Chapter 49 Care of the Patient With a Respiratory Disorder

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply) A client who has a BMI of 30 A female client who is postmenopausal A client who has a fractured femur A client who is a marathon runner A client who has chronic atrial fibrilation

A client who has a BMI of 30 A client with a fractured femur A client who has chronic atrial fibrilation

COPD (chronic obstructive pulmonary disease)

A group of lung diseases that block airflow and make it difficult to breathe. Emphysema and chronic bronchitis

*The exchange of oxygen and carbon dioxide in external respiration takes place in the:

Alveoli

Pneumonia expected findings:

Anxiety Fatigue Weakness Chest Discomfort due to coughing Confusion from hypoxia - most common in older adults

The nurse is assisting with the care of a patient with an acute asthma attack. The patient has audible wheezes and o2 sat of 92%. What type of medication would you administer?

Beta 2 agonist (albuterol)

A nurse is collecting data from a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Bronchospasms

____________ in the brain perform what function. How does it affect breathing? Carotid and aortic bodies (chemoreceptors) specialized receptors when stimulated by increasing levels of blood carbon dioxide (CO2), decreasing levels of blood oxygen (O2), or increasing blood acidity, these receptors send nerve impulses to the respiratory centers (the medulla oblongata and pons), which in turn modify respiratory rates.

Chemoreceptors

A patient who was in a motor vehicle accident and has a lacerated pleura secondary to fractured ribs. To promote reexpansion of his lung, what type of thoracic drainage system was used?

Closed system to maintain the lungs' normal negative pressure

Which instruction by the nurse is inappropriate for teaching the proper technique for collecting a sputum specimen?

Collect specimens after meals. Collecting specimens before meals will avoid possible emesis from coughing after eating.

PH 7.3 PACO2 high Bicarb low = metabolic acidosis - not compensated. PH 7.35 pco2 25

Compensated respiratory acidosis

A nurse is collecting data on a client who has pulmonary embolism. Which of the following manifestations should the nurse expect (Select all that apply) Bradypnea Diaprhoresis Hypertension Cyanosis Tachycardia

Diaphoresis Cyanosis Tachycardia

Which nursing intervention does the nurse add to the care plan to help a patient with thick sputum mobilize and expectorate those secretions?

Drink 3 to 4 L of water a day. Encourage fluids to liquefy secretions and aid in their expectoration.

*What is the concern for patients who are being treated for tuberculosis?

Drug therapy lasts 6-9 months and about 50% of patients are non-compliant.

Tuberculosis (TB) is treated with multiple drugs to which organisms are susceptible. How many drugs are usually preferred to increase therapeutic effectiveness?

Four At least four drugs, in combination, are used to prevent the emergence of organisms resistant to the others, thus increasing the therapeutic effectiveness.

In what manner would the nurse examine a patient with pleurisy. What sounds would you expect to hear?

Friction rub.

The patient, age 72, is admitted with acute pulmonary edema. In pulmonary edema, the medical management will often include:

IV infusion of D5LR at less than 30 mL/hr. Medications for acute pulmonary edema will include diuretics such as Lasix and a narcotic analgesic, usually morphine sulfate. A patent IV line must be maintained, usually at a very slow rate to keep the vein open for medicatio

Which patient problem for a client with an acute asthma attack has the highest priority?

Inability to Maintain Adequate Breathing Pattern, related to anxiety

*A patient, age 69, has emphysema. On assessing him, the nurse notes the presence of a "barrel chest." This pathology results from a(n):

Increased anteroposterior diameter caused by overinflation of the alveoli. The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation).

Asthma

Involves episodic increased tracheal and bronchial responsiveness to various stimuli, resulting in widespread narrowing of the airways. Extrinsic means it is caused by external factors, such as environmental allergens (e.g. pollen, dust, feathers, animal dander, foods); Intrinsic asthma is from internal causes, not fully understood but often triggered by respiratory tract infection.

Which intervention should the nurse use to keep the chest tube from becoming occluded?

Keep the patient from laying on it.

Which is an age related change in an older adult that increases the risk of respiratory distress?

Kyphosis Inactive TB may become active Statis of secretions Reduced number of cilia.

