Chapter 28 Influenza (flu), Pandemics (COVID-19), Pneumonia, and Tuberculosis (TB)

Which information for a patient who is beginning treatment of tuberculosis helps to ensure suppression of the disease? "Eat a diet rich in vitamin K." "Do not drink alcoholic beverages." "Take the medication exactly as prescribed." "Contact the health care provider if you feel ill."

"Take the medication exactly as prescribed." Rationale It is most important for the nurse to teach the patient to take the medication regularly, exactly as prescribed, for as long as it is prescribed to ensure adequate suppression of the disease. The patient should be instructed to eat a diet rich in vitamins B and C. A diet rich in vitamin K will not assist the patient in any way. Staying away from alcoholic beverages will prevent liver damage from the medications, but it will not ensure suppression of the disease. It is important for the patient to understand that the health care provider should be contacted in the case of illness; however, it will not ensuresuppression of the disease. p. 578

The emergency department (ED) manager is reviewing client charts to determine how well the staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission. b. Blood cultures obtained within 20 minutes. c. Chest x-ray obtained within 30 minutes. d. Pulse oximetry obtained on all clients.

ANS: A Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inclient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a. "Breathing so quickly can be dehydrating." b. "Everyone with pneumonia is dehydrated." c. "This is really just to administer your antibiotics." d. "Why do you think you are so dehydrated?

ANS: A Tachypnea and mouth breathing (from increased work of breathing), both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information that addresses this specific concern.

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse that the precautions are meant to keep other clients safe. c. Show the spouse how to follow the Isolation Precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

ANS: A The nurse needs to obtain further information about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining Isolation Precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse that it's safe to visit is demeaning of the spouse's feelings.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

ANS: A The treatment regimen for TB often ranges from 26 weeks, but can be up to 2 years, making adherence problematic for many people. The nurse would stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

A nurse admits a client from the emergency department. Client data are listed below: History: ° 70 years of age ° History of diabetes ° On insulin twice a day ° Reports new onset dyspnea and productive cough Physical Assessment: ° Crackles and rhonchi heard throughout the lungs ° Dullness to percussion LLL ° Afebrile ° Oriented to person only LABS: ° WBC 5,200/mm3 (5.2 × 109/L) ° PaO2 on room air 85 mm Hg What action by the nurse is the priority? a. Administer oxygen at 4 L per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.

ANS: A All actions are appropriate for this client who has signs and symptoms of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics

A client has been diagnosed with an empyema. What interventions would the nurse anticipate providing to this client? (Select all that apply.) a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed e. Suctioning deeply every 4 hours

ANS: A, B, C, D The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse would perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.

ANS: A, B, E, F The nurse would teach the client that preexisting gout may get worse and the client should report this as medications for gout may need to be adjusted. The nurse would also inform the client about the multi-drug routine used for TB. Optic neuritis can occur with this drug so the client needs to report visual changes right away. The medication should be taken with a full glass of water. Drinking while taking ethambutol causes severe nausea and vomiting. Avoiding antacids and food (within 2 hours) is a precaution with isoniazid

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. A 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

ANS: A, C, D, E Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/µL (5.2 × 1012/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5 × 109/L)

ANS: B INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best? a. "Chest x-rays are always ordered when we suspect pneumonia." b. "Older people often have vague symptoms, so an x-ray is essential." c. "The x-ray can be done and read before laboratory work is reported." d. "We are testing for any possible source of infection in the client."

ANS: B It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive signs and symptoms are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has symptoms of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Inquire as to recent travel outside the United States. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

ANS: B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Preventing the spread of disease is vital. The nurse would ask the "clients" about recent overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to be in Contact and Airborne Precautions the infectious organism is identified and routes of transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions are not appropriate.

A client in the emergency department is taking rifampin for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL (6.7 mmol/L) b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L (130 mmol/L) e. White blood cell (WBC) count: 72,000/mm3 (72 × 109/L)

ANS: B, C Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.

A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective? a. "I need to take extra vitamin C while on isoniazid." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

ANS: C Isoniazid needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin.

A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C Oral colonization by gram-negative bacteria is a risk factor for health care-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the AP. Encouraging good nutrition is important, but this will not prevent pneumonia.Monitoring temperature and reporting new cough in clients are important to detect the onset of possible pneumonia but do not prevent it.

