NUR 2211 Medical Surgical Nursing Chapter 10: Nursing Management: Patients With Chest and Lower Respiratory Tract Disorders (including end of chapter questions)

A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?

"Client is becoming agitated and complains of pleuritic pain."

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?

"The mucus-secreting glands are abnormal."

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?

"The tube will drain air from the space around the lung."

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6 to 12 months

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate?

A disease process is present.

Which action should the nurse take first when providing care for a client during an acute asthma attack?

Administer prescribed short-acting bronchodilator.

A nurse is caring for a patient diagnosed with lung cancer who has a chest tube. The chest tube has continuous bubbling in the water-seal chamber. What does the nurse understand that this indicates?

An air leak in the system

The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?

Black-streaked sputum

A patient is receiving thrombolytic therapy for treatment of a pulmonary emboli. For what side effect should the nurse must monitor the patient?

Bleeding

A nurse should include what instruction for the client during postural drainage?

Change positions frequently and cough up secretions.

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

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

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

Daily doses of isoniazid, 300 mg for 6 months to 1 year

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?

Early ambulation and the use of compression stockings

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

Impaired gas exchange

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?

Negative

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician.

Which is a key characteristic of pleurisy?

Pain

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Placing the client in respiratory isolation

A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that they will be safe from infecting others approximately how long after initiation of the medication therapy?

Two to 3 weeks after initiation of bactericidal drugs

A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?

Venous thromboemboli

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

Vitamin B6

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

asbestos.

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:

empyema.

Class 1 with regard to TB indicates

exposure and no evidence of infection.

What does a positive Mantoux test indicate?

production of an immune response

A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.

vaccinations hand antisepsis

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?

"My cough has changed from a dry cough to one with lots of sputum production."

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?

Correct use of incentive spirometry

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?

Coughing

The nurse is helping to give Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?

Intradermal injection into the inner forearm

The nurse is performing discharge teaching with a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse tell the patient?

It is important to take the same brand of medicine.

A client continues to report dyspnea on exertion and overall weakness. A pulmonary artery catheter is placed and the mean pulmonary arterial pressure is 35 mm Hg. What condition is the client experiencing?

Pulmonary arterial hypertension

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

Stabbing pain during respiratory movement

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

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

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

Acute respiratory distress syndrome

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

skin test doesn't differentiate between active and dormant tuberculosis infection.

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?

staphylococcal pneumonia

The nurse assesses a patient recently diagnosed with absorptive atelectasis. She is aware that the most common condition that causes the inactivation of surfactant is which of the following?

ARDS

On auscultation, which finding suggests a right pneumothorax?

Absence of breath sounds in the right thorax

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest

The nurse is assessing a patient with a blunt chest trauma due to an MVA. What finding would be indicative of a flail chest?

Paradoxical chest movement

Arterial blood gas analysis would reveal which value related to acute respiratory failure?

pH 7.28

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

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

A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?

0 to 4 mm

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

Chemical irritation

A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention?

Encourage the client to cough

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?

Paradoxical chest movement

The most diagnostic clinical symptom of pleurisy is:

Stabbing pain during respiratory movements.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?

Sudden onset of lung impairment in a client who had normal lung function

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

Tachypnea

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?

Tense and relax muscles in the lower extremities.

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

Tension pneumothorax

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

The nurse assigned to a patient with possible pulmonary edema assesses the patient's lungs. Using auscultation, she identifies a characteristic breath sound diagnostic of pulmonary edema. Which of the following describes that breath sound?

Crackles in the lung bases

A patient is diagnosed with hypoxemic hypoxia. The nurse knows that the etiology directs medical and nursing interventions. Which of the following is the cause?

Decreased oxygen diffusion into the tissues

What is the reason for chest tubes after thoracic surgery?

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

A medical patient developed a new onset of shortness of breath with pulse oximetry (POX) ranging between 70% and 75% and a respiratory rate of 30 to 35 breaths per minute. The patient did not respond to oxygen therapy with nasal prongs and was fitted with a partial rebreathing mask by the respiratory therapist. When maintaining this patient's oxygen delivery system, the nurse should:

Ensure that the reservoir bag remains inflated at all times

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail chest

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

It prolongs exhalation.

Which type of lung cancer is characterized as fast growing and tends to arise peripherally?

