Ch. 27 Lower Resp. Problems

d. Spontaneous pneumothorax (Spontaneous pneumothorax is seen from the rupture of small blebs on the apex of the lung in patients with lung disease or smoking, as well as in tall, thin males with a family history of or a previous spontaneous pneumothorax. Tension pneumothorax occurs with mechanical ventilation and with blocked chest tubes. Iatrogenic pneumothorax occurs due to the laceration or puncture of the lung during medical procedures. Traumatic pneumothorax can occur with penetrating or blunt chest trauma.)

A male patient has chronic obstructive pulmonary disease (COPD) and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring? a. Tension pneumothorax b. Iatrogenic pneumothorax c. Traumatic pneumothorax d. Spontaneous pneumothorax

c. Take all medications for full length of time to prevent multi drug-resistant TB. d. Wear a standard isolation mask if leaving the airborne infection isolation room. e. Maintain precautions in airborne infection isolation room by coughing into a paper tissue. (To reduce antibiotic-resistant TB, patients must take multiple drugs for a minimum of 3 months (possibly longer). If patients need to be out of the negative-pressure room, they must wear a standard isolation mask to prevent exposure to others. Teach patients to cover those nose and mouth with paper tissue every time they cough, sneeze, or produce sputum. If a person has a positive reaction to the TB skit test, he or she need not to be tested again. Nurses and visitors must wear high-efficiency particulate air (HEPA) masks when entering the patient's room.)

A patent with TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the patient be taught (SATA)? a. Expect routine TST to evaluate infection. b. Visitors will not be allowed while in airborne isolation. c. Take all medications for full length of time to prevent multi drug-resistant TB. d. Wear a standard isolation mask if leaving the airborne infection isolation room. e. Maintain precautions in airborne infection isolation room by coughing into a paper tissue.

a. candidiasis. (Pulmonary fungal infections occur most commonly in seriously ill patients being treated with corticosteroids, antineoplastic, and immunosuppressive drugs or with multiple antibiotics & in patients with HIV infection and CF. Candida albicans is the leading cause of fungal infections.)

A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to a. candidiasis. b. aspergillosis. c. histoplasmosis. d. coccidioidomycosis.

a. Cover the chest wound with a nonporous dressing taped on three sides. (The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.)

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood.

a. Lung biopsy

A patient with a lung mass found on chest x-ray is undergoing further testing. The nurse explains that a diagnosis of lung cancer can be confirmed using which diagnostic test? a. Lung biopsy b. Lung tomograms c. Pulmonary angiography d. Computed tomography (CT) scans

a. Antibiotic (Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.)

A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? a. Antibiotic b. Corticosteroid c. Bronchodilator d. Cough suppressant

d. Arrange for directly observed therapy by a public health nurse. (Notification of the public health department is required. If drug compliance is questionable, follow-up of patients can be made by directly observed therapy by a public health nurse. A patient who cannot remember to take the medication usually will not remember to come to the clinic daily or will find it too inconvenient. Additional teaching or support from others is not usually effective for this type of patient.)

A patient with active TB continues to have positive sputum cultures after 6 months of treatment. She says she cannot remember to take the medication all the time. What is the best action for the nurse to take? a. Schedule the patient to come to the clinic every day to take the medication. b. Have a patient who has recovered from TB tell the patient about his successful treatment. c. Schedule more teaching sessions so the patient will understand the risks of noncompliance. d. Arrange for directly observed therapy by a public health nurse.

b. "Can you tell me what the pain means to you?" (Before making any judgments about the patient's statement, it is important to explore what meaning he or she finds in the pain. It may be that the patient feels it is deserved punishment for smoking but further information needs to be obtained from the patient. Immediate referral to a counselor negates the nurse's responsibility in helping the patient and there is no indication that the patient is not dealing effectively with his or her feelings.)

A patient with advanced lung cancer refuses pain medication, saying, "I deserve everything this cancer can give me." What is the nurse's best response to this patient? a. "Would talking to a counselor help you?" b. "Can you tell me what the pain means to you?" c. "Are you using the pain as a punishment for your smoking?" d. "Pain control will help you to deal more effectively with your feelings."

d. Bronchiolitis obliterans (BOS) (BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.)