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: (TB test) The reddened area is firm. What action by the nurse is best? a. Assess the client for possible items to which he or she is allergic. b. Call the primary health care provider's office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

ANS: C This "allergy test" is actually a positive tuberculosis test. The client would be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting nurses for directly observed therapy

ANS: D Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir. b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

ANS: D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have symptoms of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client would be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? High fever Profound bradycardia Acute confusion Coughing spasms

Acute confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Tachycardia is triggered by hypoxia, not bradycardia.

Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? Administer oxygen to prevent hypoxemia and atelectasis. Administer the prescribed bronchodilator therapy to decrease bronchospasms. Encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration. Maintain semi-Fowler position to facilitate breathing and prevent further fatigue

Administer the prescribed bronchodilator therapy to decrease bronchospasms. Although all actions are helpful and important, bronchodilator therapy is performed first to increase the size of the airways to improve clearance.

Which patient characteristic increases the risk for tuberculosis (TB)? Select all that apply. One, some, or all responses may be correct. Alcohol abuse History of congestive heart failure Recent emigration from Spain Lack of a permanent residence Recent release from a correctional facility

Alcohol abuse Lack of a permanent residence Recent release from a correctional facility Rationale People who are most at risk for the development of TB are those who are in close contact with, among others, people who abuse drugs or alcohol, older homeless people, and people who live in crowded facilities such as homeless shelters or prisons. A person with congestive heart failure and someone who is a recent immigrant from Spain would not be at risk for TB. p. 576

Which patient should receive education about pneumococcal vaccine? Select all that apply. One, some, or all responses may be correct. An adult older than 65 A patient who is pregnant A patient who is human immune deficiency virus (HIV) positive A patient who has alcoholism A patient with chronic lung disease

An adult older than 65 A patient who is human immune deficiency virus (HIV) positive A patient who has alcoholism A patient with chronic lung disease Rationale Patients that should receive education about a pneumococcal vaccine include patients who are older than 65, have alcoholism, are HIV positive, or have a chronic lung disease. A patient who is pregnant does not need to receive education about pneumococcal vaccines because this is not necessarily recommended for every pregnant patient. p. 570

A nurse interviewing an 82-year-old somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? "Your mother is older now and is more fragile, so she should have one this year too as a booster." "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." "The "flu shot" she had 2 years ago will still protect her this year but if she has not had a previous pneumonia vaccination, she should have one now." "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

Answer: B Rationale: A is incorrect because each year's influenza vaccine is composed of some different strains of antigen and is not really a booster. C is incorrect because the older vaccination may not contain the viral antigens most likely to cause influenza this season. The nasal mist vaccination is not recommended for anyone over age 49 years.

A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? Encourage the client to use the incentive spirometer hourly. Increase her O2 flow rate by 2 L and re-assess in 5 minutes. Increase the flow rate of the IV antibiotic. Document the changes as the only action.

Answer: B Rationale: The low oxygen saturation and the client's confusion suggests hypoxia and a possible worsening of the client's condition. The increased respiratory rate supports this possibility. Increasing the oxygen flow rate and re-assessing in 5 minutes helps the nurse to determine whether the hypoxia responds to increased oxygen. If more oxygen is going to help, it will do so quickly. Even if the oxygen saturation increases with more oxygen, the health care provider needs to be informed of these events urgently. The incentive spirometer is not likely to be performed correctly with a confused client and would not immediately improve the client's hypoxia. Increasing the flow rate of the antibiotic also is not going to help the hypoxia immediately.

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F (39.7 degrees C). What is the nurse's primary concern for this client? The client may not be taking the prescribed antiviral drug correctly A second strain of influenza is likely Pneumonia may be present The client may be dehydrated

Answer: C Rationale: A major and relatively common complication of severe seasonal influenza is development of pneumonia. It is likely this client's influenza was severe because hospitalization was required. The client would no longer be receiving the antiviral drug after discharge. A second strain of influenza is not likely in this context. Temperature elevation from dehydration is usually less dramatic.

A nursing home client who has completed a 2 week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheel chair. What is the nurse's best response? "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." "No, the risk that you could spread this disease to other people is much too high." "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." "Yes, if you agree to wear a face mask to prevent spreading droplets."