Large cell carcinoma

Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?

Receiving vaccinations

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

The tissues give a crackling sensation when palpated.

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?

"It is all right if I have a grilled cheese sandwich with American cheese."

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Acute respiratory distress syndrome

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

Aspiration pneumonia

Which intervention does a nurse implement for clients with empyema?

Encourage breathing exercises

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

Increased restlessness

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:

Ineffective airway clearance.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?

Intubate the client and control breathing with mechanical ventilation

Following thoracic surgery, what should the nurse include in the care plan for a client at risk for impaired gas exchange? Select all that apply.

Monitor vital signs frequently. Reinforce preoperative breathing exercises. Elevate head of bed 30 to 40 degrees as tolerated. Administer pain medications.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

Partial pressure of arterial oxygen (PaO2)

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

Pneumothorax

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

Rapid onset of severe dyspnea

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

Streptococcus pneumoniae

A patient has been receiving 100% oxygen therapy by way of a non-rebreather mask for several days. He complains of tingling in his fingers and shortness of breath. He has limitations, is extremely restless, and states that he has pain beneath his breastbone. The nurse should suspect oxygen-induced:

Toxicity.

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

continue to take antibiotics for the entire 10 days.

A patient is postoperative day 3 following major bowel surgery and has been reluctant to ambulate since being admitted from postanesthetic recovery 2 days ago. As a result, the patient has developed atelectasis and is now being treated for this problem. When administering the patient's bronchodilator by nebulizer, what teaching should the nurse provide?

"If possible, take slow, deep breaths while your nebulizer is running."

For a client with pleural effusion, what does chest percussion over the involved area reveal?

Dullness over the involved area

A nurse working on a general medical-surgical floor is discussing the clinical manifestations of pulmonary arterial hypertension (PAH) with a recent nursing graduate. What is the main symptom of PAH that the nurse would explain?

Dyspnea

A patient has been brought to the emergency department (ED) by the paramedics. The patient is suspected of having acute respiratory distress syndrome (ARDS). What action should the nurse anticipate?

Preparing to assist with intubating the patient

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

Wearing a disposable particulate respirator that fits snugly around the face

A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate?

"Fluid has built up between your lungs and the lining that surrounds your lungs."

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:

"I'll stop being contagious when I have a negative acid-fast bacilli test."

A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response?

"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."

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

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

The nurse educator is discussing aspiration with new nursing graduates. Which patient would the educator tell the nurses is at the greatest risk for aspiration?

A stroke patient with dysarthria

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Blood-tinged sputum

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate?

Chemical irritation

A 72-year-old patient who was admitted to the hospital for a total hip arthroplasty has developed increasing dyspnea and leukocytosis over the past 48 hours and has been diagnosed with hospital-acquired pneumonia (HAP). The choice of antibiotic therapy for this patient will be primarily based on which of the nurse's assessments?

Collection of a sputum sample for submission to the hospital laboratory

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?

Elevated B-type natriuretic peptide (BNP) levels

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?

Encourage breathing exercises.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake.

To assist a patient with the use of an incentive spirometer, the nurse should:

Encourage the patient to pause after a deep breath, relax, and exhale.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

The nurse is caring for a client diagnosed with ARDS. In evaluating the use of PEEP, what outcome would the nurse expect to find?

Increased FRC

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?

Ineffective airway clearance

A nurse who provides care in a long-term care facility has observed a sharp decline in an 88-year-old man's level of consciousness and activity over the past 36 hours. The nurse recognizes the high incidence of pneumonia among older adults. How does pneumonia present differently among the elderly than among younger patients?

Older adults often lack a fever when they develop pneumonia.

A 66-year-old man with a 60 pack-year history of cigarette smoking was diagnosed with non-small cell lung cancer several months ago and has been admitted to the palliative care unit following unsuccessful surgical resection and radiation therapy. What patient teaching should the nurse prioritize when providing care for this patient?

Pain management techniques

A 72-year-old patient is status post right knee replacement, and the nurse recognizes the patient's risk of hospital-acquired pneumonia (HAP). What is a priority nursing measure for the prevention of HAP?

Providing anticipatory interventions

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?

See if there are leaks in the system.

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

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

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?

Turn onto the affected side.