Pneumonia #2 nurselabs

A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing: A. Carbon monoxide poisoning B. Carbon dioxide narcosis C. Respiratory alkalosis D. Metabolic acidosis

B. Carbon dioxide narcosis rationales: Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possible coma. The delineating feature of CO2 narcosis is a depressed level of consciousness. It is essential to recognize impending or current CO2 narcosis; if left untreated, it can result in coma or death.

A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean that the client has: A. Active TB B. Had contact with Mycobacterium tuberculosis. C. Developed a resistance to tubercle bacilli. D. Developed passive immunity to TB.

B. Had contact with Mycobacterium tuberculosis. rationales: A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. If the infection risk is very high, the PPD test need not be repeated. The positive PPD test is usually followed by TB symptom assessment, physical exam, and chest radiograph. If there are no TB symptoms and no evidence of active tuberculosis infection on physical exam and chest radiograph, the patient most likely has latent TB. The treatment of latent TB should be encouraged once detected.

INH treatment is associated with the development of peripheral neuropathies. Which of the following interventions would the nurse teach the client to help prevent this complication? A. Adhere to a low cholesterol diet. B. Supplement the diet with pyridoxine (vitamin B6). C. Get extra rest. D. Avoid excessive sun exposure.

B. Supplement the diet with pyridoxine (vitamin B6). rationales: INH competes with the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Peripheral neuropathy is avoided and treated with daily pyridoxine administration along with INH. Though there are no specific therapies for INH-induced liver damage, some studies have shown a mortality benefit in using corticosteroids and N-acetylcysteine early in the course of liver injury.

Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia? A. A respiratory rate of 25 to 30 breaths per minute. B. The ability to perform ADLs without dyspnea. C. A maximum loss of 5 to 10 pounds of body weight. D. Chest pain that is minimized by splinting the ribcage.

B. The ability to perform ADL's without dyspnea rationales: An expected outcome for a client recovering from pneumonia would be the ability to perform ADLs without experiencing dyspnea. Determine patient's response to activity. Note reports of dyspnea, increased weakness and fatigue, changes in vital signs during and after activities. Establishes patient's capabilities and needs and facilitates choice of interventions.

A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? A. Acute pain related to lung expansion secondary to lung infection. B. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever. C. Anxiety related to dyspnea and chest pain. D. Ineffective airway clearance related to retained secretions.

D. Ineffective airway clearance related to retained secretions. rationales: Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.

The client experiencing eighth cranial nerve damage will most likely report which of the following symptoms? A. Vertigo B. Facial paralysis C. Impaired vision D. Difficulty swallowing

A. Vertigo rationales: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve. Ototoxicity and vestibular impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be exercised when combining streptomycin with other potentially ototoxic drugs. Vestibular impairment usually manifests during the course of treatment and is typically permanent.

Which of the following symptoms is common in clients with TB? A. Weight loss B. Increased appetite C. Dyspnea on exertion D. Mental status changes

A. Weight loss rationales: TB typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Secondary tuberculosis differs in clinical presentation from the primary progressive disease. In secondary disease, the tissue reaction and hypersensitivity is more severe, and patients usually form cavities in the upper portion of the lungs.

A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: A. Positive B. Negative C. Inconclusive D. The need for repeat testing.

A. Positive rationales: The client with HIV+ status is considered to have positive results on PPD skin test with an area greater than 5-mm of induration. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC. If the infection risk is very high, the PPD test need not be repeated. The positive PPD test is usually followed by TB symptom assessment, physical exam, and chest radiograph.

A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. Which action should the nurse take? A. Remove the airway and insert a shorter one. B. Reposition the airway. C. Leave the airway in place until the client gets used to it. D. Remove the airway and attempt suctioning without it.

A. Remove the airway and insert a shorter one. rationales: If the client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse should remove it and insert a shorter one. A nasopharyngeal airway device (NPA) is a hollow plastic or soft rubber tube that a healthcare provider can utilize to assist with patient oxygenation and ventilation in patients who are difficult to oxygenate or ventilate via bag mask ventilation, for example.

Which of the following antituberculous drugs can cause damage to the eighth cranial nerve? A. Streptomycin B. Isoniazid C. Para-aminosalicylic acid D. Ethambutol hydrochloride

A. Streptomycin rationales: Streptomycin is an aminoglycoside, and eighth cranial nerve damage (ototoxicity) is a common side effect from aminoglycosides. Ototoxicity and vestibular impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be exercised when combining streptomycin with other potentially ototoxic drugs.