Answer: C Rationale: The client is no longer contagious after completing the course of antibiotics and is just in the recovery phase of the illness. If he feels rested enough to be up in a wheel chair, there is no reason he must be isolated physically or socially. A face mask is not needed to protect others.

Which finding would the nurse expect in a patient diagnosed with pneumonia? Pleuritic chest pain Trismus Difficulty swallowing Muffled voice

Pleuritic chest pain Rationale Chest pain from the irritation of the pleural is common with pneumonia. Trismus, difficulty swallowing, and muffled voice are findings associated with peritonsillar abscess. p. 572

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. Blurry vision Constipation Difficulty sleeping Nausea when drinking beer Red-tinged urine Sunburn with minimal sun exposure Yellowing of the sclera

Answers: A, G Blurry vision Yellowing of the sclera Rationale: The drug ethambutol can cause optic neuritis that can lead to blindness. The drug should be stopped and the patient's vision evaluated immediately. Yellowing of the sclera is associated with jaundice from liver problems, which can be serious and life-threatening. The client's liver status must be evaluated immediately. Although nausea when drinking alcohol is an expected side effect of ethambutol, it is a priority to report this change to the health care provider at this time. The nurse needs to explain the side effect to the client and remind him or her that alcohol must be avoided during TB therapy to prevent liver problems. This change only needs to be reported to the health care provider if the client continues to consume alcohol. Difficulty sleeping may or may not be associated with the TB drug therapy. It does not require immediate attention. Red-tinged urine is an expected side effect of rifampin. The nurse reinforces this information to the client to relieve his or her anxiety. The drug pyrazinamide increases photosensitivity. Sunburn is a common side effect that the nurse needs to instruct the client to prevent but does not require immediate attention from the healthcare provider.

Which adults are at higher risk for development of active tuberculosis? Select all that apply. 21-year-old college student living in a dorm at a Canadian university 38-year-old with AIDS who stopped taking antiretroviral therapy 42-year-old injection drug user 50-year-old Guatemalan migrant farm worker 62-year-old incarcerated in prison for 20 years 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

Answers: B, C, D, E Rationale: Active tuberculosis is most likely to develop in adults who are heavily exposed to the organism, such as those living in crowded conditions (prison), from less affluent foreign countries, and anyone who is immunosuppressed (has AIDS and is not taking antiretroviral therapy). Adults who use/abuse injection drugs are also at increased risk because of life style and reduced cognition while under the influence of the drugs. This can result in choices that increase his or her exposure to the organism and may reduce immunity. A healthy 21-year-old living in a dorm in an affluent country is not at increased risk for TB. Having moderate to severe COPD alone does not increase risk for TB unless immunity is greatly reduced.

Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? Arranging for a health care worker to directly observe the client take the drugs Giving the client written instructions about how and when to take the drugs Instructing the client about the consequences of not taking the drugs Having the client repeat the drug names and side effects

Arranging for a health care worker to directly observe the client take the drugs The most effective action for the nurse to take to ensure that the client complies with the treatment regimen is to arrange for the client to be directly observed during therapy. The heroin addiction reduces the client's likelihood of adherence to long-term treatment unless closely supervised while taking the drugs.Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Even if the client can state the names and side effects of the drugs does not indicate understanding of the importance of this therapy.

Which recommendation would the nurse make to a patient and family about the prevention of pneumonia? Select all that apply. One, some, or all responses may be correct. Get plenty of exercise. Avoid indoor pollutants. Eat a healthy, balanced diet. Drink at least 1 L of fluid a day. Avoid crowded areas during flu season and holidays.

