mouth. This causes the incentive spirometer to be activated. The client holds his breath for about 3 seconds. Then, the client exhales slowly through the mouth.
The most diagnostic clinical symptom of pleurisy is: Dullness or flatness on percussion over areas of collected fluid. Stabbing pain during respiratory movements. Dyspnea and coughing. 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 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? Pseudomonas aeruginosa Mycobacterium tuberculosis Streptococcus pneumoniae Staphylococcus aureus
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 client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator. Check for an apical pulse. Suction the client's artificial airway.
Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Insidious onset of lung impairment in a client who had normal 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 compromised lung function Sudden 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.
A mediastinal shift occurs in which type of chest disorder? Cardiac tamponade Tension pneumothorax Simple pneumothorax 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? Pulmonary contusion Tension pneumothorax Flail chest Cardiac tamponade
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? The client exhibits restlessness and confusion. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits bronchial breath sounds over the affected area.
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.
The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.
The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is in a hypermetabolic state. The patient is hypoxic from suctioning. The patient is having a stress reaction. The patient is having a myocardial infarction.
The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The client has a pneumothorax. The system is functioning normally. The chest tube is obstructed. The system has an air leak.
The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The system has an air leak. The chest tube is obstructed. The client has a pneumothorax.
The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
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 sensation when palpated. Bloody drainage is observed in the collection chamber. Skin around tube is pink. Absence of bloody drainage in the anterior/upper tube
The tissues give a crackling sensation 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.
A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? Troubleshoot to identify the malfunction. Reposition the endotracheal tube. Manually ventilate the client. Notify the respiratory therapist.
Troubleshoot to identify the malfunction. The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm.
A nurse is aware that the diagnostic feature of ARDS is sudden: Diminished alveolar dilation. Tachypnea Unresponsive arterial hypoxemia. Increased PaO2
Unresponsive arterial hypoxemia. Clinically, the acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs 12 to 48 hours after the initiating event. A characteristic feature is arterial hypoxemia that does not respond to supplemental oxygen.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? T-piece Partial-rebreathing mask Nasal cannula Venturi mask
Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin E Vitamin B6 Vitamin D Vitamin C
Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Time cycled Negative pressure Volume cycled Pressure cycled
Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Collection chamber Suction control chamber Water-seal chamber Air-leak chamber
Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: encourage coughing and deep breathing. clamp the chest tube once every shift. report fluctuations in the water-seal chamber. milk the chest tube every 2 hours.
encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
Class 1 with regard to TB indicates no exposure and no infection. exposure and no evidence of infection. disease that is not clinically active. 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 client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: 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. area of redness is measured in 3 days and determines whether tuberculosis is present. 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. 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 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? A blister 15-mm induration 5-mm induration Reddened area
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.
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? 3 months 6 to 12 months 13 to 18 months 3 to 5 months
6 to 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.
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: Administer prescribed pain medication. Notify the physician. Assess pulse and blood pressure. Lay the client's head to a flat position.
Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.