Which important precaution should the nurse include when instructing a patient with emphysema on the use of home oxygen?

Limit to 1 to 2 L of oxygen flow

*A patient is being evaluated to rule out pulmonary tuberculosis (TB). Which finding is most closely associated with TB?

Night sweats

A nurse is providing information about TB to clients at a community center. Which of the following manifestations should the nurse include in her presentation?

Night sweats Hemoptysis Persistent cough

The patient has COPD. To teach him pursed-lip breathing, the nurse should instruct him to inhale slowly through his

Nose, then exhale more slowly through pursed lips. The nurse should instruct the patient and family on effective breathing techniques (such as pursed-lip breathing) and relaxation exercises for anxiety control. The patient should inhale through the nose and exhale through pursed lips. The exhalation should be 2 - 3 times longer than the inhalation.

A nurse is reinforcing discharge instructions with a client with COPD and had a collapsed lung.

Notify your provider if you have a productive cough.

*A patient is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breathe. What is the name of this abnormal condition, in which there is discomfort in breathing in any but an erect sitting position?

Orthopnea

Which test is a quick and reliable aid to diagnose latent TB?

QFT-G Sputum smears, cultures and PPD skin tests are still done. However, QFT-G offers a quick and reliable diagnosis for the patient and health care provider. The results of QFT-G are greater specificity and results are available 24 hours after the blood is collected.

*A 68-year-old male patient has chronic obstructive pulmonary disease (COPD). He has a markedly increased need for protein and calories to maintain an adequate nutritional status. To help him get the nutrition he needs, the nurse would encourage him to:

Rest 30 minutes before eating. The nurse can assist the patient in maintaining nutritional intake by advising rest for 30 minutes before eating.

The older adult patient with long term emphysema reports experiencing sharp pleuritic pain. Patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds.

Spontaneous pneumothorax.

*A 71-year old patient is admitted with an exacerbation of COPD. He has dependent edema, ascites, and dyspnea. A complication that may occur in COPD, in which some of the capillaries surrounding the alveoli are destroyed, resulting in pulmonary hypertension, blood returning to the right side of the heart, and signs and symptoms of right-sided HF, is:

cor pulmonale.

*Which type of medication is used as rescue medication in an acute asthma exacerbation?

short-acting beta1-agonists

Acute Asthma attack

usually occurs at night and includes tachypnea, tachycardia, diaphoresis, chest tightness, cough, expiratory wheezing, use of accessory muscles, and nasal flaring.

*During discharge teaching of a pulmonary emphysema patient who is going home with oxygen, what does the nurse emphasize?

"Keep low flow oxygen at 1 to 2 L by nasal cannula." Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body's own respiratory regulatory centers.

*A patient, age 68, has a long history of COPD and is admitted to the hospital with cor pulmonale. He says his doctor said his heart was failing and asks whether he is having a heart attack. Which explanation by the nurse is most correct?

"You aren't having a heart attack, but your heart has been damaged by changes in your lungs caused by your respiratory disease." COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites.

Appropriate nursing care for a patient with pneumonia includes which intervention? (Select all that apply)

A. Assist the patient to conserve energy. Correct B. Position the patient with the side of the good lung up. C. Place the patient in a semi to high-Fowler's position. Correct D. Educate the patient about the importance of hand washing. Correct E. Encourage the patient to limit fluids.

*The removal of fluid from the pleural space by thoracentesis presents a possible danger in removing fluid too rapidly. How much fluid removal is recommended at one time?

1,300 to 1,500 mL at one time. A possible danger from the thoracentesis procedure is removing fluid too rapidly; less than 1,300 to 1,500 mL at one time is recommended.

*The patient with respiratory acidosis demonstrates: (Select all that apply). 1. disorientation. 2. pH of less than 7.35. 3. pH of more than 7.44. 4. rapid respirations.

1. disorientation. 2. pH of less than 7.35.

*Ineffective breathing pattern, related to decreased lung expansion during an acute attack of asthma, is an appropriate nursing diagnosis. Which nursing interventions are correct? (Select all that apply.) 1. Place the patient in a supine position. 2. Administer oxygen therapy as ordered. 3. Remain with the patient during acute attack to decrease fear and anxiety. 4. Incorporate rest periods into activities and interventions. 5. Maintain semi-Fowler's position to facilitate ventilation.

