Unit 2: Nursing Management: Patients With Chest and Lower Respiratory Tract Disorders

What is the reason for chest tubes after thoracic surgery? a. Draining secretions, air, and blood from the thoracic cavity is necessary.

After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.

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 there are leaks in the system.

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

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.

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? a. "The mucus-secreting glands are abnormal."

Cystic fibrosis is caused by dysfunction of the exocrine glands with no cystic lesions present in the lungs. Early treatment can improve symptoms and extend the life of clients, but a cure for this disorder is presently not available. Allergens are responsible for allergic asthma and not associated with cystic fibrosis.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? a. Dyspnea

Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a. Acute respiratory distress syndrome

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.

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

Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

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

Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

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? a. Intubate the client and control breathing with mechanical ventilation

A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected.

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? a. Elevated B-type natriuretic peptide (BNP) levels

Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. Cardiogenic pulmonary edema is an acute event that results from heart failure, in which the cardiac chambers release atrial natriuretic peptide (ANP) and BNP to promote vasodilation and diuresis. BNP levels are not similarly elevated with ARDS.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? a. pH 7.28, PaO2 50 mm Hg

ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

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? a. Acute respiratory distress syndrome

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.

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? a. Streptococcus pneumoniae

Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.

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

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 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? a. Rapid onset of severe dyspnea

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.

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

The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: a. continue to take antibiotics for the entire 10 days.

The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

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? a. 6 to 12 months

Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

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. Crackles in the lung bases

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.

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

A pleural effusion is characterized by an accumulation of fluid in the pleural space. This excess fluid is not located in the lung tissue itself or in the alveoli. A pleural effusion is not normally infectious in etiology.

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply. a. Rock quarry worker b. Miner c. Stone cutter

A quarry worker and stone cutter are exposed to rock dust and silica. A miner can inhale dust, causing silicosis or pneumoconiosis. A banker, nurse, and mechanic may have work hazards, but none specific to the development of an occupational lung disease.

A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized? a. Impaired gas exchange

Anxiety and pain are both possible during treatment for ARDS. However, maintenance of the patient's airway with the goal of facilitating gas exchange is an absolute priority. The patient's risk of aspiration is low due to NPO status and the presence of inline suctioning.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2typically 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.

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

In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? a. Sudden onset of lung impairment in a client who had normal lung function

In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? a. Progressive loss of lung function associated with chronic disease

In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease.

A 47-year-old male client presented to the medical unit and the health care team suspects tuberculosis (TB). The nurse is admitting the client to a reverse isolation room. QuantiFERON testing and chest x-ray are pending. Urinalysis results are negative. No other testing was performed prior to admission to isolation. The client denies any chest pain, shortness of breath (SOB), or respiratory difficulty. The client presents with productive yellow sputum. Based on the provided assessment status, the nurse should utilize airborne precautions to prevent exposure and sputum to collect specimens for additional testing.

A client admitted with suspected tuberculosis (TB) should be placed in a reverse isolation room. Because diagnostic testing is pending, the nurse should limit exposure of the staff to the client and provide a safe therapeutic environment. Additional testing/collection of specimens may be needed to further isolate pathology. Because TB is spread through the respiratory tract, the client should be placed on airborne precautions. Because the client has productive sputum, a specimen should be collected to identify pathological organisms. Tuberculosis is not spread through droplets and contact precautions are used for infectious diseases that can be transmitted through direct contact and/or within the client's environment. Sterile technique is not indicated as part of the precautions used to prevent transmission of TB. Because the urinalysis results were normal, there is no further need to obtain an additional urine specimen. A rapid plasma reagin (RPR) test is used to detect syphilis. There is no clinical indication that the client has a sexually transmitted infection (STI); therefore, this action is not needed.

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? a. Cough or change in chronic cough

A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.

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. A stroke patient with dysarthria

Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. The muscles that become paralyzed in dysarthria are the same ones used for swallowing. This increases the patient's risk of aspiration. Patients with Alzheimer's disease who are still ambulatory probably don't have the voluntary muscle problems that occur later in the disease. Patients who need help with ADLs or have severe arthritis shouldn't have difficulty swallowing unless it exists secondary to another problem.

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? a. Crackles in the lung bases

Auscultation reveals crackles in the lung bases (especially in the dependent lung areas) that rapidly progress toward the apices of the lungs. These crackles are caused by the movement of air through the alveolar fluid. The chest X-ray reveals increased interstitial markings, with or without cardiomegaly. The patient may have tachycardia. Pulse oximetry values begin to fall, and arterial blood gas analysis demonstrates worsening hypoxemia.