Avoid indoor pollutants. Eat a healthy, balanced diet. Avoid crowded areas during flu season and holidays. Rationale The nurse will recommend avoiding indoor pollutants, eating a healthy, balanced diet, and avoiding crowded areas during the flu season and holidays. Getting plenty of exercise and drinking at least 1 L of fluid a day is not included in the education for the prevention of pneumonia. The patient may not be able to exercise, and he or she should be encouraged to drink at least 3 L of nonalcoholic fluid a day. p. 570

A nurse is caring for a patient who is orally intubated and being mechanically ventilated. Which factor regarding an artificial airway increases this patient's risk for developing ventilator-associated pneumonia? Select all that apply. One, some, or all responses may be correct. Bypassing the protective airway mechanisms Altering and decreasing the body's immune response Preventing adequate gas exchange at the cellular level Causing a hyperactive reaction of mucociliary clearance Allowing aspiration of secretions from the oropharynx

Bypassing the protective airway mechanisms Allowing aspiration of secretions from the oropharynx Rationale An artificial airway, or endotracheal tube, bypasses the normal protective airway mechanisms when inserted into the trachea. It also allows aspiration of secretions from the oropharynx and stomach, increasing the risk for developing ventilatorassociated pneumonia. The immune response is not decreased by the presence of an artificial airway. Intubation and mechanical ventilation improve rather than prevent gas exchange at the cellular level. The mucociliary clearance of the lungs may be impaired rather than hyperactive in the presence of an artificial airway. p. 571

Which finding is an adverse effect of ethambutol? Changes in vision Darkening of the urine Yellowing appearance of skin Increased bruising or bleeding

Changes in vision Rationale When taking ethambutol for tuberculosis, the patient should report any vision changes to the health care provider as the medication can cause optic neuritis. Darkening of the urine, yellowing appearance of the skin, and increased bleeding or bruising is associated with liver toxicity or failure and may be seen with isoniazid, rifampin, and pyrazinamide.

Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? Chest tightness and SpO2 of 86% Productive cough and yellow-colored sputum Anorexia and weight loss Intermittent fever and sweating

Chest tightness and SpO2 of 86% Symptoms of COVID-19 are similar to those of seasonal asthma. However, the inflammatory responses occurring in the lungs with serious COVID-19 infection causes lung stiffness with chest tightness and greatly reduced gas exchange. The other symptoms are not specific to COVID-19 or other pandemic respiratory infections.

Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? Client has been afebrile for 48 hours. Oxygen saturation ranges between 90% and 92% on room air. White blood cell count is 16, 000 cells/mm3 (16 × 109/L). Bronchial breath sounds present in lung periphery.

Client has been afebrile for 48 hours. A positive outcome is indicated by the client having been afebrile for 48 hours.Bronchial breath sounds in lung peripheral areas are abnormal. The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The listed count is elevated and indicates continuing infection. The normal oxygen saturation is expected to be above 95%.

Which finding is the most common indicator for pneumonia in an older patient? Fever Cough Confusion Increased white blood cell count

Confusion Rationale The most common indication of pneumonia in an older patient is confusion caused by hypoxemia. Cough and fever may be absent, and the white blood cell count may not be elevated until the infection is severe. Treatment should begin if the older patient is confused. p. 572

Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Decreased level of consciousness Magnetic resonance imaging (MRI) procedure Stroke Chest tube

Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Decreased level of consciousness Stroke The risk for aspiration pneumonia is increased whenever the client has a reduced or absent gas reflex (e.g., decreased level of consciousness, stroke, following local anesthesia for a bronchoscopy procedure), and when a client's lower esophageal sphincter does not close complete. This situation occurs when an NG tube is in place, preventing complete or tight constriction of the sphincter

Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? Assessing the need for an immediate dose of lorazepam Requesting a referral to a social worker for alcohol counseling Drawing blood for aerobic and anaerobic blood cultures Administering intravenous antibiotics

Drawing blood for aerobic and anaerobic blood cultures The nurse will first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed to identify the specific causative organism. Initiating antibiotic therapy before cultures are obtained could affect the results of the culture and possibly delay identification an antibiotic more for the infection. Thus, antibiotic therapy is started after blood for cultures is obtained.Unless this client is a danger to self or staff, giving lorazepam for agitation is not the first action. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

Which clinical manifestation is usually present when an older adult has pneumonia? Select all that apply. One, some, or all responses may be correct. Fever Cough Fatigue Weakness Confusion Poor appetite

Fatigue Weakness Confusion Poor appetite Rationale: The most common manifestation of pneumonia in the older adult is acute confusion from hypoxia. The older adult also typically exhibits weakness, fatigue, and poor appetite when pneumonia is present. Fever and cough may be absent; the white blood cell count may not be elevated until the infection is severe. p. 572

Which symptom of pneumonia may present differently in the older adult than in the younger adult? Fever Headache Wheezing Crackles

Fever Rationale Older adults may not have a fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups. p. 572

Which factor is a pathophysiologic basis for the clinical manifestation of pneumonia? Select all that apply. One, some, or all responses may be correct. Movement of red blood cells into the alveoli causes pleuritic chest discomfort. Suppression of fever with the use of acetaminophen speeds the recovery process in older adults. Fluid accumulation in the receptors of the respiratory system triggers the coughing mechanism. Pulmonary capillary shunting leads to hypoxemia. Stimulation of chemoreceptors and decreased lung compliance lead to an increased respiratory rate and dyspnea.

