Incorrect PrepU- Exam 3- Ch 23- Management of Patients With Chest and Lower Respiratory Tract Disorders

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? a) "The tube will drain air from the space around the lung." b) "The tube will drain secretions from the lung." c) "Chest tube will allow air to be restored to the lung." d) "Chest tubes provide a route for medication instillation to the lung."

"The tube will drain air from the space around the lung." Explanation: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range? a) 3.0 to 3.5 b) 0.5 to 1.0 c) 1.5 to 2.5 d) 2.0 to 2.5 Submit your answer

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

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.46, PaO2 80 mm Hg b) pH 7.36, PaCO2 32 mm Hg c) pH 7.35, PaCO2 48 mm Hg d) pH 7.28, PaO2 50 mm Hg

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? You selected: pH 7.28, PaO2 50 mm Hg Correct Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Anxiety b) Impaired gas exchange c) Ineffective tissue perfusion (cardiopulmonary) d) Decreased cardiac output

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? You selected: Impaired gas exchange Correct Explanation: 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.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis

Acute respiratory distress syndrome Explanation: 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. Options A, C and D are incorrect.

You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Acute respiratory distress syndrome b) Lung cancer c) Tracheobronchitis d) Bronchitis

Acute respiratory distress syndrome Explanation: 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.

Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women? a) Squamous cell carcinoma b) Large cell carcinoma c) Adenocarcinoma d) Small cell carcinoma

Adenocarcinoma Explanation: Adenocarcinoma presents more peripherally as peripheral masses or nodules and often metastasizes. Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. Small cell carcinomas arise primarily as proximal lesions, but may arise in any part of the tracheobronchial tree.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? a) Auscultate breath sounds bilaterally every 4 hours. b) Instruct the client to breathe into a paper bag. c) Encourage the client to deep-breathe and cough every 2 hours. d) Administer oxygen by nasal cannula as ordered.

Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? a) Pollen b) Asbestos c) Silica d) Coal dust

Asbestos Explanation: Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.

Nursing instruction during postural drainage should include telling the patient to: a) Lie supine to rest the lungs. b) Remain in each position for 30 to 45 minutes for best results. c) Change positions frequently and cough up secretions. d) Sit upright to promote ventilation.

Change positions frequently and cough up secretions. Explanation: Patients 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 (see Fig. 10-2 in the text), secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.

You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a) Drug ingestion b) Direct lung damage c) Chemical irritation d) Aspiration

Chemical irritation Explanation: 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 patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? a) "It is all right if I have a grilled cheese sandwich with American cheese." b) "It is all right if I drink a glass of red wine with my dinner." c) "I am going to have a tuna fish sandwich for lunch." d) "It is fine if I eat sushi with a little bit of soy sauce."

Correct response: "It is all right if I have a grilled cheese sandwich with American cheese." Explanation: Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Chest pain on inspiration b) Clubbing of fingers and toes c) Respiratory acidosis d) Paradoxical chest movement

Correct response: Paradoxical chest movement Explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall 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.

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? a) Coughing b) Dyspnea c) Copious sputum production d) Severe pain

Coughing Explanation: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection.

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? a) Low-pitched rhonchi during expiration b) Pleural friction rub c) Crackles in the lung bases d) Sibilant wheezes

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

What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.

A Class 1 with regards to TB indicates a) exposure and no evidence of infection. b) latent infection with no disease. c) no exposure and no infection. d) disease that is not clinically active.

Exposure and no evidence of infection. Correct Explanation: Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active.

Which of the following clinical manifestations of hemorrhage is related to carotid artery rupture? a) Increased pulse rate b) Increased blood pressure c) Dry skin d) Shallow respirations

Increased pulse rate Explanation: The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active bleeding.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? a) Decreased level of consciousness (LOC) b) Increased blood pressure c) Decreased heart rate d) Increased restlessness

Increased restlessness Explanation: In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Risk for Infection b) Ineffective Airway Clearance c) Impaired Gas Exchange d) Ineffective Breathing Pattern

Ineffective Airway Clearance Explanation: The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.