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? a. Pulmonary infarction b. Pulmonary hypertension c. Cytomegalovirus (CMV) d. Bronchiolitis obliterans (BOS)

b. Lungs clear to auscultation (Clear lung sounds indicate that the airways are clear. SpO2 exchange. Tolerating walking in the hallway also indicates of 90% to 100% indicates appropriate gas appropriate gas exchange, not improved airway clearance. Deep breaths are necessary to move mucus from distal airways but this is not an outcome.)

A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. What is an expected outcome for this patient? a. SpO2 is 90% b. Lungs clear to auscultation c. Patient tolerates walking in hallway d. Patient takes three or four shallow breaths before coughing to minimize pain

a. administering ordered analgesia. (Chemical pleurodesis involves the instillation of a chemical slurry after the pleural effusion is drained. The chest tubes are clamped while the patient is turned in different positions. Pain is common, and thus analgesic agents should be administered.)

A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia. b. monitoring chest tube drainage. c. sending pleural fluid for lab analysis. d. monitoring the patient's LOC.

b. Spiral (helical) CT scan (A spiral (helical) CT scan is the most frequently used test to diagnose pulmonary emboli because it allows illumination of all anatomic structures and produces a 3-D picture. If a patient cannot have contrast media, a ventilation-perfusion scan is done. Although pulmonary angiography is most sensitive, it is invasive, expensive, and carries more risk for complications. Chest x-rays do not detect pulmonary emboli until necrosis or abscesses occur.)

A pulmonary embolus is suspected in a patient with a deep vein thrombosis who develops hemoptysis, tachycardia,and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? a. Chest x-rays b. Spiral (helical) CT scan c. Take the patient's pulse and blood pressure. d. Ventilation-perfusion lung scan

b. Sputum culture and sensitivity (The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.)

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? a. Orthostatic blood pressures b. Sputum culture and sensitivity c. Pulmonary function evaluation d. Serum laboratory studies ordered for AM

d. teach the patient how to cough effectively to bring secretions to the mouth. (A forced expiratory technique (i.e., huff coughing) clears secretions with less change in pleural pressure and less likelihood of bronchial collapse. Before the patient attempts coughing, the nurse should ensure the patient is breathing deeply from the diaphragm. The nurse should place hands on the patient's lower lateral chest wall and then ask the patient to breathe deeply through the nose. The nurse hands should move outward, which represents a breath from the diaphragm.)

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively to bring secretions to the mouth.

d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. (Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.)

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? a. Perform a comprehensive health history with the patient to review prior respiratory problems. b. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

a. Sudden onset of confusion (Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.)

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? a. Sudden onset of confusion b. Oral temperature of 102.3oF c. Coarse crackles in lung bases d. Clutching chest on inspiration

c. stripping or milking the chest tube to promote drainage. (If chest tubes are to be milked or stripped, this procedure should be done only by the professional nurse. This procedure is no longer recommended, as it may dangerously increase pleural pressure, but there is no indication to milk the tubes when there is no bloody drainage, as in a pneumothorax. The UAP can loop the chest tubing on the bed to promote drainage and patients should be reminded to cough and deep breathe at least every 2 hours to aid in lung reexpansion. Securing the drainage container in an upright position is also a necessary activity that can be completed by UAP.)

An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed. b. securing the drainage container in an upright position. c. stripping or milking the chest tube to promote drainage. d. reminding the patient to cough and deep breathe every 2 hours.

a, b, d

During a health promotion program, why should the nurse plan to target women in a discussion of lung cancer prevention (select all that apply)? a. Women develop lung cancer at a younger age than men. b. More women die of lung cancer than die from breast cancer. c. Women have a worse prognosis from lung cancer than do men. d. Nonsmoking women are at greater risk for developing lung cancer than men. e. African American women have a higher rate of lung cancer than other ethnic groups

a, b, d (Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos & uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.)

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? Select all that apply. a. Asbestos exposure b. Exposure to uranium c. Chronic interstitial fibrosis d. History of cigarette smoking e. Geographic area in which he was born

b. Obtain a pneumococcal vaccine now and get a booster 12 months later (A second dose of the pneumococcal vaccine should be provided to all persons 65 years of age or older who have not received the vaccine within 5 years and were younger than 65 years of age at the time of vaccination. Influenza vaccine should be taken each year by those older than 65 years of age. Antibiotic therapy is not appropriate for all upper respiratory infections unless secondary bacterial infections develop.)

