Chapter 23: Management of Patients With Chest and Lower Respiratory Tract Disorders
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperventilation, hypertension, and hypocapnia b) Hypercapnia, hypoventilation, and hypoxemia c) Hypotension, hyperoxemia, and hypercapnia d) Hyperoxemia, hypocapnia, and hyperventilation
b) Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems. pg.595
A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is: a) 1.4 L. b) unspecified. c) 2 L. d) 3 L.
a) 1.4 L. Explanation: Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily. pg.582
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Apply a compression dressing to the area. b) Record the observation. c) Measure the patient's pulse oximetry. d) Report the finding to the physician immediately.
a) Apply a compression dressing to the area. Explanation: Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. During surgery the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. pg.616
A 23-year-old male client who has recently started working in a coal mine confides that he is concerned about his long-term health. The nurse instructs the client which of the following ways to prevent occupational lung disease? Select all that apply. a) Do not smoke or quit smoking if currently smoking. b) Wear appropriate protective equipment when around airborne irritants and dusts. c) Schedule an annual lung x-ray to monitor his health. d) Try to find another occupation as soon as possible.
a) Do not smoke or quit smoking if currently smoking. b) Wear appropriate protective equipment when around airborne irritants and dusts. Explanation: The nurse may instruct clients that the following precautions may help prevent occupational lung disease: not smoking, wearing appropriate protective equipment when around airborne irritants and dusts, scheduling lung function evaluation with spirometry as recommended, becoming educated about lung diseases, and paying attention to risk evaluation of the workplace to identify risks for lung disease. pg.605
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: a) Significant b) Negative c) Nonreactive d) Not significant
a) Significant Explanation: 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. pg.588
A Class 1 with regards to TB indicates a) disease that is not clinically active. b) exposure and no evidence of infection. c) no exposure and no infection. d) latent infection with no disease.
b) exposure and no evidence of infection. Explanation: Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active. pg.588
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: a) acute respiratory distress syndrome (ARDS). b) chronic obstructive pulmonary disease (COPD). c) bronchial asthma. d) renal failure.
a) acute respiratory distress syndrome (ARDS). Explanation: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation. pg.596
Which of the following community-acquired pneumonias demonstrates the highest occurrence during summer and fall? a) Viral pneumonia b) Mycoplasmata pneumonia c) Legionnaires' disease d) Streptococcal (pneumococcal) pneumonia
c) Legionnaires' disease Explanation: Legionnaires' disease accounts for 15% of community-acquired pneumonias. Streptococcal pneumonia demonstrates the highest occurrence in winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter. Viral pneumonia demonstrates the greatest incidence during winter months. pg.574
A patient suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which of the following interventions to improve oxygenation and provide comfort for the patient? a) Assist the patient up to a chair b) Force fluids for the next 24 hours c) Position the patient in the prone position d) Administer small doses of pancuronium (Pavulon)
c) Position the patient in the prone position Explanation: The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs. pg.597
Which of the following terms refers to lung tissue that has become more solid in nature due to a collapse of alveoli or an infectious process? a) Bronchiectasis b) Empyema c) Atelectasis d) Consolidation
d) Consolidation Explanation: 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. pg.578
An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion? a) Mottling of the skin upon inspection b) Resonance upon percussion c) Wheezing upon auscultation d) Decreased chest wall excursion upon palpation
d) Decreased chest wall excursion upon palpation Explanation: Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound on percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area. pg.593
Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? a) Fungal b) Streptococcal c) TB d) Pneumocystis
d) Pneumocystis Explanation: Pneumocystis pneumonia incidence is greatest in patient with AIDS and patients receiving immunosuppressive therapy for cancer. pg.574
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4? (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? a) The X-ray is inconclusive. b) A disease process is present. c) The ET tube must be pulled back. d) The ET tube must be advanced.
b) A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4? above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back. pg.588
You are caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? a) Pain on inspiration b) Mucopurulent sputum c) Obvious trauma d) Shortness of breath
b) Mucopurulent sputum Explanation: For a client with lung cancer, a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign 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 are not considered indicative of lung cancer. pg.607
When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) bruising. b) redness and induration. c) drainage. d) tissue sloughing.
