CC Ch. 23
Which of the following is a key characteristic of pleurisy?
Pain
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:
Significant
The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure?
Sudden onset in client who had normal lung function
You've been invited to speak to the Hospital Guild of the hospital where you practice nursing. You've been asked to address "Communicable Diseases of Winter" and are speaking to a large group of volunteer women, most of whom are older than 60 years. What practices should you encourage in these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.
• Techniques for incentive spirometry • Receiving vaccinations • Hand antisepsis
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?
Crackling is heard when skin around tube is touched.
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
The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation?
Shortness of breath
A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that he will be safe from infecting others approximately how long after initiation of the chemotherapy regimen?
• Two to 3 weeks after initiation of bacteriocidal drugs
Which statement would indicate that the parents of child with cystic fibrosis understand the disorder?
"The mucus-secreting glands are abnormal."
What dietary recommendations should a nurse provide a patient with a lung abscess?
A diet rich in protein
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
A patient admitted to the hospital following a motor vehicle crash has suffered a flail chest. A nurse assesses the patient for what most common clinical manifestation of flail chest?
Paradoxical chest movement
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?
Placing the client in respiratory isolation
The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer?
Symptoms often do not appear until the disease is well established.
A mediastinal shift occurs in which type of chest disorder?
Tension pneumothorax
Which of the following comfort techniques does a nurse teach to a patient with pleurisy to assist with splinting the chest wall?
Turn onto the affected side
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:
continue to take antibiotics for the entire 10 days.
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?
6 to 12 months
What is the reason for chest tubes after thoracic surgery?
Draining secretions, air, and blood from the thoracic cavity is necessary.
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?
Negative
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 Class 1 with regards to TB indicates
exposure and no evidence of infection.
Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is
primary drug resistance.
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?
0 to 4 mm
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?
Classes at community centers to teach about smoking cessation strategies
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
Dyspnea
Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises.
Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)?
It is the most contagious during the second week of illness
A positive Mantoux test indicates that a client:
has produced an immune response.
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."
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?
Putting on an individually fitted mask when entering the client's room
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.
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
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?
"You should switch to wearing your glasses while taking this medication."
Nursing instruction during postural drainage should include telling the patient to:
Change positions frequently and cough up secretions.
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
Few early symptoms
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange
A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?
"It is all right if I have a grilled cheese sandwich with American cheese."
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax
Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections?
Receiving vaccination
A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following?
Tense and relax muscles in lower extremities.
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:
Ineffective airway clearance.
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
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
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
The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:
"I'll stop being contagious when I have a negative acid-fast bacilli test."
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
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 nasogastric tube
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered.
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
Encourage increased fluid intake.
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?
Flail chest
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?
Ineffective Airway Clearance
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
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?
Using strict hand hygiene
