Chapter 23

Which intervention does a nurse implement for clients with empyema?

Encourage breathing exercises

The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

acute respiratory distress syndrome

On auscultation, which finding suggests a right pneumothorax?

Absence of breath sounds in the right thorax

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

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

aspiration pneumonia

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

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

tachypnea

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?

"Viruses like influenza are the most common cause of pneumonia."

An emergency room nurse is assessing a client who is complaining of dyspnea. Which sign would indicate the presence of a pleural effusion?

Decreased chest wall excursion upon palpation

What is the reason for chest tubes after thoracic surgery?

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

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange

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?

Rapid onset of severe dyspnea

Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?

Turn onto the affected side.

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?

Using strict hand hygiene

A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan?

Wearing a disposable particulate respirator that fits snugly around the face

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

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

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

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

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Pneumothorax

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

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.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

Significant

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

continue to take antibiotics for the entire 10 days.

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?

15mm induration

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?

"You must consume a diet rich in protein, such as chicken, fish, and beans."

A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?

"You should switch to wearing your glasses while taking this medication."

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

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.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

Airborne and contact precautions

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?

Blood-tinged sputum

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Cough or change in chronic cough

A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?

Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

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.

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

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 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 nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?

Shortness of breath

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

The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer?

Symptoms often do not appear until the disease is well established

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Tension pneumothorax

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

Vitamin B6

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

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?

acute respiratory distress syndrome

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:

asbestos

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?

chemical irritation

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

plueral effusion

A mediastinal shift occurs in which type of chest disorder?

tension pneumothorax