2. Administer oxygen therapy as ordered. 3. Remain with the patient during acute attack to decrease fear and anxiety. 4. Incorporate rest periods into activities and interventions. 5. Maintain semi-Fowler's position to facilitate ventilation.

Which statement most accurately describes the disease tuberculosis (TB)?

A. TB is easily spread from person to person via respiratory secretions. B. TB has the highest rates in the white U.S. population. C. All strains of TB are resistant to antibiotic therapy. D. Most people who become infected with the TB organism do not progress to the active disease stage. Correct

Interventions that contribute to comfort in patients experiencing dyspnea include: (Select all that apply)

Breathing exercises Acupuncture Visualization Massage. Breathing exercises, acupuncture, visualization and massage help decrease the level of dyspnea by using distraction and relaxation methods to provide the patient with some control.

*The patient is diagnosed with pleurisy. Which adventitious breath sounds is the nurse most likely to hear?

Dry, creaking, grating with a machinelike quality loudest over the anterior chest. ***Friction rub***

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risk for complications? (Select all that apply)

Dyspnea Fever Hypotension

A patient with long term emphysema has developed cor pulmonale. What symptoms would they likely exhibit?

Edema of the lower extremities Extended neck veins Pulmonary circulation hypertension.

A patient is on post op day 2 after a hip replacement complaining of sudden chest pain, coughing up blood tinged sputum. Which action by the nurse would be the first intervention?

Elevate the head of the bed and give oxygen.

The nurse is caring for a patient with bronchiectasis. Based on an understanding of the pathologic changes that occur with this disease, which intervention to promote clearance of respiratory secretions does the nurse plan?

Postural drainage Encourage postural drainage. Suction the patient as needed and provide assistance in turning, coughing, and deep breathing every 2 hours. Assist with chest physiotherapy.

Prevention of acute respiratory complications in surgical patients is a nursing goal that involves which intervention?

Teaching all preoperative patients how to use incentive spirometers and how to cough and deep breathe effectively. Postoperatively, patients should be reminded to cough, deep breathe, and change positions every 1 to 2 hours.

*Which are signs of respiratory distress?

Abdominal breathing, SaO2 89% Observe the patient's facial expressions and signs of respiratory distress such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing.

The ___________ are the structures of the lung in which gas exchange occurs.

Alveoli The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place.

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?

Apply sterile gauze or occlusive dressing to the insertion site

*A patient, age 54, is on postoperative day 2 after undergoing an open cholecystectomy. Immediately after the surgery, she vomited and may have aspirated some emesis. The nurse is concerned that the patient will develop pneumonia. In planning for her care, the nurse suspects the patient may have

Aspiration pneumonia. Aspiration pneumonia occurs most commonly as a result of aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure, drugs, alcohol, anesthesia, acute infection, or shock.

What does a nurse teach an adult male who has had a tonsillectomy?

Avoid coughing and clearing the throat during the first week postoperatively. The nurse should teach the patient to avoid attempting to clear the throat immediately after surgery and to avoid coughing, sneezing, or vigorous nose blowing for 1 to 2 weeks. Maintain IV fluids until the nausea subsides, at which time the patient may begin drinking ice-cold clear liquids. The diet is advanced to custard and ice cream and then to a normal diet as soon as possible. Apply an ice collar to the neck for comfort and to reduce bleeding by vasoconstriction.

*When a patient has experienced a pneumothorax, chest auscultation reveals:

Bilateral unequal breath sounds, with no breath sounds over the affected area. Findings on auscultation are bilaterally unequal breath sounds, with no breath sounds over the affected area. A larger pneumothorax causes respiratory distress, including rapid shallow respirations, air hunger, dyspnea, and oxygen desaturation.

Cor pulmonale, right ventricular failure

Chronic enlargement of the right ventricle resulting from congestion of the pulmonary circulation Results in edema in the lower extremities and in the sacral and perineal areas, distended neck veins, and enlargement of the liver with ascites. Cor pulmonale is a late complication of emphysema.