A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Schedule the patient for pulmonary surgery c) Increase oxygen administration d) Intubate the patient and control breathing with mechanical ventilation

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

Which of the following community-acquired pneumonias demonstrates the highest occurrence during summer and fall? a) Legionnaires' disease b) Streptococcal (pneumococcal) pneumonia c) Viral pneumonia d) Mycoplasmata pneumonia

Legionnaires' disease Explanation: Legionnaires' disease accounts for 15% of community-acquired pneumonias. Streptococcal pneumonia demonstrates the highest occurrence in winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter. Viral pneumonia demonstrates the greatest incidence during winter months.

Which of the following is a key characteristic of pleurisy? a) Anxiety b) Dyspnea c) Pain d) Blood-tinged secretions

Pain Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? a) Inability to dorsiflex b) Pain in the calf c) Pain in the feet d) Negative Homan's sign

Pain in the calf Explanation: When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis.

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? a) Myocardial infarction (MI) b) Heart failure c) Pneumothorax d) Pulmonary embolism

Pneumothorax Explanation: 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.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) See if the wall suction unit has malfunctioned. b) See if there are leaks in the system. c) See if a kink has developed in the tubing. d) See if the chest tube is clogged.

See if there are leaks in the system. Explanation: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

The most diagnostic clinical symptom of pleurisy is: a) Stabbing pain during respiratory movements. b) Dyspnea and coughing. c) Fever and chills. d) Dullness or flatness on percussion over areas of collected fluid.

Stabbing pain during respiratory movements. Explanation: 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.

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an increase in the death rates of pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza? a) Staphylococcal pneumonia b) Tracheobronchitis c) Cardiovascular disease d) Viral pneumonia

Staphylococcal pneumonia Explanation: Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease. Staphylococcal pneumonia is the most serious complication. Although tracheobronchitis is a complication of the flu, it is not the most serious one. Although cardiovascular disease is a complication of the flu, it is not the most serious one. Bacterial, not viral, pneumonia is a possible complication of the flu, although not its most serious one.

A mediastinal shift occurs in which type of chest disorder? a) Tension pneumothorax b) Traumatic pneumothorax c) Cardiac tamponade d) Simple pneumothorax

Tension pneumothorax Explanation: A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client exhibits bronchial breath sounds over the affected area. b) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. c) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. d) The client exhibits restlessness and confusion.

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

The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Inspiratory crackles b) Rapid onset of severe dyspnea c) Bilateral wheezing d) Cyanosis

The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? You selected: Rapid onset of severe dyspnea Correct Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event

Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall? a) Use a prescribed analgesic. b) Use a heat or cold application. c) Avoid using a pillow while splinting. d) Turn onto affected side.

Turn onto affected side. Explanation: 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.

Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall? a) Elevate the head of the bed b) Turn onto the affected side c) Use a prescribed analgesic d) Use a heat application

Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain.

The nurse is caring for a patient with suspected ARDS with a pO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? a) Increased PaO2 b) Unresponsive arterial hypoxemia c) Diminished alveolar dilation d) Tachypnea

Unresponsive arterial hypoxemia Correct Explanation: 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 ( Dushianthan, Grott, Postle, et al., 2011).

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? a) Using strict hand hygiene b) Keeping the head of the bed at 15 degrees or less c) Turning the client every 4 hours to prevent fatigue d) Providing oral hygiene daily

Using strict hand hygiene Explanation: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperoxemia, hypocapnia, and hyperventilation b) Hyperventilation, hypertension, and hypocapnia c) Hypotension, hyperoxemia, and hypercapnia d) Hypercapnia, hypoventilation, and hypoxemia

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? You selected: Hypercapnia, hypoventilation, and hypoxemia Correct Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

The most diagnostic clinical symptom of pleurisy is: a) Dyspnea and coughing. b) Fever and chills. c) Dullness or flatness on percussion over areas of collected fluid. d) Stabbing pain during respiratory movements.

You selected: Stabbing pain during respiratory movements. Correct Explanation: 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 patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Bloody, productive cough b) Sucking sound at the site of injury c) Diminished breath sounds d) Decreased respiratory rate

b) Sucking sound at the site of injury

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) empyema. b) lobar pneumonia. c) infected chest tube wound site. d) Pneumocystis carinii pneumonia.

empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.