b) redness and induration. Explanation: The injection site is inspected for redness and palpated for hardening. Drainage at the injection site does not indicate a reaction to the tubercle bacillus. Sloughing of tissue at the injection site does not indicate a reaction to the tubercle bacillus. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus. pg.588
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions. b) Do not allow visitors with respiratory infection. c) Encourage breathing exercises. d) Place suspected patients together.
c) Encourage breathing exercises. Explanation: The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings. pg.595
The nurse knows the mortality rate is high in lung cancer clients due to which factor? a) Increased exposure to industrial pollutants b) Increase in women smokers c) Few early symptoms d) Increased incidence among the elderly
c) Few early symptoms Explanation: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to increase in number of women smokers, growing aging population, and exposure to pollutants but not indicative of mortality rates. pg.607
Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women? a) Large cell carcinoma b) Squamous cell carcinoma c) Small cell carcinoma d) Adenocarcinoma
d) Adenocarcinoma Explanation: Adenocarcinoma presents more peripherally as peripheral masses or nodules and often metastasizes. Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposures. Small cell carcinomas arise primarily as proximal lesions, but may arise in any part of the tracheobronchial tree. pg.605
Which of the following interventions does a nurse implement for patients with empyema? a) Institute droplet precautions b) Do not allow visitors with respiratory infections c) Place suspected patients together d) Encourage breathing exercises
d) Encourage breathing exercises Explanation: The nurse instructs the patient in lung-expanding breathing exercises to restore normal respiratory function. pg.595
The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? a) Fever b) Headache c) Weight loss d) Shortness of breath
d) Shortness of breath Explanation: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss. pg.604
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a) Flail chest b) Cardiac tamponade c) Pulmonary contusion d) Tension pneumothorax
d) Tension pneumothorax Explanation: Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation. pg.614
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin E b) Vitamin D c) Vitamin C d) Vitamin B6
d) Vitamin B6 Explanation: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate. pg.589
A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? a) "I'll stay in isolation for 6 weeks." b) "This disease may come back later if I am under stress." c) "I'll have to take the medication for up to a year." d) "I'll always have a positive test for tuberculosis."
a) "I'll stay in isolation for 6 weeks." Explanation: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease. pg.587
Approximately what percentage of people who are initially infected with TB develop active disease? a) 10% b) 40% c) 20% d) 30%
a) 10% Explanation: Approximately 10% of people who are initially infected develop active disease. The other percentages are inaccurate. pg.587
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 b) A client who is receiving acetaminophen (Tylenol) for pain c) A client who ambulates in the hallway every 4 hours d) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago
a) A client with a nasogastric tube Explanation: 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. pg.577
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? a) Classes at community centers to teach about smoking cessation strategies b) Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays c) Legislation that requires homes and apartments be checked for asbestos leakage d) Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes
a) Classes at community centers to teach about smoking cessation strategies Explanation: 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. pg.605
What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
a) Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect. pg.493
For a patient with pleural effusion, what does chest percussion over the involved area reveal? a) Dullness over the involved area b) Absent breath sounds c) Fluid presence d) Friction rub
a) Dullness over the involved area Explanation: Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography (CT) scan show fluid in the involved area. pg.594
A client who is diagnosed with chronic respiratory failure will have which of the following symptoms? a) Dyspnea b) Hypercapnia c) Hypoxemia d) Ventilatory failure
a) Dyspnea Explanation: Chronic respiratory failure develops over a long time period as the result of another condition. The most common diseases leading to chronic respiratory failure are COPD and neuromuscular disorders. A fall in arterial oxygen levels is a sign of acute respiratory failure. A rise in arterial CO2 is a sign of acute respiratory failure. Ventilatory failure develops in acute respiratory failure when the alveoli cannot adequately expand. pg.595
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? a) Fibrotic changes in lungs b) Hemorrhage c) Damage to surrounding tissues d) Lung contusion
a) Fibrotic changes in lungs Explanation: 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. pg.606
What are the conditions that make up Virchow's triad? Select all that apply. a) Hypocoagulability b) Disruption of the vessel lining c) Edema d) Hypercoagulability e) Venostasis
a) Hypercoagulability b) Disruption of the vessel lining e) Venostasis Explanation: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad. pg.846
The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Large cell carcinoma b) Squamous cell carcinoma c) Bronchoalveolar carcinoma d) Adenocarcinoma
a) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located. pg.606
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 b) Sudden loss of lung function associated with chronic disease c) Progressive loss of lung function with history of normal lung function d) Sudden loss of lung function with history of normal lung function
