326 prepu - ch.19: management of patients with chest and lower respiratory tract disorders

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client?

Ineffective breathing pattern Rationale: Ineffective breathing pattern takes priority for a client with a pulmonary contusion with a pulmonary embolism. The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. Fluid volume, pain, and activity intolerance are not priority concerns.

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client?

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Rationale: The client should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The client should then exhale slowly through the mouthpiece.

The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?

Pulmonary function studies Rationale: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the client who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.

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

tachypnea Rationale: Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

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." Rationale: 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.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.

- monitor pulmonary status as directed and needed - regularly assess the client's vital signs every 2 to 4 hours - encourage deep breathing exercises

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

1) "inhale through your nose" 2) "slowly count to 3" 3) "exhale slowly through pursed lips" 4) "slowly count to 7"

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

A positive reaction indicates that the client has been exposed to the disease. Rationale: A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

How should the nurse best assess whether a client receiving oxygen therapy is hypoxemic?

Assess the client using pulse oximetry. Rationale: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes Rationale: Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.

Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?

Blood pressure increase of 20 mm Hg Rationale: Criteria for terminating the weaning process include heart rate increase of 20 beats/min and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?

Classes at community centers to teach about smoking cessation strategies Rationale: Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)?

Cleaning the client's mouth with chlorhexidine daily Rationale: The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Cough or change in chronic cough Rationale: 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.

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 Rationale: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.

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. Rationale: 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.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2 Rationale: Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6 Rationale: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

airborne and contact precautions Rationale: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

What assessment method would the nurse use to determine the areas of the lungs that need draining?

auscultation Rationale: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

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

pH 7.28 Rationale: Acute respiratory failure 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 greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

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

pleural effusion Rationale: 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.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

water-seal chamber Rationale: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

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 Rationale: 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.

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

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

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 Rationale: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal suctioning Rationale: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?

Fit all employees with protective masks Rationale: The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases.

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

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

Impaired gas exchange related to ventilator setting adjustments Rationale: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing Rationale: One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care Rationale: HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

Which long-term care facility resident most likely faces the greatest risk for aspiration?

A resident who suffered a severe stroke several weeks ago Rationale: Aspiration may occur if the client cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A client with mid-stage Alzheimer disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have arthritis should not have difficulty swallowing unless it exists secondary to another problem.

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

Acute respiratory distress syndrome Rationale: 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.

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

Administer prescribed short-acting bronchodilator. Rationale: Administering a short-acting bronchodilator will dilate the airway and enable oxygen to reach the lungs. Although ABGs and a chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute asthma attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.

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

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

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds Rationale: When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?

Consolidation Rationale: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

Continuous positive airway pressure (CPAP) Rationale: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

What is the reason for chest tubes after thoracic surgery?

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

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs Rationale: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the client's oxygen saturation. Rationale: The client's response to suctioning is usually determined by performing chest auscultation and by measuring the client's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Monitor the pressure in the cuff at least every 8 hours Rationale: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the client from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

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 Rationale: 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.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2) Rationale: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order?

Removal from the ventilator, tube, and then oxygen Rationale: The process of withdrawing the client from dependence on the ventilator takes place in three stages: the client is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Routinely deflating the cuff Rationale: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

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 Rationale: 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 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 Rationale: When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. 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. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

The nurse has explained to the client that after his thoracotomy, it will be important to adhere to a coughing schedule. The client is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client?

Teach him how to perform huffing. Rationale: The technique of "huffing" may be helpful for the client with diminished expiratory flow rates or for the client who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

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. Rationale: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

A mediastinal shift occurs in which type of chest disorder?

Tension pneumothorax Rationale: 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.

Which comfort technique does a nurse teach to a client with pleurisy to assist with splinting the chest wall?

Turn onto the affected side Rationale: The nurse teaches the client to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain. The client will also take prescribed analgesic medications and use heat or cold applications to relieve pain, but these do not splint the chest wall. Another option for splinting the chest wall is for the client to use the hands or a pillow when coughing.

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 Rationale: 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.

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 Rationale: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

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 Rationale: 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 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 Rationale: When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner 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 exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.