Fluid accumulation in the receptors of the respiratory system triggers the coughing mechanism. Pulmonary capillary shunting leads to hypoxemia. Stimulation of chemoreceptors and decreased lung compliance lead to an increased respiratory rate and dyspnea. Rationale Fluid accumulation in the receptors of the trachea, bronchi, and bronchioles cause the coughing seen with pneumonia. Pulmonary capillary shunting leads to hypoxemia. Stimulation of chemoreceptors in the respiratory system and the increased work of breathing secondary to decreased lung compliance lead to the clinical manifestation of increased respiratory rate and dyspnea. Movement of red blood cells into the alveoli causes the presence of purulent, blood-tinged, or rust-colored sputum but does not cause chest pain. Fever is secondary to the release of pyrogens that cause the hypothalamus to increase body temperature; this is a normal physiologic response— suppression of or masking the fever will not speed recovery. p. 572

Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? Productive cough and normal temperature Flushed cheeks and increased respiratory rate Hypotension and rapid, weak pulse SpO2 of 86% and confusion

Hypotension and rapid, weak pulse Hypotension and a rapid, weak pulse are indications of dehydration with possible impending sepsis and shock. This condition all result in poor perfusion and can progress to extreme hypoxemia and death. These symptoms require immediate attention and intervention.The other symptoms are expected with pneumonia and do not represent rapid progression to a more serious problem.

What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? Increasing the flow rate of the IV piggy-back antibiotic Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes Assisting the client to a more upright position Reporting the change in status to the client's primary health care provider

Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes The client is becoming increasingly hypoxemic and needs more supplemental oxygen. After oxygen delivery is increased, the nurse will determine the client's response to this action.Although moving the client to a more upright position is not harmful and can increase oxygenation, it is not as effective in managing hypoxemia as increasing the oxygen flow rate. It should be the second action, not the first. Although the pneumonia may be worsening, giving the IV antibiotic at a faster rate is not going to make an immediate difference. In addition, infusing it faster may increase the risk for side effects and adverse effects. Before notifying the primary health care provider, the nurse will assess the client's response to increased oxygen flow rate. If the oxygen saturation has not improved or has decreased further in 5 minutes, the nurse would then immediately notify the primary health care provider.

A patient has been diagnosed with tuberculosis (TB). Which medications would the nurse expect to be prescribed for the patient? Metronidazole, acyclovir, flunisolide, rifampin Isoniazid, rifampin, pyrazinamide (PZA), ethambutol Prednisone, guaifenesin, ketorolac, PZA Salmeterol, cromolyn sodium, dexamethasone, isoniazid

Isoniazid, rifampin, pyrazinamide (PZA), ethambutol Rationale The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB. Metronidazole is used to treat anaerobic bacteria and some parasites but is not effective against TB Acyclovir is used to treat viral infection. Flunisolide is a corticosteroid that is useful in asthma or other airway diseases to prevent wheezing. Prednisone is a steroid. Guaifenesin is a mucolytic. Ketorolac is an NSAID that is used for short-term pain relief. Salmeterol and cromolyn sodium would most likely be given to patients with respiratory difficulties such as poorly controlled asthma from allergic sources. Dexamethasone is a steroid. p. 579

Which statement is true about health care-associated pneumonia (HAP) but not true about community-acquired pneumonia (CAP)? It is likely to be resistant to some antibiotics. The fibrin and edema of inflammation stiffen the lung. Capillary leak spreads the infection to areas of the lung. It requires antibiotics for effective treatment.