a) Progressive loss of lung function associated with chronic disease Explanation: 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. pg.595
The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS? a) Rapid onset of severe dyspnea b) Cyanosis c) Inspiratory crackles d) Bilateral wheezing
a) Rapid onset of severe dyspnea Explanation: 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 pg.596
Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections? a) Receiving vaccination b) Using prescribed opioids c) Using incentive spirometry d) Mobilizing early
a) Receiving vaccination Explanation: Identifying the patients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages patients 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. pg.574
You've been invited to speak to the Hospital Guild of the hospital where you practice nursing. You've been asked to address "Communicable Diseases of Winter" and are speaking to a large group of volunteer women, most of whom are older than 60 years. What practices should you encourage in these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. a) Receiving vaccinations b) Techniques for incentive spirometry c) Hand antisepsis d) Using prescribed opioids
a) Receiving vaccinations c) Hand antisepsis b) Techniques for incentive spirometry Explanation: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. Teaching the Guild members the proper method and times to wash their hands go a long way in disease prevention. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae. pg.571
The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? a) Sudden onset in client who had normal lung function b) Insidious onset in client who had normal lung function c) Insidious onset in client who had compromised lung function d) Sudden onset in client who had compromised lung function
a) Sudden onset in client who had normal lung function Explanation: Acute respiratory failure occurs suddenly in a client who previously had normal lung function. pg.595
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. b) The client exhibits bronchial breath sounds over the affected area. c) The client exhibits restlessness and confusion. d) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: 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. pg.584
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) empyema. b) Pneumocystis carinii pneumonia. c) infected chest tube wound site. d) lobar pneumonia.
a) empyema. Explanation: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage. pg.594
A positive Mantoux test indicates that a client: a) has produced an immune response. b) has an active case of tuberculosis. c) will develop full-blown tuberculosis. d) is actively immune to tuberculosis.
a) has produced an immune response. Explanation: The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has (or will develop) tuberculosis. pg.588
A nurse is caring for a patient after a thoracentesis. Which of the following signs if noted in the patient should be reported to the physician immediately? a) "Patient has subcutaneous emphysema around needle insertion site." b) "Patient is becoming agitated and complains of pleuritic pain." c) "Patient is drowsy and complains of headache." d) "Patient has an oxygen saturation level of 93%."
b) "Patient is becoming agitated and complains of pleuritic pain." Explanation: After a thoracentesis, the nurse monitors the patient for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the patient may become anxious and develop dyspnea with increased use of the accessory muscles. pg.583
A nurse recognizes that a client with tuberculosis needs further teaching when the client states: a) "I'll have to take these medications for 9 to 12 months." b) "The people I have contact with at work should be checked regularly." c) "I'll need to have scheduled laboratory tests while I'm on the medication." d) "It won't be necessary for the people I work with to take medication."
b) "The people I have contact with at work should be checked regularly." Explanation: The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements. pg.587
A nurse is preparing instructions for a patient with a lung abscess regarding dietary recommendations. Which of the following statements would be included in the plan of care? a) "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." b) "You must consume a diet rich in protein, such as chicken, fish, and beans." c) "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." d) "You must consume a diet low in fat by limiting dairy products and concentrated sweets."
b) "You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: For a patient with a lung abscess the nurse encourages a diet that is high in protein and calories to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a patient with a lung abscess. pg.592
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? a) No fluid normally is present b) 5 - 15 ml c) 15 - 25 ml d) 20 - 30 ml
b) 5 - 15 ml Explanation: Under normal conditions, approximately 5 to 15 mL of fluid between the pleurae prevent friction during pleural surface movement. pg.593
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) 1 to 3 weeks b) 6 to 12 months c) 2 to 4 months d) 3 to 5 days
b) 6 to 12 months Explanation: 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. pg.589
On auscultation, which finding suggests a right pneumothorax? a) Inspiratory wheezes in the right thorax b) Absence of breath sounds in the right thorax c) Bilateral pleural friction rub d) Bilateral inspiratory and expiratory crackles
b) Absence of breath sounds in the right thorax Explanation: 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. pg.614
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? a) Atelectasis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Respiratory acidosis
b) Acute respiratory distress syndrome Explanation: 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. pg.596
A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner? a) Apply vented dressing. b) Apply airtight dressing. c) Apply direct pressure to the wound. d) Clean the wound and leave open to the air.