During an annual health assessment of a 65-year-old patient at the clinic, the patient tells the nurse he had the pneumonia vaccine when he was age 58. What should the nurse advise him about the best way for him to prevent pneumonia? a. Seek medical care and antibiotic therapy for all upper respiratory infections b. Obtain a pneumococcal vaccine now and get a booster 12 months later c. Obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia d. Obtain only the influenza vaccine every year because he should have immunity to the pneumococcus because of his age

a. Pneumococcal (The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.)

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? a. Pneumococcal b. Staphylococcus aureus c. Haemophilus influenzae d. Bacille-Calmette-Guérin (BCG)

d. Paradoxical chest movement (Flail chest may occur when two or more ribs are fractured, causing an unstable segment. The chest wall cannot provide the support for ventilation and the injured segment will move paradoxically to the stable portion of the chest (in on expiration; out on inspiration). Hypotension occurs with a number of conditions that impair cardiac function, and chest pain occurs with a single fractured rib and will be of high priority with flail chest. Absent breath sounds occur following pneumothorax or hemothorax.)

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest? a. Severe hypotension b. Chest pain over ribs c. Absence of breath sounds d. Paradoxical chest movement

c .doing range-of-motion exercises on the affected upper limb. (Teach a patient who has had a pneumonectomy (i.e., removal of one whole lung) to perform range-of-motion exercises on the surgical side that are similar to those for patients who have undergone mastectomy. The patient will not always have chest tube drainage, should not be positioned on the uncooperative tube, and will not have lung sounds on the operative side because the entire lung has been removed.)

Following a pneumonectomy, an appropriate nursing intervention is a. monitoring chest tube drainage and functioning. b. position the patient on the unaffected side or back. c .doing range-of-motion exercises on the affected upper limb. d. auscultating frequently for lung sounds on the affected side.

d. Medicate the patient with analgesics 20 to 30 minutes before assisting to cough and deep breathe. (A thoracotomy incision is large and involves cutting into bone, muscle, and cartilage, resulting in significant postoperative pain. The patient has difficulty deep breathing and coughing because of the pain and analgesics should be provided before attempting these activities. Water intake is important to liquefy secretions but is not indicated in this case, nor should a patient with chest trauma or surgery be placed in Trendelenburg position, because it increases intrathoracic pressure.)

Following a thoracotomy, the patient has a nursing diagnosis of ineffective airway clearance related to inability to cough as a result of pain and positioning. What is the best nursing intervention for this patient? a. Have the patient drink 16 oz of water before attempting to deep breathe. b. Auscultate the lungs before and after deep-breathing and coughing regimens. c. Place the patient in the Trendelenburg position for 30 minutes before the coughing exercises. d. Medicate the patient with analgesics 20 to 30 minutes before assisting to cough and deep breathe.

a. SpO2 of 86% (Oxygen saturation obtained by pulse oximetry should be between 90% and 100%. An SpO2 hypoxemia and impaired gas exchange. Crackles, purulent sputum, and fever are all manifestations of pneumonia, but do not necessarily relate to impaired gas exchange. lower than 90% indicates)

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding? a. SpO2 of 86% b. Crackles in both lower lobes c. Temperature of 101.4oF (38.6oC) d. Production of greenish purulent sputum

a. Patient with seizures. b. Patient with head injury. e. Patient who is receiving NG tube feeding. (Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., as a result of seizure, anesthesia, head injury, stroke, or alcohol intake), difficulty swallowing, and nasogastric tubes with or without feeding.)

For which patients with pneumonia would the nurse suspect aspiration is the likely cause of pneumonia (select all that apply)? a. Patient with seizures. b. Patient with head injury. c. Patient who had thoracic surgery. d. Patient who had a myocardial infarction. e. Patient who is receiving NG tube feeding.

a, c, e (Microorganisms that cause pneumonia reach the lungs by aspiration from the nasopharynx or oropharynx, inhalation of microbes in the air, and hematogenous spread from infections elsewhere in the body. The other causes of infection do not contribute to pneumonia.)

