Chapter 27 - Lower Respiratory Problems

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher. b. Blood cultures from two sites. c. Ciprofloxacin (Cipro) 400 mg IV. d. Acetaminophen (Tylenol) suppository.

Answer: b. Blood cultures from two sites. Rationale: Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation. b. Reasons for annual sputum cytology testing. c. Erlotinib (Tarceva) therapy to prevent tumor risk. d. Computed tomography (CT) screening for cancer. e. Importance of obtaining a yearly influenza vaccination

Answer: A, D, E Rationale: Because smoking is the major cause of lung cancer, an important role for the nurse is teaching patients about the benefits of and means of smoking cessation. Screening for using low-dose CT is recommended for high-risk patients Encourage those at risk for pneumonia (e.g., those who smoke) to obtain both influenza and pneumococcal vaccines. Sputum cytology is a diagnostic test but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

Answer: c. Medicate the patient with prescribed morphine. Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

Answer: a. Auscultate for breath sounds. Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

Answer: a. Document the amount of drainage every 8 hours. Rationale: UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

Answer: a. O2 saturation is 88%. Rationale: O2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

Answer: a. Observe for distended neck veins. Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 77-yr-old patient with tuberculosis (TB) who has four medications due. b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath. c. A 35-yr-old patient with pneumonia who has a temperature of 100.2° F (37.8° C). d. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled.

Answer: b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath. Rationale: Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

Answer: b. A surgical face mask is applied before visiting the patient. Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.

Answer: b. Continue to monitor the collection device. Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.

Answer: b. Place a patient with altered consciousness in a side-lying position. Rationale: With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."

Answer: c. "My spouse will sleep in another room." Rationale: Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."

Answer: c. "Tell me what you know about the treatments available." Rationale: More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy. b. Ways to limit oral fluid intake. c. Appropriate use of cough suppressants. d. Safety concerns with home O2 therapy.

Answer: c. Appropriate use of cough suppressants Rationale: Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours. b. Positioning only on the right side. c. Frequent use of an incentive spirometer. d. Chest tube placement to continuous suction.

Answer: c. Frequent use of an incentive spirometer. Rationale: Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg

Answer: c. Patient reports a decrease in exertional dyspnea Rationale: Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? a. Remind the patient not to eat or drink 6 hours. b. Start a peripheral IV line to administer sedation. c. Position the patient sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.

Answer: c. Position the patient sitting up on the side of the bed. Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.

Answer: c. Teach the patient about providing specimens for 3 consecutive days. Rationale: Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used to test for tuberculosis. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis. b. Teaching family members about the need for careful hand washing. c. Teaching patients about the need for adult pertussis immunizations. d. Encouraging patients to complete the prescribed course of antibiotics.

Answer: c. Teaching patients about the need for adult pertussis immunizations. Rationale: The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

Answer: d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?" Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

Answer: d. "I will call the health care provider right away if I develop a fever." Rationale: Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

Answer: d. "I will use the incentive spirometer every hour or two during the day." Rationale: Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis. b. Stabilization of the chest wall. c. Bronchodilator administration. d. Chest tube connected to suction.

Answer: d. Chest tube connected to suction. Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

Answer: d. Elevate the head of the bed to a semi-Fowler's position. Rationale: The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be performed after the head is elevated and O2 is started. The health care provider may order a spiral CT to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? a. Fatigue b. Hyperthermia c. Impaired mobility d. Impaired gas exchange

Answer: d. Impaired gas exchange. Rationale: All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

Answer: d. Piperacillin/tazobactam (Zosyn) Rationale: Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.

Answer: d. Tape a nonporous dressing on three sides over the wound. Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Assist the patient with chest physiotherapy and postural drainage. b. Teach the patient to avoid the use of over-the-counter expectorants. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

Answer: d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. Rationale: Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.

Answer: d. The patient is being treated with antiretrovirals for HIV infection. Rationale: Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.

Answer: d. UAP lowers the head of the patient's bed to 15 degrees. Rationale: Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.