Chapter 23: Management of Patients with Chest and Lower Respiratory Tract Disorders

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

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

"You must consume a diet rich in protein, such as chicken, fish, and beans." The 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 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." The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.

A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.

-A chest radiograph -Complete history and physical examination -Drug susceptibility testing Once a client had a positive skin test or a positive sputum culture for acid-fast bacilli, additional tests such as complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing are done. The nurse does not need to teach about a complete blood count or a repeat multiple puncture skin test, as the initial positive skin test will serve as the indicator of tuberculosis.

The nurse is planning for the care of a client with acute tracheobronchitis. What nursing interventions should be included in the plan of care? Select all that apply.

-Increasing fluid intake to remove secretions -Encouraging the client to rest -Using cool-vapor therapy to relieve laryngeal and tracheal irritation In most cases, treatment of tracheobronchitis is largely symptomatic. Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal irritation. A primary nursing function is to encourage bronchial hygiene, such as increased fluid intake and directed coughing to remove secretions. Fatigue is a consequence of tracheobronchitis; therefore, the nurse cautions the client against overexertion, which can induce a relapse or exacerbation of the infection. The client is advised to rest.

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

-Monitor vital signs frequently. -Reinforce preoperative breathing exercises. -Elevate head of bed 30 to 40 degrees as tolerated. -Administer pain medications. Nursing management for a client with the goal of maintaining optimal gas exchange includes assessing vital signs frequently; reinforcing preoperative instructions about deep breathing, coughing, and incentive spirometry; and elevating the head of the bed as tolerated. Administering pain medications may help the client with breathing exercises. Accurate record of intravenous fluids is a nurse action, but not a client care issue.

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 The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

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 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.

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

A client with a nasogastric tube 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.

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

A nurse washes her hands before beginning client care. 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.

On auscultation, which finding suggests a right pneumothorax?

Absence of breath sounds in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

Which action should the nurse take first in caring for a client during an acute asthma attack?

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

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 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.

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 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 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 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.

Which intervention does a nurse implement for clients with empyema?

Encourage breathing exercises Empyema is an accumulation of thick fluid within the pleural space. To help the client with the condition, the nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function. Placing clients together, instituting precautions, and forbidding visitors would all be interventions that would depend upon what condition was causing the empyema.

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

Few early symptoms Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

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 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.

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

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

Paradoxical chest movement Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

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 In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

Significant An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

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 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 nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer?

Symptoms often do not appear until the disease is well established. Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. Option A is correct, but it is not the best answer. Option B is incorrect because it is not a true statement. Option C is incorrect because lung cancer is not an infectious disease.

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. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically 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.

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. Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.

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 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.

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

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

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 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.

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. 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.