How do microorganisms reach the lungs and cause pneumonia (select all that apply)? a. Aspiration b. Lymphatic spread c. Inhalation of microbes in the air d. Touch contact with the infectious microbes e. Hematogenous spread from infections elsewhere in the body

c. Chest tube with a loose-fitting dressing (If the dressing at the CT insertion site is loose, an air leak will occur & will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.)

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber c. Chest tube with a loose-fitting dressing d. Small pneumothorax at CT insertion site

b. Admitting the patient to an airborne infection isolation room (A patient with class 3 TB has clinically active disease and airborne infection isolation is required for active disease until the patient is noninfectious, indicated by negative sputum smears. Cardiac monitoring and observation will need to be done with the patient in isolation. The nurse will administer the antitubercular drugs after the patient is in isolation. There should be no need for suction or extra linens after the TB patient is receiving drug therapy.)

Priority Decision: A patient diagnosed with class 3 TB 1 week ago is admitted to the hospital with symptoms of chest pain and coughing. What nursing action has the highest priority? a. Administering the patient's antitubercular drugs b. Admitting the patient to an airborne infection isolation room c. Preparing the patient's room with suction equipment and extra linens d. Placing the patient in an intensive care unit where he can be closely monitored

c. Sputum specimen for Gram stain and culture and sensitivity (A sputum specimen for Gram stain and culture should be done before initiating antibiotic therapy and while waiting for the antibiotic to be delivered from the pharmacy in a hospitalized patient with suspected pneumonia and then antibiotics should be started without delay. If the sputum specimen cannot be obtained rapidly, the chest x-ray will be done to assess the typical pattern characteristic of the infecting organism. Blood cell tests will not be altered significantly by delaying the tests until after the first dose of antibiotics.)

Priority Decision: After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which order should the nurse implement first? a. Anterior/posterior and lateral chest x-rays b. Start IV levofloxacin(Levaquin) 500mg Q24 hr c. Sputum specimen for Gram stain and culture and sensitivity d.CBC with WBC count and differential

b. Using masks and effective ventilation systems to reduce exposure to irritants. (Although all of the precautions identified in this question are appropriate in decreasing the risk of occupational lung diseases, using masks and effective ventilation systems to reduce exposure is the most efficient and affects the greatest number of employees.)

Priority Decision: To reduce the risk for most occupational lung diseases, what is the most important measure the occupational nurse should promote? a. Maintaining smoke-free work environments for all employees. b. Using masks and effective ventilation systems to reduce exposure to irritants. c. Inspection and monitoring of workplaces by national occupational safety agencies. d. Requiring periodic chest x-rays and pulmonary function tests for exposed employees.

a. Raise the head of the bed. (All of the activities are correct but the first thing to do is to raise the head of the bed to promote respiration in the patient who is dyspneic. The health care provider would not be called until the nurse has assessment data relating to vital signs, pulse oximetry, & any other patient complaints.)

Priority Decision: Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. What s the first action that the nurse should take? a. Raise the head of the bed. b. Notify the health care provider. c. Take the patient's pulse and blood pressure. d. Determine the patient's SpO2 with an oximeter.

c. Acute rejection that may be treated with corticosteroids (Acute rejection may occur as early as 5-7 days after surgery & is manifested by low-grade fever, fatigue, & oxygen desaturation with exertion. Complete remission of symptoms can be accomplished with bolus corticosteroids. Cytomegalovirus & other infections can be fatal but usually occur weeks after surgery and manifest with symptoms of pneumonia. Obliterative bronchiolitis is a late complication of lung transplantation, reflecting chronic rejection.)

Six days after a heart-lung transplant, the patient develops a low-grade fever, dyspnea, and decreased SpO2 should the nurse recognize that this may indicate? a. A normal response to extensive surgery b. A frequently fatal cytomegalovirus infection c. Acute rejection that may be treated with corticosteroids d. Obliterative bronchiolitis that plugs terminal bronchioles

a. pulmonary edema. (Chemical pneumonitis results from exposure chemical fumes. In the acute scenario, lung injury is diffuse and characterized as pulmonary edema.)

