PrepU Med Surge Ch. 19: Management of patients with Chest and lower respiratory tract disorders
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis? "I will come back in 1 week to have the test read." "If the test area turns red that means I have tuberculosis." "I will avoid contact with my family until I am done with the test." "Because I had a previous reaction to the test, this time I need to get a chest X-ray."
"Because I had a previous reaction to the test, this time I need to get a chest X-ray." Explanation: A client who previously had a positive PPD test (a reaction to the antigen) can't receive a repeat PPD test and must have a chest X-ray done instead. The test should be read 48 to 72 hours after administration. Redness at the test area doesn't indicate a positive test; an induration of greater than 10 mm indicates a positive test. The client doesn't need to avoid contact with people during the test period.
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 nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? "You must consume a diet rich in protein, such as chicken, fish, and beans." "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." "You must consume a diet low in fat by limiting dairy products and concentrated sweets."
"You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.
The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device
-Encouraging a liberal fluid intake -Instructing the client to move the legs in a "pumping" exercise -Using elastic stockings, especially when decreased mobility would promote venous stasis -Applying a sequential compression device Explanation: The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.
Approximately what percentage of people who are initially infected with TB develop active disease? 10% 20% 30% 40%
10% Explanation: Approximately 10% of people who are initially infected develop active disease. The other percentages are inaccurate.
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 ICU 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 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 acute respiratory distress syndrome 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. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.
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 new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? Auscultate the lung for adventitious sounds. Have the patient inform the nurse of the need to be suctioned. Assess the CO2 level to determine if the patient requires suctioning. Have the patient cough.
Auscultate the lung for adventitious sounds. Explanation: When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
What assessment method would the nurse use to determine the areas of the lungs that need draining? Inspection Chest X-ray Arterial blood gas (ABG) levels Auscultation
Auscultation Explanation: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
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.
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Anemic hypoxia Circulatory hypoxia Histotoxic hypoxia Hypoxemic hypoxia
Circulatory hypoxia Explanation: Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Surgery to remove the tonsils and adenoids Medications to assist the patient with sleep at night Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BiPAP)
Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? Cough or change in chronic cough Pain on inspiration Obvious trauma Shortness of breath
Cough or change in chronic cough Explanation: A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? Cough or change in chronic cough Pain on inspiration Obvious trauma Shortness of breath
Cough or change in chronic cough Explanation: A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? Administering oxygen, coughing, breathing deeply, and maintaining bed rest Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Administering pain medications, frequent repositioning, and limiting fluid intake
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Explanation: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Crackles in the lung bases Low-pitched rhonchi during expiration Pleural friction rub Sibilant wheezes
Crackles in the lung bases Explanation: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?' Crackles in the lung bases Low-pitched rhonchi during expiration Pleural friction rub Sibilant wheezes
Crackles in the lung bases Explanation: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
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.
A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Passive range of motion exercises for the upper and lower extremities Early ambulation and the use of compression stockings Incentive spirometry and deep breathing and coughing exercises Maintenance of SpO2 levels ≥90% using supplementary oxygen
Early ambulation and the use of compression stockings Explanation: For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? Encourage coughing to mobilize secretions. Restrict intravenous fluids for at least 24 hours. Make sure that a thoracotomy tube is linked to open chest drainage. Assist with positioning the client on the right side.
Encourage coughing to mobilize secretions. Explanation: The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. The chest tube is always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration.
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 Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. 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.
The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? Fibrotic changes in lungs Hemorrhage Lung contusion Damage to surrounding tissues
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.
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 Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) 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. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
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.
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.
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Hypoxia Delirium Hyperventilation Semiconsciousness
Hypoxia Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.
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.
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: Risk for falls. Ineffective breathing pattern. Impaired tissue integrity. Ineffective airway clearance.
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.
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. Administer a heparin bolus and begin an infusion at 500 units/hour. Administer analgesics as ordered. Perform nasopharyngeal suctioning.
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.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Institute isolation precautions. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Obtain a sputum specimen for enzyme immunoassay testing.
Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
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.
Which is a true statement regarding severe acute respiratory syndrome (SARS)? Constipation usually develops. It is spread by fecal contamination. Hypothermia will occur. It is most contagious during the second week of illness.
It is 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 clients 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.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? Kinking of the ventilator tubing A disconnected ventilator circuit An ET cuff leak A change in the oxygen concentration without resetting the oxygen level alarm
Kinking of the ventilator tubing Explanation: Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? Pain in the feet Coolness to lower extremities Decreased urinary output Localized calf tenderness
Localized calf tenderness Explanation: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Stripping the chest tube every hour
Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Bicarbonate (HCO3-) Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2)
Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to Sit in an upright position only. Initially inhale through the mouth. Purse the lips when exhaling air from the lungs. Hold the breath for 5 seconds and then exhale.
Purse the lips when exhaling air from the lungs. Explanation: To prolong exhalation, the client may perform breathing while sitting in a chair or walking. The client is to inhale through the nose and then exhale against pursed lips. There is no holding the breath.
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.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Deflating the cuff before removing the tube Routinely deflating the cuff Checking the cuff pressure every 6 to 8 hours Ensuring that humidified oxygen is always introduced through the tube
Routinely deflating the cuff Explanation: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? Staphylococcus aureus Mycobacterium tuberculosis Pseudomonas aeruginosa Streptococcus pneumoniae
Streptococcus pneumoniae Explanation: Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator.
Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
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 Cardiac tamponade Flail chest Pulmonary contusion
Tension pneumothorax Explanation: Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits restlessness and confusion. The client exhibits bronchial breath sounds over the affected area.
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.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. The client exhibits restlessness and confusion. The client exhibits bronchial breath sounds over the affected area.
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.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is hypoxic from suctioning. The patient is having a stress reaction. The patient is having a myocardial infarction. The patient is in a hypermetabolic state.
The patient is hypoxic from suctioning. Explanation: Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is hypoxic from suctioning. The patient is having a stress reaction. The patient is having a myocardial infarction. The patient is in a hypermetabolic state.
The patient is hypoxic from suctioning. Explanation: Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The client has a pneumothorax. The system has an air leak. The chest tube is obstructed.
The system has an air leak. Explanation: Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Water-seal chamber Air-leak chamber Collection chamber Suction control chamber
Water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan? Wearing a disposable particulate respirator that fits snugly around the face Instructing the client to wear a mask at all times Wearing a gown and gloves when providing direct care Keeping the door to the client's room open to observe the client
Wearing a disposable particulate respirator that fits snugly around the face Explanation: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face 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.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.28, PaO2 50 mm Hg 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 Explanation: ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. pneumothorax. hemothorax. consolidation.
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 as a result of the collapse of alveoli or an infectious process.