b) Apply airtight dressing. Explanation: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted. pg.613
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and assist in the diagnosis of an occupational lung disease? a) Cough and dyspnea b) Black-streaked sputum c) Tenacious secretions d) Barrel chest
b) Black-streaked sputum Explanation: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time. pg.606
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? a) Drug ingestion b) Chemical irritation c) Direct lung damage d) Aspiration
b) Chemical irritation Explanation: Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. 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. pg.573
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? a) Bloody drainage is seemed in the collection chamber. b) Crackling is heard when skin around tube is touched. c) Skin around tube is pink. d) Absence of bloody drainage in the anterior/upper tube
b) Crackling is heard when skin around tube is touched. Explanation: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers not 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. pg.616
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years b) Daily doses of isoniazid, 300 mg for 6 months to 1 year c) Isolation until 24 hours after antitubercular therapy begins d) Nothing, until signs of active disease arise
b) Daily doses of isoniazid, 300 mg for 6 months to 1 year Explanation: All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis. pg.589
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? a) Social isolation b) Deficient knowledge (disease process and treatment regimen) c) Impaired social interaction d) Anxiety
b) Deficient knowledge (disease process and treatment regimen) Explanation: This client is exhibiting Deficient knowledge about the disease process and treatment regimen; treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen. Although the client is upset, his question reflects sadness at the prospect of being separated from his family rather than anxiety about the disease. Because he has just been diagnosed and hasn't had a chance to demonstrate compliance, a nursing diagnosis of Social isolation isn't appropriate. A diagnosis of Impaired social interaction usually has a psychiatric or neurologic basis, not a respiratory one, such as pulmonary tuberculosis. pg.587
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? a) Client teaching about the cause of TB b) Developing a list of people with whom the client has had contact c) Client teaching about the importance of TB testing d) Reviewing the risk factors for TB
b) Developing a list of people with whom the client has had contact Explanation: 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. pg.590
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? a) Cardiac tamponade b) Flail chest c) Simple pneumothorax d) Pulmonary contusion
b) Flail chest Explanation: 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. pg.611
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: a) "My tuberculosis isn't contagious after I take the medication for 24 hours." b) "I'll stop being contagious when I have a negative acid-fast bacilli test." c) "I'm contagious as long as I have night sweats." d) "I'm clear when my chest X-ray is negative."
b) I'll stop being contagious when I have a negative acid-fast bacilli test." Explanation: A client with drug-resistant tuberculosis isn't contagious when he's had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce negative acid-fast test results for several days. The client won't have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they don't indicate whether the client is contagious. pg.588
The client, with a lower respiratory airway infection, is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Risk for Infection b) Ineffective Airway Clearance c) Ineffective Breathing Pattern d) Impaired Gas Exchange
b) Ineffective Airway Clearance Explanation: The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis. pg. 582
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? a) Perform nasopharyngeal suctioning. b) Initiate oxygen therapy. c) Administer a heparin bolus and begin an infusion at 500 units/hour. d) Administer analgesics as ordered.
b) Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism. pg.601
A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient'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 assist the patient to breathe easier? a) Administer a large dose of furosemide (Lasix) IVP stat b) Intubate the patient and control breathing with mechanical ventilation c) Schedule the patient for pulmonary surgery d) Increase oxygen administration
b) Intubate the patient and control breathing with mechanical ventilation Explanation: A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate. pg.597
The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress? a) Chronic lung disease b) Normal lung function c) Loss of lung function d) Slow onset of symptoms
b) Normal lung function Explanation: Acute respiratory failure occurs suddenly in clients who previously had normal lung function. pg.596
Which of the following is a key characteristic of pleurisy? a) Blood-tinged secretions b) Pain c) Dyspnea d) Anxiety
b) Pain Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. pg.592
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pulmonary embolism b) Pneumothorax c) Heart failure d) Myocardial infarction (MI)
b) Pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure. pg.613
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Measure the patient's pulse oximetry b) Record the observation c) Report the finding to the physician immediately d) Apply a compression dressing to the area
b) Record the observation Explanation: Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. pg.614
A mediastinal shift occurs in which type of chest disorder? a) Traumatic pneumothorax b) Tension pneumothorax c) Cardiac tamponade d) Simple pneumothorax
b) Tension pneumothorax Explanation: 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. pg.614
The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis? a) pH 7.47, PaCO2 28, HCO3 30 b) pH 7.25, PaCO2 48, HCO3 24 c) pH 7.87, PaCO2 38, HCO3 28 d) pH 7.49, PaCO2 34, HCO3 25
b) pH 7.25, PaCO2 48, HCO3 24 Correct Explanation: pH 7.25, PaCO2 48, HCO3 24 = respiratory acidosis pH 7.87, PaCO2 38, HCO3 28 = metabolic alkalosis pH 7.47, PaCO2 28, HCO3 30 = respiratory alkalosis pH 7.49, PaCO2 34, HCO3 25 = respiratory alkalosis pg.595
Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? a) pH 7.35 b) pH 7.28 c) PaCO 32 mm Hg d) PaO 80 mm Hg
b) pH 7.28 Explanation: Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. pg.597
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.35, PaCO2 48 mm Hg b) pH 7.28, PaO2 50 mm Hg c) pH 7.46, PaO2 80 mm Hg d) pH 7.36, PaCO2 32 mm Hg
b) pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. pg.595
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? a) "There are fibrous cysts in the lungs." b) "Early treatment can stop the progression of the disease." c) "The mucus-secreting glands are abnormal." d) "Allergic reactions cause inflammation in the lungs."
c) "The mucus-secreting glands are abnormal." Explanation: 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. pg.648
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? a) "Chest tube will allow air to be restored to the lung." b) "Chest tubes provide a route for medication instillation to the lung." c) "The tube will drain air from the space around the lung." d) "The tube will drain secretions from the lung."
c) "The tube will drain air from the space around the lung." Explanation: 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. pg.614
What dietary recommendations should a nurse provide a patient with a lung abscess? a) A diet low in calories b) A carbohydrate-dense diet c) A diet rich in protein d) A diet with limited fat
c) A diet rich in protein Explanation: For a patient with pleural effusion, a diet rich in protein and calories is pivotal. A carbohydrate-dense diet or diets with limited fat are not advisable for a patient with lung abscess. pg.591
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) Respiratory alkalosis b) Productive cough c) Blood-tinged sputum d) Bradypnea
c) Blood-tinged sputum Explanation: 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. pg.613
You are a clinic nurse caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? a) Aspiration b) Direct lung damage c) Chemical irritation d) Drug ingestion
c) Chemical irritation Explanation: 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. pg.573
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) Place client on bed rest. b) Offer nutritious snacks 2 times a day. c) Encourage increased fluid intake. d) Give antibiotics as ordered.
c) Encourage increased fluid intake. Explanation: 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. pg.583
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? a) Provide employees with smoking cessation materials. b) Insist on adequate breaks for each employee. c) Fit all employees with protective masks. d) Give workshops on disease prevention.
c) Fit all employees with protective masks. Explanation: 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. pg.605
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) Risk for falls. b) Ineffective breathing pattern. c) Ineffective airway clearance. d) Impaired tissue integrity.
c) Ineffective airway clearance. Explanation: 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. pg.582
You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? a) Negative Homan's sign b) Pain in the feet c) Pain in the calf d) Inability to dorsiflex
c) Pain in the calf Explanation: When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis. pg.600
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest? a) Clubbing of fingers and toes b) Respiratory acidosis c) Paradoxical chest movement d) Chest pain on inspiration
c) Paradoxical chest movement Explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall 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. pg.612
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? a) Partial pressure of arterial carbon dioxide (PaCO2) b) pH c) Partial pressure of arterial oxygen (PaO2) d) Bicarbonate (HCO3-)
c) Partial pressure of arterial oxygen (PaO2) Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed. pg.595
A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following? a) Pneumothorax b) Hemothorax c) Pleural effusion d) Consolidation
c) Pleural effusion Explanation: 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 due to collapse of alveoli or infectious process. pg.593
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? a) Keeping the door to the client's room open to observe the client b) Instructing the client to wear a mask at all times c) Putting on an individually fitted mask when entering the client's room d) Wearing a gown and gloves when providing direct care
c) Putting on an individually fitted mask when entering the client's room Explanation: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask 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. pg.591
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 the chest tube is clogged. b) See if the wall suction unit has malfunctioned. c) See if there are leaks in the system. d) See if a kink has developed in the tubing.