The ED nurse is caring for patients exposed to a chlorine lead from a local factory. The nurse would closely monitor these patients for a. pulmonary edema. b. anaphylactic shock. c. respiratory alkalosis. d. acute tubular necrosis.

a. COPD (Chronic obstructive pulmonary disease (COPD) causes pulmonary capillary and alveolar damage. Sarcoidosis is a granulomatous disease. Pulmonary fibrosis stiffens the pulmonary vasculature and pulmonary embolism obstructs pulmonary blood flow.)

Which condition contributes to secondary pulmonary arterial hypertension by causing pulmonary capillary and alveolar damage? a. COPD b. Sarcoidosis c. Pulmonary fibrosis d. Pulmonary embolism

b. Opportunistic pneumonia (People at risk for opportunistic pneumonia include those with altered immune responses. Pneumocystis jiroveci rarely causes pneumonia in healthy individuals but is the most common cause of pneumonia in persons with HIV disease. Cytomegalovirus (CMV) occurs in people with an impaired immune response. Medical care-associated pneumonia is frequently caused by Pseudomonas aeruginosa, Escherichia coli, Klebsiella, and Acinetobacter species. Community-acquired pneumonia is most commonly caused by Streptococcus pneumonia.)

The microorganisms Pneumocystis jiroveci (PCP) and cytomegalovirus (CMV) are associated with which type of pneumonia? a. Bronchial pneumonia b. Opportunistic pneumonia c. Hospital-associated pneumonia d. Community-acquired pneumonia

d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." (The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.)

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? a. "I will seek immediate medical treatment for any upper respiratory infections." b. "I should continue to do deep breathing and coughing exercises for at least 12 weeks." c. "I will increase my food intake to 2400 calories a day to keep my immune system well." d. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

c. paradoxical chest movement occurs during respiration. (Flail chest produces paradoxical respiration. On inspiration, the flail sinks in, with a mediastinal shift to the uninjured side. On expiration, the flail sections bulges outward, with a mediastinal shift to the injured side.)

The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determine by x-ray. b. a tracheal deviation to the unaffected side is present. c. paradoxical chest movement occurs during respiration. d. there is decreased movement of the involved chest wall.

b. "The medicine will be prescribed for 10 days." (Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen)

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? a. "I need to take this medicine with meals." b. "The medicine will be prescribed for 10 days." c. "I will inject this medicine into my upper arm." d. "The medicine will dissolve the clot in my lung."

a, c, d, e (An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.)

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Select all that apply. a. Obesity b. Pneumonia c. Malignancy d. Cigarette smoking e. Prolonged air travel

c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube (Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.)

The nurse is caring for a group of patients. Which patient is at risk of aspiration? a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery b. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

a, b, d (A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.)

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (SATA)? a. A temperature of 101.4°F b. Heart rate of 120 beats/min c. Respiratory rate of 20 breaths/min d. A productive cough with yellow sputum e. Reports of unable to have a bowel movement for 2 days

a, c, e (Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.)

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Select all that apply. a. Maintain adequate fluid intake. b. Maintain a 30-degree elevation. c. Splint the chest when coughing. d. Maintain a semi-Fowler's position. e. Instruct patient to cough at end of exhalation.

d. Increase fluid intake to 3 L/day if tolerated. (Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.)

The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? a. Humidify the oxygen as able. b. Administer cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated.

c. Obtain a sputum specimen for culture and Gram stain. (A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.)

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? a. Teach the patient to cough and deep breathe. b. Take the temperature, pulse, and respiratory rate. c. Obtain a sputum specimen for culture and Gram stain. d. Check the patient's oxygen saturation by pulse oximetry.

c. Positioning patient with "good lung" down (Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.)

The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? a. Positioning patient on right side b. Maintaining adequate fluid intake c. Positioning patient with "good lung" down d. Performing postural drainage every 4 hours

d. Sit the patient up in bed as tolerated and apply oxygen. (The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.)

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? a. Notify the health care provider. b. Administer a nitroglycerin tablet sublingually. c. Conduct a thorough assessment of the chest pain. d. Sit the patient up in bed as tolerated and apply oxygen.

b. Mucociliary clearance (Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.)

