Ch 23: Management of Patients with Lower Respiratory Tract Disorders,
6. A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?
A) Preparing to assist with intubating the patient Feedback: A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.
28. A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?
B) A tracheostomy Feedback: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.
Which type of lung cancer is characterized as fast growing and tends to arise peripherally?
Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and usually grows slowly. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?
Receiving vaccinations Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis.
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
A patient with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this patient?
calcium channel blockers
The nurse is conducting a community program about prevention of respiratory illness. What illness does the nurse recognize is the most common cause of death in the United States?
pneumonia
Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as
primary drug resistance. Primary drug resistance refers to resistance to one of the first-line antituberculotic agents in people who have not received previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in clients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.
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"
What dietary recommendations should a nurse provide a client with a lung abscess?
A diet rich in protein For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.
19. The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? =
A) "The younger you are when you start smoking, the higher your risk of lung cancer. Feedback: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor.
14. The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
A) A resident who suffered a severe stroke several weeks ago Feedback: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimer's disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.
13. The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
A) Pneumothorax Feedback: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patient's recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.
10. An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care?
A) Suction the patient's airway secretions. Feedback: As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.
12. An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize?
A) The importance of adhering closely to the prescribed medication regimen Feedback: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.
The nurse is collecting a sputum culture to identify the causative organism for a patient with acute tracheobronchitis. What causative fungal organism does the nurse suspect?
Haemophilus
Which is a key characteristic of pleurisy?
Pain The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.
Which comfort technique does a nurse teach to a client with pleurisy to assist with splinting the chest wall?
Turn onto the affected side The nurse teaches the client to splint the chest wall by turning onto the affected side in order to reduce the stretching of the pleurae and decrease pain.
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?
stabbing pain during respiratory movement
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." 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.
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What information should the nurse provide to the patient?
"You should switch to wearing your glasses while taking this medication"
The nurse is administering anticoagulant therapy with heparin. What international normalized ratio (INR) would the nurse know is within therapeutic range?
2.0 to 2.5
Which would be least likely to contribute to a case of hospital-acquired pneumonia?
A nurse washes her hands before beginning client care. HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.
3. The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
A) Administer intradermal injections into the children's inner forearms. Feedback: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
39. The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patient's history is most likely to have caused the empyema?
C) Pneumonia Feedback: Most empyemas occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.
40. An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patient's plan of care?
D) Cautious hydration Feedback: Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the patient.
For a client with pleural effusion, what does chest percussion over the involved area reveal?
Dullness over the involved area Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.
The nursing instructor is teaching students about types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally?
Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and usually grows slowly. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.
Which community-acquired pneumonia demonstrates the highest occurrence during summer and fall?
Legionnaires disease Legionnaires disease accounts for 15% of community-acquired pneumonias; it occurs mainly in summer and fall. Streptococcal and viral pneumonias demonstrate the highest occurrence during the winter months. Mycoplasmal pneumonia demonstrates the highest occurrence in fall and early winter.
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 lung bases
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?
tachypnea
The nurse is caring for a patient with suspected acute respiratory distress syndrome (ARDS) with a PO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?
unresponsive arterial hypoxemia
The nurse is planning the care for a patient 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 -assisting patient to do leg elevations above level of heart -using elastic stockings, esp. when decreased mobility would promote venous stasis -applying SCD
The nurse is developing a plan of care for 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 patient to remain in bed -using cool-vapor therapy to relieve laryngeal & tracheal irritation
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?
0-4mm
9. A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patient's exposure risk to toxic substances?
B) "Wear protective attire and devices when working with a toxic substance." Feedback: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.
25. The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with non-small cell tumors is what?
C) Surgical resection Feedback: Surgical resection is the preferred method of treating patients with localized non-small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.
5. The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action?
D) Smoking damages the ciliary cleansing mechanism. Feedback: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.
An emergency room nurse is assessing a client who is complaining of dyspnea. Which sign would indicate the presence of a pleural effusion?
Decreased chest wall excursion upon palpation Symptoms of pleural effusion are shortness of breath, pain, assumption of a position that decreases pain, absent breath sounds, decreased fremitus, a dull, flat sound upon percussion, and decreased chest wall excursion. The nurse may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.
Which type of pneumonia has the highest incidence in clients with AIDS and clients receiving immunosuppressive therapy for cancer?