c) See if there are leaks in the system. Explanation: 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. pg.526
Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall? a) Use a prescribed analgesic b) Use a heat or cold application c) Turn onto the affected side d) Avoid using a pillow while splinting
c) Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side. The nurse also instructs the patient to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The patient can also splint the chest wall with a pillow when coughing. pg.593
A mechanically ventilated patient is receiving a combination of atracurium (Tracrium) and an opioid analgesic morphine. The nurse monitors the patient for which potential complication? a) Pulmonary hypertension b) Cor pulmonale c) Venous thromboemboli d) Pneumothorax
c) Venous thromboemboli Explanation: Neuromuscular blockers predispose the patient to venous thromboemboli (VTE), muscle atrophy, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The patient may have discomfort or pain but be unable to communicate these sensations. pg.597
Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is a) tertiary drug resistance. b) secondary drug resistance. c) primary drug resistance. d) multidrug resistance.
c) primary drug resistance. Explanation: Primary drug resistance to one of the first-line antituberculotic agents is people who have not had previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in patients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance. pg.589
A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? a) "Getting the flu can complicate pneumonia." b) "Influenza vaccine will prevent typical pneumonias." c) "Influenza is the major cause of death in the United States." d) "Viruses, like influenza, are the most common cause of pneumonia."
d) "Viruses, like influenza, are the most common cause of pneumonia." Explanation: Influenza type A is the most common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States. pg.573
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? a) A negative reaction always excludes the diagnosis of TB. b) The PPD can be read within 12 hours after the injection. c) A positive reaction indicates that the client has active tuberculosis (TB). d) A positive reaction indicates that the client has been exposed to the disease.
d) A positive reaction indicates that the client has been exposed to the disease. Explanation: 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. pg.588
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following? a) Bronchitis b) Lung cancer c) Tracheobronchitis d) Acute respiratory distress syndrome
d) Acute respiratory distress syndrome Explanation: 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. pg.596
The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension? a) Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. b) Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. c) Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. d) Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
d) Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Explanation: In secondary pulmonary arterial hypertension, alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Therefore options A, B, and C are incorrect. pg.598
A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? a) Silica b) Coal dust c) Pollen d) Asbestos
d) Asbestos Explanation: Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis. pg.605
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? a) Crackles b) Wheezes c) Rhonchi d) Decreased breath sounds
d) Decreased breath sounds Explanation: In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis. pg.593
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Sore throat and abdominal pain b) Nonproductive cough and normal temperature c) Hemoptysis and dysuria d) Dyspnea and wheezing
d) Dyspnea and wheezing Explanation: 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. pg.577
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a) Decreased cardiac output b) Anxiety c) Ineffective tissue perfusion (cardiopulmonary) d) Impaired gas exchange
d) Impaired gas exchange Explanation: 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. pg.610
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a) Activity intolerance b) Impaired oral mucous membranes c) Imbalanced nutrition: Less than body requirements d) Impaired gas exchange
d) Impaired gas exchange Explanation: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client. pg.582
Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? a) Constipation usually develops b) It is spread by fecal contamination c) Hypothermia will occur d) It is the most contagious during the second week of illness
d) It is the most contagious during the second week of illness Explanation: Based on available information, SARS is most likely to be contagious only when symptoms are present, and patients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes. pg.586
Which of the following types of lung cancer is characterized as fast growing and tending to arise peripherally? a) Bronchoalveolar carcinoma b) Adenocarcinoma c) Squamous cell carcinoma d) Large cell carcinoma
d) Large cell carcinoma Explanation: Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow growing. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located. pg.605
A 62-year-old female client arrives at the office complaining of dyspnea and fatigue. She tells the nurse that she's had a persistent productive cough for the last few months, which she attributes to a bout with the flu. The nurse suspects that this client may have which of the following? a) Pleurisy b) Lung abscess c) Pleural effusion d) Lung cancer
d) Lung cancer Explanation: Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. The sputum is examined for malignant cells. Chest x-rays may or may not show a tumor. With pleurisy, the client's respirations become shallow secondary to excruciating pain. The client may have a dry cough, fatigue easily, and experience dyspnea. Fever, pain, and dyspnea are the most common symptoms of pleural effusion. Signs and symptoms of lung abscess include chills, fever, weight loss, chest pain, and a productive cough. pg.607