It is likely to be resistant to some antibiotics. Rationale HAP is more likely to be resistant to some antibiotics, most likely related to the widespread use of antibiotics in the health care environment. Pneumonia acquired in the community is less likely to be caused by organisms that have been exposed to antibiotics and developed resistance. The fibrin and edema that accompanies the inflammation with pneumonia can stiffen the lung in both CAP and HAP. As red blood cells and fibrin move into the alveoli with pneumonia, the infection spreads to other areas of the lung in both CAP and HAP. Both CAP and HAP require antibiotics for effective treatment. p. 571

Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct. Lethargy Dyspnea Weight gain Night sweats Low-grade fever

Lethargy Night sweats Low-grade fever Rationale Expected assessment findings in a patient diagnosed with tuberculosis include lethargy, night sweats, and a low-grade fever. Dyspnea does not occur with tuberculosis. Weight loss and anorexia occur in patients with tuberculosis. pp. 576-577

Which type of pneumonia is consistent with a chest x-ray report of consolidation in a segment of the patient's left lung? Viral Lobar Bronchial Bacterial

Lobar Rationale Lobar pneumonia manifests as consolidation in a segment or an entire lobe of the lung. Bronchopneumonia manifests as diffusely scattered patches around the bronchi. The pattern of lung involvement does not necessarily indicate that the pneumonia is of viral or bacterial etiology. pp. 57

Which statement provides accurate information about a key difference between seasonal influenza and pandemic influenza? Pandemic influenza has the potential to spread globally because of its highly infectious nature in humans. Seasonal influenza is caused by viral infections; pandemic influenza is more likely to be bacterial in nature. People over the age of 50 who have chronic illness should be vaccinated yearly to decrease the risk for pandemic influenza. Humans have a natural resistance to viral infections found in animals and birds and do not require immunization against pandemic influenza.

Pandemic influenza has the potential to spread globally because of its highly infectious nature in humans. Rationale Mutated animal and bird viruses can be highly infectious to humans and spread globally very quickly because humans have no natural resistance to the mutated virus. Both seasonal and pandemic influenza are caused by viruses. Although there is the potential to develop a monovalent vaccine to a given mutated virus, widespread prophylactic vaccination is not realistic as a preventive measure. People over age 50 with chronic illnesses and those who are immunocompromised should receive a yearly flu vaccine for the seasonal variety. pp. 568-569

Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? Tuberculosis Pneumonia Emphysema Heart failure

Pneumonia Pneumonia is the most common complication of seasonal influenza, especially among older clients. The symptoms of pneumonia include fever that does not resolve and acute confusion.Although heart failure is a complication of pneumonia, it is less common and not accompanied by fever. Neither emphysema nor tuberculosis is a complication of seasonal influenza.

Which infectious agent is responsible for the most common community-acquired pneumonia? Adenovirus Rhinovirus Parainfluenza virus Respiratory syncytial virus

Respiratory syncytial virus Rationale Respiratory syncytial virus is responsible for the most common community-acquired pneumonia. The adenovirus, rhinovirus, and parainfluenza viruses are less common causes of community-acquired pneumonia. p. 571

Which position assumed by a patient with pneumonia leads the nurse to suspect that the patient is developing hypoxia? Side-lying Sitting in tripod position Prone with head of bed flat Supine with head of bed at 30 degree angle

Sitting in tripod position Rationale A patient with hypoxia will assume the tripod position (seated and positioned leaning on the hands, often leaning on an over-the-bed table). The patient who is hypoxic will not assume a side-lying or prone position because these positions will only increase a patient's feelings of inability to obtain enough air. Elevating the head of the bed 30 degrees will not be adequate to relieve the smothering feelings associated with hypoxia. p. 572

Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? Starting an IV line to begin hydration therapy Administering IM influenza vaccination Asking the client when symptoms began Placing the client in a negative air pressure room

Starting an IV line to begin hydration therapy The nurse's first priority is to start an IV line and begin intravenous hydration to maintain perfusion. Older clients with influenza symptoms can develop dehydration quickly because of fever, vomiting, and possible diarrhea.Asking when the symptoms first started is not important. A negative airflow room is not required and is usually in short supply. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority because it takes weeks for full immunity to develop.

Which action to prevent harm has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? Be sure to drink at least 2 L of fluids daily. Take these drugs daily exactly as prescribed. Expect a change in urine color. Wear use sunscreen and wear protective clothing when you are outdoors.