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? a. Cough reflex b. Mucociliary clearance c. Reflex bronchoconstriction d. Ability to filter particles from the air

c. Increased vocal fremitus on palpation (A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.)

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? a. Hyperresonance on percussion b. Vesicular breath sounds in all lobes c. Increased vocal fremitus on palpation d. Fine crackles in all lobes on auscultation

a. Basilar crackles (The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.)

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? a. Basilar crackles b. Oxygen saturation of 85% c. Presence of greenish sputum d. Respiratory rate of 28 breaths/min

c. "I need to be isolated from my family and friends so they won't get it." (The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.)

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? a. "I will be given amphotericin B to treat the fungus." b. "I got this fungus because I am immunocompromised." c. "I need to be isolated from my family and friends so they won't get it." d. "The effectiveness of my therapy can be monitored with fungal serology titers."

a. continue to monitor the patient. (Tidaling is a normal fluctuation of the water in the water-seal chamber of a chest tube. Tidaling reflects the intracellular pressure during inspiration and expiration.)

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should a. continue to monitor the patient. b. check all connections for a leak in the system. c. lower the drainage collector further from the chest. d. clamp the tubing at progressively distal points away from the patient until the tidaling stops.

b. administer both vaccines at the same time in different arms. (Patients at risk for pneumonia (e.g., patients with lung cancer) should obtain influenza and pneumococcal vaccines. The vaccines may be administered at the same time in different arms.)

The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will a. call the HCP to question the order. b. administer both vaccines at the same time in different arms. c. administer the flu shot and tell the patient to come back 1 weeks later to receive the pneumococcal vaccine. d. administer the pneumococcal vaccine and suggest FluMist (nasal vaccine) instead of the influenza injection.

d. Less discomfort and faster return to normal activity (The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.)

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a. The patient has lung cancer. b. The incision will be medial sternal or lateral. c. Chest tubes will not be needed postoperatively. d. Less discomfort and faster return to normal activity

b. Severe respiratory distress and tracheal deviation (A tension pneumothorax causes many of the same manifestations as other types of pneumothoraces but severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures and trachea to the unaffected side is present in a tension pneumothorax. Percussion dullness on the injured site indicates the presence of blood or fluid and decreased movement and diminished breath sounds are characteristic of a pneumothorax. Muffled and distant heart sounds indicate a cardiac tamponade.)

To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. Dull percussion sounds on the injured side b. Severe respiratory distress and tracheal deviation c. Muffled and distant heart sounds with decreasing blood pressure d. Decreased movement and diminished breath sounds on the affected side

d. Treating the underlying pulmonary condition (If possible, the primary management of cor pulmonale is treatment of the underlying pulmonary problem that caused the heart problem. Low-flow oxygen therapy will help to prevent hypoxemia and hypercapnia, which cause pulmonary vasoconstriction.)

What is a primary treatment goal for cor pulmonale? a. Controlling dysrhythmias b. Dilating the pulmonary arteries c. Strengthening the cardiac muscle d. Treating the underlying pulmonary condition

d. History and physical examination and characteristic chest x-ray findings (Prompt treatment of pneumonia with appropriate antibiotics is important in treating bacterial and mycoplasma pneumonia and antibiotics are often administered on the basis of the history, physical examination, and a chest x-ray indicating a typical pattern characteristic of a particular organism without further testing. Sputum and blood cultures take 24 to 72 hours for results and microorganisms often cannot be identified with either Gram stains or cultures. Whether the pneumonia is community acquired or medical-care associated is more significant than the severity of symptoms.)

What is the initial antibiotic treatment for pneumonia based on? a. The severity of symptoms b. The presence of characteristic leukocytes c. Gram stains and cultures of sputum specimens d. History and physical examination and characteristic chest x-ray findings

d. Used to inspect, diagnose, and manage intrathoracic injuries (During video-assisted thoracic surgery (VATS), a video scope is inserted into the thorax to assess, diagnose, and treat intrathoracic injuries. A pneumonectomy is the removal of a lung. A wedge resection is the removal of a lung segment. Lung volume-reduction surgery is the removal of lung tissue by excising multiple wedges.)