The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply. A. "I will need to dispose of my old clothing when I return home." B. "I should always cover my mouth and nose when sneezing." C. "It is important that I isolate myself from family when possible." D. "I should use paper tissues to cough in and dispose of them properly." E. "I can use regular plates and utensils whenever I eat."

B, C, D, E rationales: Review pathology of disease (active and inactive phases; dissemination of infection through bronchi to adjacent tissues or via bloodstream and/or lymphatic system) and potential spread of infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, singing.

A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? A. Position changes q4h. B. Nasotracheal suctioning to clear secretions. C. Frequent linen changes. D. Frequent offering of a bedpan.

C. Frequent linen changes. rationales: Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Adjust and monitor environmental factors like room temperature and bed linens as indicated.

Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client's history, would require physician notification? A. Heart disease B. Allergy to penicillin C. Hepatitis B D. Rheumatic fever

C. Hepatitis B rationales: Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury. In all adults preparing to begin isoniazid treatment, the clinician should order baseline measurements of aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, alkaline phosphatase, serum creatinine, and platelet count.

Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? A. Coma B. Apathy C. Irritability D. Depression

C. Irritability rationales: Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Apathy and depression are not symptoms of hypoxia.

An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct? A. Using intermittent suction while advancing the catheter. B. Using continuous suction while withdrawing the catheter. C. Using intermittent suction while withdrawing the catheter. D. Using continuous suction while advancing the catheter.

C. Using intermittent suction while withdrawing the catheter. rationales: Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia, suctioning shouldn't last more than 10-seconds at a time. Suction shouldn't be applied while the catheter is being advanced. Ensure preoxygenation with 100% FiO2 was done with adequate pulse oximetry measurements. Preoxygenation is required because airway suctioning procedure may be associated with significant hypoxemia.

Which of the following family members exposed to TB would be at highest risk for contracting the disease? A. 45-year-old mother B. 17-year-old daughter C. 8-year-old son D. 76-year-old grandmother

D. 76-year-old grandmother rationales: Elderly persons are believed to be at higher risk for contracting TB because of decreased immunocompetence. Other high-risk populations in the US include the urban poor, AIDS, and minority groups. Tuberculosis is present globally. However, developing countries account for a disproportionate share of tuberculosis disease burden. In addition to the six countries listed above, several countries in Asia, Africa, Eastern Europe, and Latin and Central America continue to have an unacceptably high burden of tuberculosis.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? A. Decreased cardiac output. B. Pleural effusion. C. Inadequate peripheral circulation. D. Decreased oxygenation of the blood.

D. Decreased oxygenation of the blood. rationales: A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. It is evident that the cyanosis of pneumonia patients is due to the incomplete saturation of venous blood with oxygen in the lungs, and that the various shades of blue observed in the distal parts are caused by an admixture of reduced hemoglobin and oxyhemoglobin in the superficial capillaries.

A client with pneumonia has a temperature ranging between 101° and 102°F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority? A. Maintain complete bed rest. B. Administer oxygen therapy. C. Provide frequent linen changes. D. Provide fluid intake of 3 L/day.

D. Provide fluid intake of 3 L/day rationales: A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result of the fever and diaphoresis; this is a high-priority intervention. Force fluids to at least 3000 mL/day or as individually appropriate. Meets basic fluid needs, reducing risk of dehydration and to mobilize secretions, and promote expectoration.

A client's ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

D. Respiratory acidosis rationales: Respiratory acidosis is a state in which there is usually a failure of ventilation and an accumulation of carbon dioxide. The primary disturbance of elevated arterial PCO2 is the decreased ratio of arterial bicarbonate to arterial PCO2, which leads to a lowering of the pH. To compensate for the disturbance in the balance between carbon dioxide and bicarbonate (HCO3-), the kidneys begin to excrete more acid in the forms of hydrogen and ammonium and reabsorb more base in the form of bicarbonate. This compensation helps to normalize the pH.

The public health nurse is providing follow-up care to a client with TB who does not regularly take his medication. Which nursing action would be most appropriate for this client? A. Ask the client's spouse to supervise the daily administration of the medications. B. Visit the clinic weekly to ask him whether he is taking his medications regularly. C. Notify the physician of the client's non-compliance and request a different prescription. D. Remind the client that TB can be fatal if not taken properly.

A. Ask the client's spouse to supervise the daily administration of the medications. rationales: Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment.

Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. A. Auscultation of breath sounds. B. Auscultation of bowel sounds. C. Presence of chest pain. D. Presence of peripheral edema. E. Color of nail beds.