Identify the purposes of chest drainage: (Select all that apply)

Drains air, blood and fluid from pleural space Restores positive pressure in chest cavity Allows route for medication administration. A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavity's normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water-seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space.

COPD nursing interventions

Elevating the head of the bed and administering low-flow oxygen (1 to 2L by nasal cannula). Assist the patient in maintaining nutritional intake by advising rest for 30 minutes before eating. A high-protein, high-calorie diet should be divided into five or six small meals a day. Oral fluid intake should be 2 to 3 L/day unless contraindicated Encouraging the patient to get a flu vaccination each year and a pneumococcal revaccination every 5 years

An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. The chest radiograph reveals an accumulation of fluid in the pleural space, which the physician removes by performing a thoracentesis. The nurse correctly records the purulent exudate as:

Empyema. If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.

Which interventions are health promotions to prevent pneumonia? (Select all that apply.)

Encourage elderly patients to receive influenza and pneumococcal vaccines. Provide for good health habits (nutrition, hygiene, exercise). Check for placement before administering tube feedings. Older adults should receive pneumococcal and influenza vaccines. Good health habits are the basis for preventing disease. Aspiration can occur if the nasogastric tube is not correctly placed in the stomach. New stroke patients should be assisted with eating until the gag reflex is established.

A nurse is collecting data from a client who has a chest tube and drainage system in place. Which of the following are expected findings?

Gentle constant bubbling in the suction control chamber Rise and fall in the level of water in the water seal chamber with inspiration and expiration.

A second-day postoperative patient is recovering from thoracic surgery. Which therapeutic nursing intervention would the nurse carry out first?

Help the patient cough and deeply breathe by splinting the anterior and posterior chest

*In the treatment of asthma, peak flow monitoring measures include elevating the head of the bed and administering low-flow oxygen (1 to 2 L by nasal cannula) as ordered are important to help the patient manage the asthma. Peak flow monitoring measures:

How well air moves out of the lungs during forceful exhalation.

*A 52-year old patient has a laryngectomy due to cancer of the larynx. Discharge instructions are given to the patient and his family. Which response, by written communication from the patient or verbal response by the family, indicates that the instructions need to be clarified?

It is acceptable to take over-the-counter medications now that conditions is stable

Which are routes in which the anthrax bacterium may enter the body? (Select all that apply.)

Lungs Skin Intestine. In humans, anthrax gains a foothold when spores enter the body via the skin, intestines, or lungs.

Which position is the most beneficial for a patient after surgery for creation of a tracheostomy?

Mid-Fowler's. Maintain head of bed elevation of 30 degrees or higher (mid-Fowler's).

A patient informs the nurse "I cannot breathe while lying flat and must sleep with two pillows". What word would the nurse use to document this condition?

Orthopnea

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply).

Pale skin Elevated blood pressure.

Which expected outcome(s) would indicate improvement in a patient with emphysema? (Select all that apply.)

Patent airway Normal arterial blood gasses (for this patient) Decreased dyspnea. Patients will maintain patent airway as evidenced by decreased rhonchi, wheezes, tachypnea, dyspnea, and arterial blood gas (ABG) values within limits (for this patient).

The patient has been admitted for possible carcinoma of the larynx. The first sign or symptom that may be present in carcinoma of the larynx is often:

Persistent hoarseness. Progressive or persistent hoarseness is an early sign.

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?

Place an occlusive dressing over the site once the tube is removed.

A 62-year-old patient is seen in the emergency department with an epistaxis. When a patient has an epistaxis, the correct nursing interventions would be

Place the patient in Fowler's position with the head forward. Elevate head of bed. Place the patient in Fowler's position with the head forward. Compression of nostrils should be for 10-15 minutes. Hot compresses will increase bleeding-ice should be applied.

*The appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis would be to:

Place the patient in acid-fast bacillus (AFB) isolation precautions. If TB is suspected, permission to place the patient in acid-fast bacilli (AFB) isolation precautions should be requested immediately.

The patient, age 91, has COPD and complains of dyspnea and fatigue. Activity intolerance, related to an imbalance between the oxygen supply and demand, is a nursing diagnosis for COPD. Which nursing intervention would be inappropriate:

Plan care to provide optimum rest. Nursing interventions will be directed at attempting to decrease the patient's anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living.