Take these drugs daily exactly as prescribed. The most important action is to take the drugs as prescribed to be effective and to prevent development of drug-resistant tuberculosis organisms. One drug in the regimen does change urine to a reddish color, but this is harmless. Two other drugs cause some degree of photosensitivity and increase the risk for sunburn; however, this is not a reason to stop the therapy.

Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) Those who were treated previously for active tuberculosis Kidney transplant recipients Homeless adults Those who have received bacille Calmette-Guérin (BCG) vaccine Those in the local prison Recent immigrants to the United States

Those who were treated previously for active tuberculosis Kidney transplant recipients Homeless adults Those in the local prison Recent immigrants to the United States Adults who are at highest risk for TB include those who live in crowded areas such as prisons and homeless shelters, those who are recent immigrants to the United States, those who are taking long-term immunosuppressive agents, and those who have already had active TB.Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

A patient with pulmonary tuberculosis is being started on combination therapy. What does the nurse explain to the patient as the purpose of combination therapy? To allow for missed doses To reduce the length of treatment time To treat highly resistant cases of tuberculosis To improve the patient's ability to tolerate medications

To reduce the length of treatment time Rationale Combination medication shortens therapy by months. Tuberculosis medications should be taken as prescribed without missing a dose. Combination therapy reduces the emergence of resistant strains. Medications may be changed based upon the patient's ability to tolerate drugs. p. 578

The nurse notes that the patient has progressive fatigue, anorexia, weight loss, irregular menses, and a low-grade fever. Which condition would the nurse suspect in the patient? Pharyngitis Pneumonia Tuberculosis Rhinosinusitis

Tuberculosis Rationale Progressive fatigue, anorexia, weight loss, irregular menses, and a low-grade fever are clinical signs and symptoms of tuberculosis. Pharyngitis is manifested as throat soreness and dryness, throat pain, pain on swallowing (odynophagia), difficulty swallowing, and fever. Pneumonia is manifested as chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, hemoptysis, and sputum production. Rhinosinusitis is manifested as pain over the cheek radiating to the teeth, and fever, swelling, fatigue, ear pressure, referred pain to the temple, and general facial pain that is worse when bending forward. p. 577

Which risk factor is associated with community-acquired pneumonia (CAP)? Select all that apply. One, some, or all responses may be correct. Use of tobacco Recent aspiration History of chronic lung disease Pneumococcal vaccine more than 5 years ago Presence of gram-negative colonization of the mouth

Use of tobacco Pneumococcal vaccine more than 5 years ago Rationale Risk factors for CAP include smoking and receiving the pneumococcal vaccine longer than 5 years ago. Recent aspiration, chronic lung disease, and gram-negative colonization are risk factors for health care-acquired pneumonia. p. 571

Which laboratory finding regarding the white blood cell (WBC) count would the nurse expect to see for a patient who has pneumonia? WBC 5100/mm 3 WBC 6500/mm 3 WBC 9500/mm 3 WBC 12,000/mm 3

WBC 12,000/mm 3 Rationale An elevated WBC count is associated with bacterial infections such as pneumonia. A WBC count of 12,000/mm is elevated. Any WBC count below 10,000/mm is considered normal. p. 572

What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza? Performing oral care before, as well as after, suctioning the oropharynx Wearing a disposable particulate mask N95 respirator with face shield or goggles Washing hands and donning gloves prior to the procedure Keeping the door to the client room closed

Wearing a disposable particulate mask N95 respirator with face shield or goggles The most important infection control precaution the nurse must take before suctioning a client with any pandemic influenza is to wear a particulate mask respirator with protective eyewear or a face shield to prevent infectious organisms from entering the nurse's mucous membranes and respiratory tract. The door to the room needs to be closed during any care of the client with a pandemic influenza. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.

Which drug reduces the severity of infection and mortality rate during a pandemic flu? Select all that apply. One, some, or all responses may be correct. Zanamivir Oseltamivir Ethambutol Pyrazinamide

Zanamivir Oseltamivir Rationale Zanamivir and oseltamivir are antiviral drugs that reduce the severity of infection and mortality rate when widely distributed during a pandemic flu. Ethambutol and pyrazinamide are first-line drugs for the treatment of tuberculosis. p. 569