A, C, E. rationales: A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

The nurse obtains a sputum specimen from a client with suspected TB for laboratory study. Which of the following laboratory techniques is most commonly used to identify tubercle bacilli in sputum? A. Acid-fast staining B. Sensitivity testing C. Agglutination testing D. Dark-field illumination

A. Acid-fast staining rationales: The most commonly used technique to identify tubercle bacilli is acid-fast staining. The bacilli have a waxy surface, which makes them difficult to stain in the lab. However, once they are stained, the stain is resistant to removal, even with acids. Therefore, tubercle bacilli are often called acid-fast bacilli. CDC recommends the historical practice of obtaining three sputum samples with at least one early morning sample. Each specimen increases the sensitivity of testing. The first-morning specimen increases sensitivity by 12%. Sputum smear sensitivity could be increased by centrifugation or sedimentation.

A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of: A. Meats and citrus fruits B. Grains and broccoli C. Eggs and spinach D. Potatoes and fish

A. Meats and citrus fruits rationales: The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C. Encourage small, frequent meals with foods high in protein and carbohydrates. Maximizes nutrient intake without undue fatigue/energy expenditure from eating large meals, and reduces gastric irritation.

The Causative agent of Tuberculosis is said to be: A. Mycobacterium Tuberculosis B. Hansen's Bacilli C. Bacillus Anthracis D. Group A Beta Hemolytic Streptococcus

A. Mycobacterium Tuberculosis rationales: Tuberculosis (TB) is an ancient human disease caused by Mycobacterium tuberculosis which mainly affects the lungs, making pulmonary disease the most common presentation (K Zaman, 2010). However, TB is a multi-systemic disease with a protean presentation. For a human pathogen with no known environmental reservoir, Mycobacterium tuberculosis has honed the art of survival and has persisted in human communities from antiquity through modern times.

A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if any of the following were noted in the laboratory report? A. 5 mcg/mL B. 15 mcg/mL C. 25 mcg/mL D. 30 mcg/mL

B. 15 mcg/mL rationales: Therapeutic theophylline blood levels range from 10-20 mcg/mL. Patients can be administered IV theophylline for acute bronchospasm. Those who are not currently taking theophylline should be given a loading dose of 5 to 7 mg/kg intravenously, followed by a maintenance dose of 0.4 to 0.6 mg/kg per hour intravenously to maintain serum concentrations at 10 to 15 mg/L.

A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is: A. A bloody, productive cough B. A cough with the expectoration of mucoid sputum C. Chest pain D. Dyspnea

B. A cough with the expectoration of mucoid sputum rationales: One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum. A chronic cough, hemoptysis, weight loss, low-grade fever, and night sweats are some of the most common physical findings in pulmonary tuberculosis. Other options are late symptoms and signify cavitation and extensive lung involvement.

A police officer brings in a homeless client to the ER. A chest x-ray suggests he has TB. The physician orders an intradermal injection of 5 tuberculin units/0.1 ml of tuberculin purified derivative. Which needle is appropriate for this injection? A. 5/8" to ½" 25G to 27G needle. B. 1" to 3" 20G to 25G needle. C. ½" to 3/8" 26 or 27G needle. D. 1" 20G needle.

C. ½" to 3/8" 26 or 27G needle. rationales: Intradermal injections like those used in TN skin tests are administered in small volumes (usually 0.5 ml or less) into the outer skin layers to produce a local effect. A TB syringe with a ½" to 3/8" 26G or 27G needle should be inserted about 1/8" below the epidermis.

A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. Which of the following is a normal physiologic change related to aging? A. Increased elastic recoil of the lungs. B. Increased number of functional capillaries in the alveoli. C. Decreased residual volume. D. Decreased vital capacity.

D. Decreased vital capacity. rationales: Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase is residual volume. Lung volumes depend on body size, especially height. Total lung capacity (TLC) corrected for age remains unchanged throughout life. Functional residual capacity and residual volume increase with age, resulting in a lower vital capacity.

A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem? A. Non Productive or productive cough B. Anorexia and weight loss C. Chills and night sweats D. High-grade fever

D. High-grade fever rationales: The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever. Clients with TB typically have low-grade fevers, not higher than 102*F. A chronic cough, hemoptysis, weight loss, low-grade fever, and night sweats are some of the most common physical findings in pulmonary tuberculosis.

The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB? A. Take the medication with antacids. B. Double the dosage if a drug dose is forgotten. C. Increase intake of dairy products. D. Limit alcohol intake.

D. Limit alcohol intake rationales: INH and rifampin are hepatotoxic drugs. Clients should be warned to limit intake of alcohol during drug therapy. Liver function tests should be monitored routinely as rifampin, isoniazid, pyrazinamide, and ethambutol all may exert hepatotoxic effects. CBC also requires regular monitoring for patients taking rifampin, as it can cause thrombocytopenia and neutropenia.