Nur1130-test2-ch23-wrong

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

"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 c

.induration size of_________ is considered not significant.

0 to 4 mm

TB - size of induration determines the significance of the reaction.

0-4 mm: not significant. >=5 mm: significant in ppl at risk. >=10 mm significant in ppl who have normal or mildly impaired immunity.

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range? 0.5 to 1.0 1.5 to 2.5 2.0 to 2.5 3.0 to 3.5

2.0 to 2.5 Explanation: Low-molecular- weight heparin and fondaparinux (Arixtra) are the cornerstones of therapy, but IV unfractionated heparin may be used during the initial phase (ACCP, 2012).

.induration size of__ ______may be significant in people who are considered to be at risk.

5 mm or greater

What dietary recommendations should a nurse provide a patient with a lung abscess?

A diet rich in protein

On auscultation, which finding suggests a right pneumothorax?

Absence of breath sounds in the right thorax

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?

Acute respiratory distress syndrome

You know that this client is at increased risk for ?

Acute respiratory distress syndrome

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

Administer bronchodilator as ordered.

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? Decreased chest wall excursion upon palpation Wheezing upon auscultation Resonance upon percussion Mottling of the skin upon inspection

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? Decreased chest wall excursion upon palpation Wheezing upon auscultation Resonance upon percussion Mottling of the skin upon inspection

potential complication of a low pressure in the endotracheal cuff?

Aspiration pneumonia

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? Blood-tinged sputum Bradypnea Respiratory alkalosis Productive cough

Blood-tinged sputum -severity of bruising and parenchymal involvement. -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.

Nursing instruction during postural drainage should include telling the patient to:

Change positions frequently and cough up secretions.

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

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? Copious sputum production Coughing Dyspnea Severe pain

Coughing People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity is necessary.

Which of the following interventions does a nurse implement for patients with empyema? Institute droplet precautions Place suspected patients together Encourage breathing exercises Do not allow visitors with respiratory infection

Encourage breathing exercises - institute droplet precautions and isolate suspected and confirmed influenza patients in private rooms or place suspected and confirmed patients together. -no visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Turning the client every 2 hours Elevating the head of the bed 30 degrees Encouraging increased fluid intake Maintaining a cool room temperature

Encouraging increased fluid intake Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

T/F: Smoke inhalation does increase the risk for lung cancer, bronchitis, and tracheobronchitis.

FALSE

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?

Fit all employees with protective mask

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? Pneumothorax Flail chest ARDS Tension pneumothorax

Flail chest

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hypotension, hyperoxemia, and hypercapnia Hyperventilation, hypertension, and hypocapnia Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation, and hypoxemia

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.

Heparin must be continued until the

INR is within a therapeutic range, typically 2.0 to 3

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Impaired gas exchange Anxiety Decreased cardiac output Ineffective tissue perfusion (cardiopulmonary)

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.

The nurse is planning for the care of a patient with acute tracheobronchitis. What nursing interventions should be included in the plan of care? (Select all that apply.) Increasing fluid intake to remove secretions Encouraging the patient to remain in bed Using cool-vapor therapy to relieve laryngeal and tracheal irritation Giving 3 L fluid per day Administering a narcotic analgesic for pain

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

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?.

Initiate oxygen therapy 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

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? Intubate the patient and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the patient for pulmonary surgery

Intubate the patient and control breathing with mechanical ventilation 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

The ______method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the _________determines the significance of the reaction

Mantoux /induration

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Pain in the calf

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?

Paradoxical chest movement

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?

Pleural effusion

Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer?

Pneumocystis

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? Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing Cyanosis

Rapid onset of severe dyspnea 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

Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections? Mobilizing early Using incentive spirometry Receiving vaccination Using prescribed opioids

Receiving vaccination

The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? Insidious onset in client who had normal lung function Sudden onset in client who had normal lung function Insidious onset in client who had compromised lung function Sudden onset in client who had compromised lung function

Sudden onset in client who had normal lung function

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Tension pneumothorax

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Keeping the head of the bed at 15 degrees or less Turning the client every 4 hours to prevent fatigue Using strict hand hygiene Providing oral hygiene daily

Using strict hand hygiene The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin B6 Vitamin C Vitamin D Vitamin E

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

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.

inspiratory wheezes may signal

asthma,

acute respiratory failure ARF is defined as an increase in arterial carbon dioxide tension (PaCO2)

greater than 50 mm Hg (hypercapnia),

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.

Consolidation

is lung tissue that has become more solid in nature due to collapse of alveoli or infectious process.

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.

acute respiratory failure ARF is defined as a decrease in the arterial oxygen tension (PaO2) to

less than 50 mm Hg (hypoxemia)

acute respiratory failure ARF is defined as arterial pH

less than 7.35.

acute respiratory failure ARF all measurements

pH < 7.35 PaCO2 < 50 PaO2 >50 (respiratory acidosis)

pleural friction rub may indicate

pleural inflammation.

Bilateral crackles may result from

pulmonary congestion,

syncope

temporary loss of consciousness caused by a fall in blood pressure.

In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in .

the affected lung field are absent

Primary drug resistance

to one of the first-line antituberculotic agents is people who have not had previous treatment.

potential complication of a high pressure in the endotracheal cuff?

tracheal bleeding, ischemia, and pressure necrosis.

Flail chest occurs when

two or more adjacent ribs fracture and results in impairment of chestwall movement.

Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? Constipation usually develops It is spread by fecal contamination Hypothermia will occur It is the most contagious during the second week of illness

It is the most contagious during the second week of illness -contagious only when symptoms are present -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.

anticoagulation early maintenance phase consists of

overlapping regimens of heparins or fondaparinux for at least 5 days with an oral vitamin K antagonist (e.g., warfarin [Coumadin]).

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? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg

pH 7.28, PaO2 50 mm Hg

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. 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.

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?

"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 absces

warfarin long-term maintenance is

3- to 6-month regimen - but depends on the risks of recurrence and bleeding

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient? 3 months 3 to 5 months 6 to 12 months 13 to 18 months

6 to 12 months

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 rightsided 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 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 -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 rightsided 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.