Chapter 23 test3
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 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 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.
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.
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.
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
Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? 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.
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? Tachypnea
Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).
Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? 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.
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 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."
The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.
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.
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Unresponsive arterial hypoxemia
Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.
What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary.
After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: Significant
An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.
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
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.
A nurse should include what instruction for the client during postural drainage? Change positions frequently and cough up secretions.
Clients who lie supine will have secretions accumulate in the posterior lung sections, whereas upright patients will pool secretions in their lower lobes. By changing positions, secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.
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
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.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? 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 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
Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
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.
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 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
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.
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? 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.
What dietary recommendations should a nurse provide a client with a lung abscess? 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 client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? Paradoxical chest movement
Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? 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.
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.
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? 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.
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows redness and induration.
The injection site is inspected for redness and palpated for hardening. Drainage at the injection site does not indicate a reaction to the tubercle bacillus. Sloughing of tissue at the injection site does not indicate a reaction to the tubercle bacillus. Bruising of tissue at the site may occur from the injection but does not indicate a reaction to the tubercle bacillus.
The most diagnostic clinical symptom of pleurisy is: 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 nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? A disease process is present
This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? Developing a list of people with whom the client has had contact
To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.
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
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.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? 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 with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? 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.
On auscultation, which finding suggests a right pneumothorax? Absence of breath sounds in the right thorax
In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
A 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.
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 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 nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse? The employee enters the room wearing a gown, gloves, and a mask.
The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. To prevent the spread of infection, a stethoscope, blood pressure cuff, and thermometer for single client use should be kept in the room of a client who requires isolation. Removing all personal protective equipment and washing hands before leaving the client's room are correct procedures.
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.