What is the purpose of video-assisted thoracic surgery (VATS)? a. Removal of a lung b. Removal of one or more lung segments c. Removal of lung tissue by multiple wedge excisions d. Used to inspect, diagnose, and manage intrathoracic injuries

b. Poor compliance with drug therapy in patients with TB (Drug-resistant strains of TB have developed because TB patients' compliance with drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of TB treatment. TB can be diagnosed effectively with sputum cultures. Antitubercular drugs are almost exclusively used for TB infections. The incidence of TB is at epidemic proportions in patients with HIV but this does not account for drug-resistant strains of TB.)

What was the resurgence in tuberculosis (TB) resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis related to? a. A lack of effective means to diagnose TB b. Poor compliance with drug therapy in patients with TB c. Indiscriminate use of antitubercular drugs in treatment of other infections d. Increased population of immunosuppressed individuals with acquired immunodeficiency syndrome (AIDS)

b. Antibiotic administration. (IV antibiotic therapy should be started as soon as possible. Postural drainage is not recommended because it may cause dissemination of infection into other bronchi. Findings in a sputum specimen are not diagnostic for a lung abscess. Patient teaching regarding home care is important but not the priority.)

When caring for a patient with a lung abscess, what is the nurse's priority intervention? a. Postural drainage. b. Antibiotic administration. c. Obtaining a sputum specimen. d. Patient teaching regarding home care.

a. auscultating lung sounds. (Assessment of lung sounds is a priority nursing intervention for patients with bronchitis. Evidence of consolidation would indicate progression of bronchitis to pneumonia, which would necessitate a change in treatment. Fluid intake and use of cough suppressants should be encouraged. Antibiotic treatment is generally not indicated.)

When caring for a patient with acute bronchitis, the nurse will prioritize a. auscultating lung sounds. b. encouraging fluid restriction. c. administerting antibiotic therapy. d. teaching the patient to avoid cough suppressants.

a. Confusion (Confusion possibly related to hypoxia may be the only finding in older adults. Although CAP is most commonly caused by Staphylococcus aureus pneumonia and is associated with an acute onset with fever, chills, productive cough with purulent or bloody sputum, and pleuritic chest pain, the older patient may not have classic symptoms. Other causes of pneumonia have a more gradual onset with dry, hacking cough; headache; and sore throat. A recent loss of consciousness or altered consciousness is common in those pneumonias associated with aspiration, such as anaerobic bacterial pneumonias.)

When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report? a. Confusion b. A recent loss of consciousness c. An abrupt onset of fever and chills d. A gradual onset of headache and sore throat

b. Fatigue, low-grade fever, and night sweats (TB usually develops insidiously with fatigue, malaise, anorexia, low-grade fevers, and night sweats. Pleuritic pain, flu-like symptoms, and a productive cough may occur with an acute sudden presentation but dyspnea and hemoptysis are late symptoms.)

When obtaining a health history from a patient suspected of having early TB, what manifestations should the nurse ask the patient about? a. Chest pain, hemoptysis, and weight loss b. Fatigue, low-grade fever, and night sweats c. Cough with purulent mucus and fever with chills d. Pleuritic pain, nonproductive cough, and temperature elevation at night

b. using sequential compression devices. (DVT is the primary cause of pulmonary embolism. Preventing DVT with the use of sequential compression devices, early ambulation, and prophylactic use of anticoagulant medications would thus be a priority nursing intervention.)

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using sequential compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.

a. There is continuous bubbling in the water-seal chamber. (The water-seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing patient. Continuous bubbling indicates a leak. The water in the suction control chamber will bubble continuously and the fluid in the water-seal chamber fluctuates with the patient's breathing. Water in the suction control chamber, and perhaps in the water-seal chamber, evaporates and may need to be replaced periodically.)

When should the nurse check for leaks in the chest tube and pleural drainage system? a. There is continuous bubbling in the water-seal chamber. b. There is constant bubbling of water in the suction control chamber. c. Fluid in the water-seal chamber fluctuates with the patient's breathing. d. The water levels in the water-seal and suction control chambers are decreased.

b. Decortication (Decortication is the stripping of a thick fibrous membrane. A lobectomy is the removal of one lung lobe. A thoracotomy is the incision into the thorax. A wedge resection is used to remove a small lesion.)