Pneumocystis Pneumocystis pneumonia incidence is greatest in clients with AIDS and clients receiving immunosuppressive therapy for cancer, organ transplanation, and other disorders.
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which intervention to improve oxygenation and provide comfort for the client?
Position the client in the prone position The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs.
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 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 client involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the client for which clinical manifestation that would indicate the presence of a pneumothorax?
Sucking sound at the site of injury Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed "sucking chest wounds."
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?
Turn onto the affected side. The nurse teaches the client to splint the chest wall by turning onto the affected side. The nurse also instructs the client to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The client can also splint the chest wall with a pillow when coughing.
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
a patient who had a colon resection 3 days ago resports discomfort in left calf. How should nurse assess Homan sign to determine if patient may have a thromnbus formation in leg?
dorsiflex foot while leg is elevated to check for calf pain
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
The nurse is assessing a patient who has been admitted with possible acute respiratory distress syndrome (ARDS). What findings would distinguish ARDS from cardiogenic pulmonary edema?
elevated BNP levels
Class 1 with regard to TB indicates
exposure and no evidence of infection. Class 1 is exposure but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection with no disease. Class 4 is disease, but not clinically active.
A patient arrives in the emergency department after being involved in a motor vehicle crash. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
flail chest
Which type of lung cancer is the most prevalent among both men and women?
Adenocarcinoma Adenocarcinoma is most prevalent in both men and women and presents more peripherally as masses or nodules and often metastasizes. Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Squamous cell carcinoma is more centrally located and arises more commonly in the segmental and subsegmental bronchi in response to repetitive carcinogenic exposure. Small cell carcinomas arise primarily as proximal lesions, but may arise in any part of the tracheobronchial tree.
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." 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.
23. When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following?
C) Asbestos Feedback: Asbestos is among the more common causes of pneumoconiosis. Organic acids, propane, and gypsum do not have this effect.
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 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 term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?
consolidation Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.
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?
coughing
6. 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
20. The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment?
A) "Lately, I have this cough that just never seems to go away." Feedback: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections and fatigue are not characteristic early signs of lung cancer.
17. While planning a patient's care, the nurse identifies nursing actions to minimize the patient's pleuritic pain. Which intervention should the nurse include in the plan of care?
A) Avoid actions that will cause the patient to breathe deeply. Feedback: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. A soft diet is not necessarily indicated and there is no need for the patient to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.
7. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds
A) Diminished or absent breath sounds on the affected side Feedback: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.
18. The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patient's risk of developing pulmonary emboli (PE)?
A) Early ambulation Feedback: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patient's risk for bleeding.
16. The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?
A) Incentive spirometry Feedback: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.
2. A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?
A) Increase oral fluids unless contraindicated. Feedback: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.
31. The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? Select all that apply.
A) Time frame of exposure B) Type of respiratory protection used D) Breath sounds E) Intensity of exposure Feedback: Key aspects of any assessment of patients with a potential occupational respiratory history include job and job activities, exposure levels, general hygiene, time frame of exposure, effectiveness of respiratory protection used, and direct versus indirect exposures. The patient's current respiratory status would also be a priority. Occupational lung hazards are not normally influenced by immunizations.
Which action by the nurse is most appropriate when a client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Apply a compression dressing to the area. Subcutaneous emphysema is a typical finding in clients after chest surgery. During surgery, the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted.
22. A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?
B) Administration of pneumococcal vaccine to vulnerable individuals Feedback: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A onetime vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all patients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.
1. A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication?
B) Atelectasis Feedback: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.
15. The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient's symptoms from those of a cardiac etiology?
B) Brain natriuretic peptide (BNP) level Feedback: Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.
34. A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply.
B) Level of consciousness D) Arterial blood gases E) Vital signs Feedback: Patients are usually treated in the ICU. The nurse assesses the patient's respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.
26. A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patient's oxygenation status at the bedside?
B) Monitor pulse oximetry readings. Feedback: The nurse assesses the patient with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status.
38. A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS?
B) Nutritional support Feedback: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS.
33. A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patient's care?
B) Restoration of adequate gas exchange Feedback: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.