*A 52-year-old patient has had a laryngectomy in treatment of cancer. A nursing diagnosis for the patient with a laryngectomy would be social isolation related to impaired verbal communication related to removal of the larynx. The correct nursing intervention would be appropriate:

Provide a pad and pencil or magic slate available. Provide patients with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation.

A patient with a new laryngectomy has feelings of isolation due to not being able to communicate. Which nursing intervention is appropriate:

Provide a pad and pencil or magic slate.

A nurse is assisting with the plan of care for a client who has respiratory distress. Which of the following interventions should the nurse include in the plan?

Provide emotional support to the client Encourage the client to cough Perform oral suctioning as needed.

The circulation of the lungs is through the

Pulmonary arteries and pulmonary veins The lungs receive their blood supply, which comes directly from the heart, through the pulmonary arteries. The blood, now rich in oxygen, is returned to the heart for circulation to the body via the pulmonary veins to the left atrium.

The surgeon administers nasal epinephrine to a patient after nasal surgery. The nurse explains to the patient that this is done primarily to

Reduce the possibility of bleeding. 1:1,000 epinephrine promotes local vasoconstriction and reduces the possibility of bleeding. Epinephrine does act as a bronchodilator, but is used primarily for vasoconstriction post nasal surgery.

Which patient assessment indicates the most severe respiratory distress.

Substernal retractions with sat at 84%.

The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient, age 64, who has undergone a pneumonectomy. A common etiology for this nursing diagnosis in patients who have had a pneumonectomy is

Surgical incision pain. Nursing interventions are often directed at post surgical interventions, including facilitating recovery and preventing complications by promoting effective airway clearance through frequent repositioning, coughing, and deep breathing. Surgical incisional pain prevents the patient from breathing deeply and coughing effectively.

*When an arterial blood gas is obtained from a patient who is taking warfarin, which special consideration is needed?

The clotting time is prolonged; pressure is held for 20 minutes on the puncture site.

The health care provider ordered a blood culture and sputum specimen for a patient who has pneumonia. When should the nurse collect these specimens? (Select all that apply.)

The morning after admission Before initiation of antibiotic therapy

*A patient has just returned to her room after a bronchoscopy. No food or fluids shall be given after the examination until which event has occurred?

The patient's gag reflex returns

Emphysema

The primary symptom of emphysema is dyspnea on exertion, which becomes progressively more severe. The patient with emphysema is disabled because all available energy must be used for breathing.

The nurse is caring for a patient with a diagnosis of pleural effusion. The physician is most likely to order a _____________ to remove fluid from around the lungs so that the patient may breathe more easily. Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort.

Thoracentesis Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort.

*A patient, age 22, is admitted with acute asthma. It is important to monitor his oxygen saturation levels. The quickest way to assess his saturation of oxygen is to:

Use pulse oximetry. In acute asthma, oxygen therapy should be started immediately, and its administration should be monitored by pulse oximetry. Pulse oximetry is noninvasive and provides continuous monitoring of SaO2.

A patient is on postoperative day 4 after undergoing a total hip replacement. He is diagnosed as having a pulmonary embolism. Pulmonary embolism may occur as a postoperative complication of

Venous thrombosis. Venous status, venous wall injury, and increased coagulability of blood cause the formation of a venous thrombosis. The thrombus (usually in the deep veins of the lower extremities) dislodges and travels through the venous circulation; it passes through the right side of the heart and enters the pulmonary artery, where it becomes lodged.

*The health care workers caring for a patient with active TB are instructed in methods of protecting themselves from contracting TB. What does the Centers for Disease Control and Prevention currently recommend for health care workers who care for TB-infected patients?

Wear a small-micron, fitted filtration mask

What are common signs of respiratory distress? A person presents to the emergency department with an acute asthma attack.

Wheezing Unable to speak full sentences Sternal retractions.

When are rapid and deeper respirations stimulated by the respiratory center of the brain? 1. When oxygen saturation levels are greater than 90% 2. When carbon dioxide levels increase 3. When the alveoli contract 4. When the diaphragm contracts and lowers its dome

When carbon dioxide levels increase

Patient with a bronchoscopy is concerned about when they can eat?

When gag reflex returns.