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? a. To remove air from the pleural space

Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

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? a. Collection of a sputum sample for submission to the hospital laboratory

Choice of antibiotic therapy is based primarily on the patient's history and the results of sputum cultures. Blood work and chest auscultation confirm the diagnosis of pneumonia but do not typically inform the choice of antibiotic.

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? a. The system has an air leak.

Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

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? a. Flail chest

During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? a. Acute respiratory distress syndrome

Factors associated with the development of acute respiratory distress syndrome 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. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? a. "You must consume a diet rich in protein, such as chicken, fish, and beans."

The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as a. pleural effusion.

Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

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

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.

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? a. Early ambulation and the use of compression stockings

For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.

When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of hypoxemia? a. PaO2 < 60 mm Hg

Hypoxemia is a decrease in the arterial oxygen content or arterial oxygen tension (partial pressure of oxygen = PaO2) and is measured by arterial blood gas analysis (ABG) or pulse oximetry (POX). Hypoxemia is defined as a PaO2 of less than 60 mm Hb and/or a POX of less than 90%. When administering oxygen to a patient, a nurse must keep in mind that oxygen transport to the tissues is not dependent solely on the arterial oxygen content.

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? a. Decreased oxygen diffusion into the tissues

Hypoxemic hypoxia is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. It may be caused by hypoventilation, high altitudes, ventilation-perfusion mismatch (as in pulmonary embolism), shunts in which the alveoli are collapsed and cannot provide oxygen to the blood (commonly caused by atelectasis), and pulmonary diffusion defects. It is corrected by increasing alveolar ventilation or providing supplemental oxygen.

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

Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis.

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? a. Providing anticipatory interventions

Important nursing measures for prevention of HAP include providing anticipatory interventions and preventive care. This scenario is asking about prevention of HAP, not what to do after it occurs, so emotional support and antibiotics are incorrect. Providing extra nutrition is not a preventive measure for HAP.

The nurse is caring for a client with atelectasis. Place in order the instructions the nurse will provide the client to use an incentive spirometer. Use all options. a. Sit in an upright or semi-Fowler position. b. Use diaphragmatic breathing. c. Place the mouthpiece in the mouth. d. Breathe in slowly through the mouth. e. Hold the breath at the end of inspiration for 3 seconds. f. Exhale slowly through the mouthpiece. g. Cough after each session. h. Use the spirometer for 10 breaths each waking hour.

Incentive spirometry is a method of deep breathing that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. The purpose of an incentive spirometer is to ensure that the volume of air inhaled is increased gradually as the client takes deeper and deeper breaths. The client is instructed to sit upright or in the semi-Fowler position and to use diaphragmatic breathing. The mouthpiece is then placed in the mouth. The client is then instructed to breathe in slowly through the mouth and hold the breath at the end of the inspiration for about 3 seconds to maintain the ball indicator between the lines. The client is then to exhale slowly through the mouthpiece and then cough after each session. The spirometer is to be used 10 times in succession, repeating the 10 breaths with the spirometer, each hour while awake.

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: a. Ineffective airway clearance.

Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? a. Correct use of incentive spirometry

Instruction in the use of incentive spirometry begins before surgery to familiarize the client with its correct use. You do not teach a client the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

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

Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

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: a. Toxicity

Oxygen toxicity occurs as a result of breathing oxygen at elevated partial pressures (e.g., scuba divers, premature babies). Hyperoxia causes CNS symptoms, breathing problems, and ocular changes. The severity of symptoms increase as exposure time increases. The initial management is to lower the fraction of oxygen administered, along with a reduction in exposure time.

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? a. Blood-tinged sputum

The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.

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? a. Encourage increased fluid intake.

The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.

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? a. Older adults often lack a fever when they develop pneumonia.

The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in elderly patients. Also, the presence of some signs may be misleading. Abnormal breath sounds, for example, may be caused by atelectasis that occurs as a result of decreased mobility, decreased lung volumes, or other respiratory function changes. However, these patients are usually not without symptoms, even though these symptoms may be atypical. Older adults do not normally maintain high oxygen levels during pneumonia.

Which intervention does a nurse implement for clients with empyema? a. Encourage breathing exercises.

The nurse teaches the client with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions and isolate suspected and clients with confirmed influenza in private rooms or place suspected and confirmed clients together. The nurse does not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.

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? a. Negative

The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.