Honan-Chapter 10: Nursing Management: Patients With Chest and Lower Respiratory Tract Disorders

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 60; 50 60; 40 75; 50 75; 40

60; 50 Explanation: Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to less than 60 mm Hg on room air) and hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to greater than 50 mm Hg with an arterial pH of less than 7.35).

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Aspiration pneumonia Tracheal bleeding Tracheal ischemia Pressure necrosis

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

A patient has been brought to the emergency department (ED) by the paramedics. The patient is suspected of having acute respiratory distress syndrome (ARDS). What action should the nurse anticipate? Preparing to assist with intubating the patient Setting up oxygen at 3 LPM by nasal prongs Consulting physiotherapy Setting up a nebulizer

Preparing to assist with intubating the patient Explanation: A patient who has ARDS usually requires mechanical ventilation with a higher than normal airway pressure. While oxygen, nebulizer, and physiotherapy will be used at various stages of the treatment of ARDS, the priority is to secure the airway.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing Cyanosis

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.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Ascites Dyspnea Hypertension Syncope

Dyspnea Explanation: Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Getting the flu can complicate pneumonia." "Influenza vaccine will prevent typical pneumonias." "Influenza is the major cause of death in the United States." "Viruses like influenza are the most common cause of pneumonia."

"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.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago A client who ambulates in the hallway every 4 hours A client with a nasogastric tube A client who is receiving acetaminophen (Tylenol) for pain

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.

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis

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.

The nurse is assessing a patient with a blunt chest trauma due to an MVA. What finding would be indicative of a flail chest? A. Hypertension B. Metabolic alkalosis C. Paradoxical chest movement D. Respiratory alkalosis

C.. Paradoxical chest movement RATIONALE 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 exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Hypotension, inadequate tissue perfusion, and metabolic acidosis often follow as the paradoxical motion of the mediastinum decreases cardiac output. Metabolic alkalosis and respiratory alkalosis would not be an assessment finding that correlates with a flail chest.

A nurse should include what instruction for the client during postural drainage? Lie supine to rest the lungs. Sit upright to promote ventilation. Remain in each position for 30 to 45 minutes for best results. Change positions frequently and cough up secretions.

Change positions frequently and cough up secretions. Explanation: Clients who lie supine will have secretions accumulate in the posterior lung sections, whereas upright patients will pool secretions in their lower lobes. By changing positions, secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? Nonproductive cough and abdominal pain Hypertension and lack of fever Bradypnea and bradycardia Chest pain and dyspnea

Chest pain and dyspnea Explanation: As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.

A patient is receiving thrombolytic therapy for treatment of a pulmonary emboli. For what side effect should the nurse must monitor the patient? A. Chest pain B. Rash C. Hyperthermia D. Bleeding

D. Bleeding RATIONALE Thrombolytic therapy dissolves the thrombi or emboli more quickly and restores more normal hemodynamic functioning of the pulmonary circulation, thereby reducing pulmonary hypertension and improving perfusion, oxygenation, and cardiac output. However, bleeding is a significant side effect. Chest pain, a rash, and elevated temperature are not therapy-specific side effects associated with the use of thrombolytics.

Which intervention does a nurse implement for clients with empyema? Encourage breathing exercises Place suspected clients together Institute droplet precautions Do not allow visitors with respiratory infections

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

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Insidious onset of lung impairment in a client who had normal lung function Sudden onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had compromised lung function

Sudden onset of lung impairment in a client who had normal lung function Explanation: In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Skin around tube is pink. Bloody drainage is observed in the collection chamber. Absence of bloody drainage in the anterior/upper tube The tissues give a crackling sensation when palpated.

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

A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately? "Client is becoming agitated and complains of pleuritic pain." "Client is drowsy and complains of headache." "Client has subcutaneous emphysema around needle insertion site." "Client has oxygen saturation of 93%."

"Client is becoming agitated and complains of pleuritic pain." Explanation: After a thoracentesis, the nurse monitors the client 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 client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm clear when my chest X-ray is negative." "I'm contagious as long as I have night sweats." "I'll stop being contagious when I have a negative acid-fast bacilli test."

"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.

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? "I am going to have a tuna fish sandwich for lunch." "It is all right if I drink a glass of red wine with my dinner." "It is all right if I have a grilled cheese sandwich with American cheese." "It is fine if I eat sushi with a little bit of soy sauce."

"It is all right if I have a grilled cheese sandwich with American cheese." Explanation: Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? "Early treatment can stop the progression of the disease." "The mucus-secreting glands are abnormal." "There are fibrous cysts in the lungs." "Allergic reactions cause inflammation in the lungs."

"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.