Which chest surgery is used for the stripping of a fibrous membrane? a. Lobectomy b. Decortication c. Thoracotomy d. Wedge resection

a, b, c, f (For the first 2 months, a four-drug regimen consists of isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol (Myambutol). Rifabutin (Mycobutin) and levofloxacin (Levaquin) may be used if the patient develops toxicity to the primary drugs. Rifabutin (Mycobutin) may be used as first-line treatment for patients receiving medications)

Which medications would be used in four-drug treatment for the initial phase of TB (SATA)? a. Isoniazid (INH) b. Rifampin (Rifadin) c. Pyrazinamide (PZA) d. Rifabutin (Mycobutin) e. Levofloxacin (Levaquin) f. Ethambutol (Myambutol)

a, b, f (Community-acquired pneumonia (CAP) and medical care-associated pneumonia (MCAP) are both associated with Klebsiella, Staphylococcus aureus, and Streptococcus pneumonia. Haemophilus influenzae and Mycoplasma pneumonia are only associated with CAP. Pseudomonas aeruginosa is only associated with MCAP.)

Which of the following microorganisms are associated with both CAP and MCAP (SATA)? a. Klebsiella b. Staphylococcus aureus c. Haemophilus influenzae d. Mycoplasma pneumonia e. Pseudomonas aeruginosa f. Streptococcus pneumonia

b. The use of a home spirometer will help to monitor lung function. c. Immunosuppressant therapy usually involves a three-drug regimen. e. The lung is biopsied using a transtracheal method if rejection is suspected. (Acute rejection after lung transplantation is common and can happen as soon as 5-7 days after surgery. Accurate diagnosis is achieved by transtracheal biopsy. Home spirometry has been useful in monitoring trends in lung function. Teach patients to keep medication logs, documentation of lab results, and spirometry records. Immunosuppressive therapy usually includes a three-drug regimen of cyclosporine or tacrolimus, mycophenolate motel (CellCept), and prednisone.)

Which statement(s) describe(s) the management of a patient following lung transplantation (SATA)? a. High doses of O2 are administered around the clock. b. The use of a home spirometer will help to monitor lung function. c. Immunosuppressant therapy usually involves a three-drug regimen. d. Most patients experience an acute rejection episode in the first 2 days. e. The lung is biopsied using a transtracheal method if rejection is suspected.

c. Obtain a physician's order for supplemental oxygen. (An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.)

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? a. Continue with ambulation. b. Obtain a physician's order for arterial blood gas. c. Obtain a physician's order for supplemental oxygen. d. Move the oximetry probe from the finger to the earlobe.

b. Right ventricular hypertrophy and dilation (High pressure in the pulmonary arteries increases the workload of the right ventricle and eventually causesright ventricular hypertrophy and dilation, known as cor pulmonale. Eventually, decreased left ventricular output may occur because of decreased return to the left atrium but it is not the primary effect of pulmonary hypertension. Alveolar interstitial edema is pulmonary edema associated with left ventricular failure. Pulmonary hypertension not cause systemic hypertension.)

While caring for a patient with idiopathic pulmonary arterial hypertension (IPAH), the nurse observes that the patient has exertional dyspnea and chest pain in addition to fatigue. What are these symptoms related to? a. Decreased left ventricular output b. Right ventricular hypertrophy and dilation c. Increased systemic arterial blood pressure d. Development of alveolar interstitial edema

c. Causative agents can be predicted and empiric treatment is often effective. (Pneumonia that has its onset in the community is usually caused by different microorganisms than pneumonia that develops related to hospitalization and treatment can be empiric—based on observations and experience without knowing the exact causative organism. Frequently a causative organism cannot be identified from cultures and treatment is based on experience.)

Why is the classification of pneumonia as community-acquired pneumonia (CAP) or medical care-associated pneumonia (MCAP) clinically useful? a. Atypical pneumonia syndrome is more likely to occur in MCAP. b. Diagnostic testing does not have to be used to identify causative agents. c. Causative agents can be predicted and empiric treatment is often effective. d. IV antibiotic therapy is necessary for MCAP but oral therapy is adequate for CAP.