Chapter 23
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
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."
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."
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 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
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
What dietary recommendations should a nurse provide a client with a lung abscess?
A diet rich in protein
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
Which type of lung cancer is the most prevalent among both men and women?
Adenocarcinoma
Which of the following is a potential complication of a low pressure in the endotracheal cuff?
Aspiration pneumonia
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
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
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
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 auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases
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
What is the reason for chest tubes after thoracic surgery?
Draining secretions, air, and blood from the thoracic cavity is necessary.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
Dyspnea
Which intervention does a nurse implement for clients with empyema?
Encourage breathing exercises
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
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
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy.
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
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 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
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?
Receiving vaccinations
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 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
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 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 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
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
Approximately what percentage of people who are initially infected with TB develop active disease?
10%
The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?
6 to 12 months
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 action should the nurse take first in caring for a client during an acute asthma attack?
Administer bronchodilator as ordered.
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.
A mediastinal shift occurs in which type of chest disorder?
Tension pneumothorax
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
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.
The most diagnostic clinical symptom of pleurisy is:
The most diagnostic clinical symptom of pleurisy is:
Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?
Turn onto the affected side.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?
Using strict hand hygiene
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation
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.
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?
Shortness of breath
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 assesses a client with pneumonia. Which assessments are diagnostic for pneumonia? Select all that apply.
Presence of crackles Egophony Wheezes Whispered pectoriloquy Percussion dullness
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
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 nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
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.
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
Few early symptoms
The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
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
Which type of pneumonia has the highest incidence in clients with AIDS and clients receiving immunosuppressive therapy for cancer?
Pneumocystis
The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse know is the most common cause of death from infectious diseases in the United States?
Pneumonia
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.
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:
Significant
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows
redness and induration.