36. A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurse's best response?
C) "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status." Feedback: Treatment of lung cancer depends on the cell type, the stage of the disease, and the patient's physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the patient's age or the patient's preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the patient and the physician of which treatment is best, though this discussion will take place.
24. A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem?
C) Acute respiratory failure Feedback: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.
8. The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? A) Coumadin will continue to break up the clot over a period of weeks B) Coumadin must be taken concurrent with ASA to achieve anticoagulation. C) Anticoagulant therapy usually lasts between 3 and 6 months. D) He should take a vitamin supplement containing vitamin K
C) Anticoagulant therapy usually lasts between 3 and 6 months. Feedback: Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.
11. The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic?
C) Assess the patient's oxygen saturation level. Feedback: The effectiveness of the patient's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patient's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.
29. The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?
C) Hypovolemia secondary to leakage of fluid into the interstitial spaces Feedback: Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.
35. A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?
C) Older adults often lack the classic signs and symptoms of pneumonia. Feedback: The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients. Mortality from pneumonia in the elderly is not a result of limited antibiotic options or lower lung compliance. The pneumococcal vaccine is appropriate for older adults.
27. The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing?
C) Pleuritic pain Feedback: 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. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patient's vital signs profoundly.
21. A client presents to the walk-in clinic complaining of a dry, irritating cough and production of a minute amount of mucus-like sputum. The patient complains of soreness in her chest in the sternal area. The nurse should suspect that the primary care provider will assess the patient for what health problem?
C) Tracheobronchitis Feedback: Initially, the patient with tracheobronchitis has a dry, irritating cough and expectorates a scant amount of mucoid sputum. The patient may report sternal soreness from coughing and have fever or chills, night sweats, headache, and general malaise. Pleural effusion and pulmonary embolism do not normally cause sputum production and would likely cause acute shortness of breath. Hemoptysis is characteristic of TB.
37. A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy?
D) Pulmonary arterial pressure Feedback: If the patient has undergone surgical embolectomy, the nurse measures the patient's pulmonary arterial pressure and urinary output. Pressure is not monitored in a patient's vena cava. White cell levels and pupillary responses would be monitored, but not to the extent of the patient's pulmonary arterial pressure.
30. The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient?
D) Residual effects of compromised oxygenation Feedback: The home care nurse should monitor the patient for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.
32. A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment treatment for his cancer. What fact about lung cancer treatment should inform the nurses response?
D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively. Feedback: Surgery is primarily used for NSCLCs, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a patient's medical instability are not the limiting factors. Lung cancer is not a self-limiting disease.
4. The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis?
D) The patient's pain intensifies when he coughs or takes a deep breath. Feedback: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The patient's ABGs would most likely be abnormal and shortness of breath would be expected.
Which intervention does a nurse implement for clients with empyema?
Encourage breathing exercises The nurse instructs the client in lung-expanding breathing exercises to restore normal respiratory function.
Which interventions does a nurse implement for clients with empyema?
Encourage breathing exercises The nurse teaches the client with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions and isolate suspected and clients with confirmed influenza in private rooms or place suspected and confirmed clients together. The nurse does not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.
Which is a true statement regarding severe acute respiratory syndrome (SARS)?
It is most contagious during the second week of illness. 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 nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?
Negative The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest?
Paradoxical chest movement 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. Upon expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the client's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections?
Receive vaccinations Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections.
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes.
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?
SOB Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.
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 recognize is the most common organism that causes community-acquired pneumonia?
Streptococcus pneumoniae
A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?
Venous thromboemboli Neuromuscular blockers predispose the client to venous thromboemboli (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The client may have discomfort or pain but be unable to communicate these sensations.
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis?
pH 7.25, PaCO2 48, HCO3 24 pH <7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2 38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30 indicate respiratory alkalosis; and pH 7.49, PaCO2 34, HCO3 25 indicate respiratory alkalosis.
Arterial blood gas analysis would reveal which value related to acute respiratory failure?
pH 7.28 Acute respiratory failure 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 greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
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 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. 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.
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows
redness and induration. The injection site is inspected for redness and palpated for hardening. Drainage at the injection site does not indicate a reaction to the tubercle bacillus. Sloughing of tissue at the injection site does not indicate a reaction to the tubercle bacillus. Bruising of tissue at the site may occur from the injection but does not indicate a reaction to the tubercle bacillus.