The nurse is caring for a client diagnosed with ARDS. In evaluating the use of PEEP, what outcome would the nurse expect to find? A. Increased ventilation-perfusion mismatch B. Increased FRC C. Decreased intrathoracic pressure D. Decreased FRC

B. Increased FRC RATIONALE The use of PEEP helps increase functional residual capacity (FRC) and reverse alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation and a reduction in the severity of the ventilation--perfusion imbalance. The use of positive-pressure ventilation increases intrathoracic pressure and causes a decrease in preload to the heart.

The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease? Cough and dyspnea Black-streaked sputum Tenacious secretions Barrel chest

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.

A nurse working on a general medical-surgical floor is discussing the clinical manifestations of pulmonary arterial hypertension (PAH) with a recent nursing graduate. What is the main symptom of PAH that the nurse would explain? A. Chest pain B. Fatigue C. Dyspnea D. Hemoptysis

C. Dyspnea RATIONALE Dyspnea, the main symptom of both types of PAH, first occurs with exertion and eventually at rest. Other signs and symptoms include chest pain, weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure.

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? Aspiration Drug ingestion Chemical irritation Direct lung damage

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.

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? Public service announcements on television to promote the use of high-efficiency particulate air (HEPA) filters in homes Advertisements in public places to encourage cigarette smokers to have yearly chest x-rays Classes at community centers to teach about smoking cessation strategies Legislation that requires homes and apartments be checked for asbestos leakage

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.

The nurse assigned to a patient with possible pulmonary edema assesses the patient's lungs. Using auscultation, she identifies a characteristic breath sound diagnostic of pulmonary edema. Which of the following describes that breath sound? Crackles in the lung bases A low-pitched rhonchi during expiration A pleural friction rub Sibilant wheezes

Crackles in the lung bases Explanation: Auscultation reveals crackles in the lung bases (especially in the dependent lung areas) that rapidly progress toward the apices of the lungs. These crackles are caused by the movement of air through the alveolar fluid. The chest X-ray reveals increased interstitial markings, with or without cardiomegaly. The patient may have tachycardia. Pulse oximetry values begin to fall, and arterial blood gas analysis demonstrates worsening hypoxemia.

A nurse is caring for a patient diagnosed with lung cancer who has a chest tube. The chest tube has continuous bubbling in the water-seal chamber. What does the nurse understand that this indicates? A. Tidaling B. The tube in the mediastinum C. A properly functioning system D. An air leak in the system

D. An air leak in the system RATIONALE Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Fluctuation of the water level in the water seal is called tidaling. Bubbling and tidaling do not occur when the tube is placed in the mediastinal space.

The nurse is caring for a client with tuberculosis. Why should the nurse always encourage a client with tuberculosis to perform active range-of-motion (ROM) exercises three times a day? For medication absorption For maintaining muscle strength For use as a baseline for evaluation For effective pain control

For maintaining muscle strength Explanation: The nurse should always encourage active ROM exercises three times a day. Active ROM exercises maintain muscle strength and joint ROM. Assessment of pain level and other factors provide a baseline for treatment and evaluation. Proper pain assessment and appropriate analgesic administration provide more effective pain control. The nurse typically instructs the client to administer medication 1 hour before or 2 hours after meals because food interferes with medication absorption.

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? Risk for Infection Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern

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.

A nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority? Disturbed body image related to changes in body functions Ineffective airway clearance related to obstruction by a tumor or secretions Anxiety related to actual threat to health status and changes in family dynamics Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy

Ineffective airway clearance related to obstruction by a tumor or secretions Explanation: Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, Ineffective airway clearance related to obstruction by a tumor or secretions takes highest priority. Although a client with bronchogenic carcinoma is likely to have Disturbed body image, Anxiety, and Imbalanced nutrition: Less than body requirements, these nursing diagnoses have a lower priority.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery

Intubate the client and control breathing with mechanical ventilation Explanation: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

The most diagnostic clinical symptom of pleurisy is: Dullness or flatness on percussion over areas of collected fluid. Dyspnea and coughing. Fever and chills. Stabbing pain during respiratory movements.

Stabbing pain during respiratory movements. Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.

A mediastinal shift occurs in which type of chest disorder? Tension pneumothorax Traumatic pneumothorax Simple pneumothorax Cardiac tamponade

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.

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? Turn onto the affected side. Use a prescribed analgesic. Avoid using a pillow while splinting. Use a heat or cold application.

Turn onto the affected side. Explanation: Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

What does a positive Mantoux test indicate? active immunity to tuberculosis production of an immune response development of full-blown tuberculosis an active case of tuberculosis

production of 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.

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: area of redness is measured in 3 days and determines whether tuberculosis is present. skin test doesn't differentiate between active and dormant tuberculosis infection. presence of a wheal at the injection site in 2 days indicates active tuberculosis. test stimulates a reddened response in some clients and requires a second test in 3 months.

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.