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? a) Uncertain b) Positive c) Borderline d) Negative
d) Negative Explanation: The size of the induration determines the significance of the reaction. A reaction of 0-4 mm is not considered to be significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity. pg.588
A 29-year-old client presents to the ED complaining of dyspnea on exertion and overall weakness. Her pulmonary arterial pressure is 40/15 mm Hg. These symptoms indicate that the client may have which of the following conditions? a) Atelectasis b) Restrictive lung disease c) Asthma d) Pulmonary arterial hypertension
d) Pulmonary arterial hypertension pg.599
Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an increase in the death rates of pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza? a) Tracheobronchitis b) Viral pneumonia c) Cardiovascular disease d) Staphylococcal pneumonia
d) Staphylococcal pneumonia Explanation: Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease. Staphylococcal pneumonia is the most serious complication. Although tracheobronchitis is a complication of the flu, it is not the most serious one. Although cardiovascular disease is a complication of the flu, it is not the most serious one. Bacterial, not viral, pneumonia is a possible complication of the flu, although not its most serious one. pg.577
A patient involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the patient for which clinical manifestation that would indicate the presence of a pneumothorax? a) Bloody, productive cough b) Diminished breath sounds c) Decreased respiratory rate d) Sucking sound at the site of injury
d) Sucking sound at the site of injury Explanation: Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed sucking chest wounds pg.614
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? a) Symptoms are often minimized by clients. b) There are no early symptoms of lung cancer. c) Symptoms often mimic other infectious diseases. d) Symptoms often do not appear until the disease is well established.
d) Symptoms often do not appear until the disease is well established. Explanation: 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. pg.607
A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following? a) Consume majority of fluid intake prior to bed. b) Wear tight-fitting clothing. c) Begin estrogen replacement. d) Tense and relax muscles in lower extremities.
d) Tense and relax muscles in lower extremities. Explanation: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent the development of 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. pg.601
A 68-year-old male client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The nurse knows that the surgical team places this catheter: a) To administer IV medication b) To ventilate the client c) To remove fluid from the lungs d) To remove air from the pleural space
d) To remove air from the pleural space Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery—one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid. Chest tubes are placed to remove anteriorly air from the pleural space following thoracic surgery. The anesthesiologist ventilates the client during surgery. Postsurgery, a chest tube is placed anteriorly to remove air from the pleural space. pg.527
Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall? a) Elevate the head of the bed b) Use a prescribed analgesic c) Use a heat application d) Turn onto the affected side
d) Turn onto the affected side Explanation: The nurse teaches the patient to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain. pg.593
A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that he will be safe from infecting others approximately how long after initiation of the chemotherapy regimen? a) Within 48 hours after initiation of bacteriocidal drugs b) Results vary with each client, so it is difficult to predict c) After completion of 6 months of bacteriocidal drugs d) Two to 3 weeks after initiation of bacteriocidal drugs
d) Two to 3 weeks after initiation of bacteriocidal drugs Explanation: The client needs to take the prescribed medications for approximately 2 to 3 weeks before discontinuing precautions against infecting others. Effectiveness of the drug therapy is determined by negative sputum smears obtained on three consecutive days. Although results can vary among clients, the majority respond to therapy within 2 to 3 weeks. pg.590
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) follow up with the physician in 2 weeks. b) turn and reposition himself every 2 hours. c) maintain fluid intake of 40 oz (1,200 ml) per day. d) continue to take antibiotics for the entire 10 days.
d) continue to take antibiotics for the entire 10 days. Explanation: 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. pg.583
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) area of redness is measured in 3 days and determines whether tuberculosis is present. b) test stimulates a reddened response in some clients and requires a second test in 3 months. c) presence of a wheal at the injection site in 2 days indicates active tuberculosis. d) skin test doesn't differentiate between active and dormant tuberculosis infection.
d) skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis. pg.588
Following thoracic surgery, the care plan for a client at risk for impaired gas exchange would include which of the following? Select all that apply. a) Elevate head of bed 30°-40° as tolerated. b) Reinforce preoperative breathing exercises. c) Administer pain medications. d) Maintain accurate record of intravenous intake. e) Monitor vital signs frequently.
e) Monitor vital signs frequently. b) Reinforce preoperative breathing exercises. a) Elevate head of bed 30°-40° as tolerated. Explanation: 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. pg.528
