Chapter 21: Caring for Clients with Lower Respiratory Disorders

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?

"My cough has changed from a dry cough to one with lots of sputum production." 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.

A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." The objective of management is to provide a cure, if possible. Treatment depends on the cell type, the stage of the disease, and the patient's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend primarily on the patient's age, or the patient's preference between the different treatment modes. The decision surrounding treatment does not depend solely on a discussion between the patient and the health care provider over which treatment is best, although patient preferences are an important consideration.

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?

"The younger you are when you start smoking, the higher your risk of lung cancer." Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor.

A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend?

"Wear protective attire and devices when working with a toxic substance." When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range?

2.0 to 2.5 Low-molecular- weight heparin and fondaparinux (Arixtra) are the cornerstones of therapy, but IV unfractionated heparin may be used during the initial phase (ACCP, 2012). The early maintenance phase of anticoagulation typically consists of overlapping regimens of heparins or fondaparinux for at least 5 days with an oral vitamin K antagonist (e.g., warfarin [Coumadin]). A 3- to 6-month regimen of long-term maintenance with warfarin is typical but depends on the risks of recurrence and bleeding (ACCP, 2012). Heparin must be continued until the INR is within a therapeutic range, typically 2.0 to 3 (Kearon, Kahn, Agnelli, et al., 2008).

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an increase in the death rates of pneumonia and cardiovascular disease. How many deaths were attributed to influenza in 2008?

36,000 More than 200,000 people are hospitalized and approximately 36,000 people die (CDC, 2008).

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 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.

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

6 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.

A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.

A chest radiograph Complete history and physical examination Drug susceptibility testing Once a client had a positive skin test or a positive sputum culture for acid-fast bacilli, additional tests such as complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing are done. The nurse does not need to teach about a complete blood count or a repeat multiple puncture skin test, as the initial positive skin test will serve as the indicator of 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 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.

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care. HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem?

Acute respiratory failure Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.

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

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

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax?

Diminished or absent breath sounds on the affected side In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?

Early ambulation For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.

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?

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.

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?

Elevated B-type natriuretic peptide (BNP) levels Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. Cardiogenic pulmonary edema is an acute event that results from heart failure, in which the cardiac chambers release atrial natriuretic peptide (ANP) and BNP to promote vasodilation and diuresis. BNP levels are not similarly elevated with ARDS.

Which intervention does a nurse implement for clients with empyema?

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

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

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

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

Flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

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

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

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?

Increase oral fluids unless contraindicated. The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

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

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

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

Intubate the client and control breathing with mechanical ventilation A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply.

Level of consciousness Arterial blood gases Vital signs Clients are usually treated in the ICU. The nurse assesses the client's respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.

A client is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the client's oxygenation status at the bedside?

Monitor pulse oximetry readings. The nurse assesses the client with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status.

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

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

When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of hypoxemia?

PaO2 < 60 mm Hg Hypoxemia is a decrease in the arterial oxygen content or arterial oxygen tension (partial pressure of oxygen = PaO2) and is measured by arterial blood gas analysis (ABG) or pulse oximetry (POX). Hypoxemia is defined as a PaO2 of less than 60 mm Hb and/or a POX of less than 90%. When administering oxygen to a patient, a nurse must keep in mind that oxygen transport to the tissues is not dependent solely on the arterial oxygen content.

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

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

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

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

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

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

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

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

A client is brought to the ED after aspirating large amounts of water and nearly drowning. This client is at risk for which complication as a result of this recent trauma?

acute respiratory distress syndrome (ARDS) Some of the factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug or alcohol ingestion/overdose; hematologic disorders; and direct damage to the lungs through prolonged smoke inhalation or corrosive substances. Empyema may follow chest trauma, such as a stab or gunshot wound, or a preexisting disease, such as pneumonia or TB. TB is a bacterial infectious disease primarily caused by Mycobacterium tuberculosis. Bronchiectasis, found in clients with COPD, is characterized by chronic infection and irreversible dilatation of the bronchi and bronchioles. It is caused by a tumor or foreign body, congenital abnormalities, exposure to toxic gases, and chronic pulmonary infections.

A resident in the long-term care facility has been experiencing a chronic, productive cough for the last 3 months. The client tells the nurse "this is just my winter cough." This client most likely has which condition?

chronic bronchitis Chronic bronchitis is a prolonged (or extended) inflammation of the bronchi, accompanied by a chronic cough and excessive production of mucus for at least 3 months each year for 2 consecutive years. Heart failure is a possible complication of many upper respiratory disorders, including pneumonia and pleural effusion. Septicemia refers to infective microorganisms in the blood, a possible complication of pneumonia. Atelectasis is the collapse of alveoli, which may involve a small portion of the lung or an entire lobe. It is a complication of COPD.

Class 1 with regard to TB indicates

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 7.28, 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.

Preventing falls in older adults directly correlates to preventing bone fractures. If an older adult falls and fractures one or more ribs, what is a possible complication that could develop after the fracture?

pneumonia Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to pneumonia after a rib fracture.

A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.

vaccinations hand antisepsis A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.