Chapter 19: Management of Patients with Chest and Lower Respiratory
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? · "You need to start using the incentive spirometer 2 days after surgery." · "Before you do the exercise, I'll give you pain medication if you need it." · "Breathe in and out quickly." · "Don't use the incentive spirometer more than 5 times every hour."
"Before you do the exercise, I'll give you pain medication if you need it."
A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? · "When you're ready, blow hard into the spirometer for as long as you can." · "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." · "Take a deep breath and then blow short, forceful breaths into the spirometer." · "Hold the spirometer at your lips and breathe in and out like you normally would."
"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."
The nurse is caring for a client who has started therapy for tuberculosis. The client demonstrates an understanding of tuberculosis transmission when stating: "I'm clear when my chest X-ray is negative." "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm not contagious even if I have night sweats." "I'll follow airborne precautions until I have three negative sputum specimens."
"I'll follow airborne precautions until I have three negative sputum specimens."
A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? · "I'll always have a positive test for tuberculosis." · "This disease may come back later if I am under stress." · "I'll stay in isolation for 6 weeks." · "I'll have to take the medication for up to a year."
"I'll stay in isolation for 6 weeks."
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says: · "I'm clear when my chest X-ray is negative." · "I'm contagious as long as I have night sweats." · "My tuberculosis isn't contagious after I take the medication for 24 hours." · "I'll stop being contagious when I have a negative acid-fast bacilli test."
"I'll stop being contagious when I have a negative acid-fast bacilli test."
A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? · "It is fine if I eat sushi with a little bit of soy sauce." · "It is all right if I have a grilled cheese sandwich with American cheese." · "I am going to have a tuna fish sandwich for lunch." · "It is all right if I drink a glass of red wine with my dinner."
"It is all right if I have a grilled cheese sandwich with American cheese."
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? · "The tube will allow air to be restored to the lung." · "The tube will drain air from the space around the lung." · "The tube will provide a route for medication instillation to the lung." · "The tube will drain secretions from the lung."
"The tube will drain air from the space around the lung."
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? · "Getting the flu can complicate pneumonia." · "Influenza is the major cause of death in the United States." · "Influenza vaccine will prevent typical pneumonias." · "Viruses like influenza are the most common cause of pneumonia."
"Viruses like influenza are the most common cause of pneumonia."
Which long-term care facility resident most likely faces the greatest risk for aspiration? · A resident who suffered a severe stroke several weeks ago · A resident with mid-stage Alzheimer disease · A 92-year-old resident who needs extensive help with activities of daily living (ADLs) · A resident with severe and deforming rheumatoid arthritis
A resident who suffered a severe stroke several weeks ago
The nurse is preparing to suction a client with an endotracheal tube. What should be the nurse's first step in the suctioning process? · Assess the client's lung sounds and SaO2 via pulse oximeter. · Turn on suction source at a pressure not exceeding 120 mm Hg. · Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask. · Explain the suctioning procedure to the client and reposition the client.
Assess the client's lung sounds and SaO2 via pulse oximeter.
The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? · Direct lung damage · Chemical irritation · Aspiration · Drug ingestion
Chemical irritation
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? · Heart rate, 112 bpm · Moderate amounts of colorless sputum · Chest tube drainage, 190 mL/hr · Pain of 5 on a 1-to-10 scale
Chest tube drainage, 190 mL/hr
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? · Histotoxic hypoxia · Hypoxemic hypoxia · Anemic hypoxia · Circulatory hypoxia
Circulatory hypoxia
The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? · Cleaning the client's mouth with chlorhexidine daily · Ensuring that the client remains sedated while intubated · Maintaining the client in a high Fowler's position · Turning and repositioning the client every 4 hours
Cleaning the client's mouth with chlorhexidine daily
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? · Atelectasis · Empyema · Bronchiectasis · Consolidation
Consolidation
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? · Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer · Administering pain medications, frequent repositioning, and limiting fluid intake · Administering oxygen, coughing, breathing deeply, and maintaining bed rest · Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? · Nothing, until signs of active disease arise · Daily doses of isoniazid, 300 mg for 6 months to 1 year · Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years · Isolation until 24 hours after antitubercular therapy begins
Daily doses of isoniazid, 300 mg for 6 months to 1 year
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? · Anxiety · Impaired social interaction · Deficient knowledge (disease process and treatment regimen) · Social isolation
Deficient knowledge (disease process and treatment regimen)
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? · Call respiratory therapy and wait until they arrive to determine what is happening. · Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. · Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. · Suction the patient since the patient may be obstructed by secretions.
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? · Inform the physician promptly that there is in imminent leak in the drainage system. · Document that the chest drainage system is operating as it is intended. · Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. · Encourage the client to do deep breathing and coughing exercises.
Document that the chest drainage system is operating as it is intended.
What is the reason for chest tubes after thoracic surgery? · Draining secretions, air, and blood from the thoracic cavity is necessary. · Chest tubes allow air into the pleural space. · Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. · Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
Draining secretions, air, and blood from the thoracic cavity is necessary.
A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply. · Drug susceptibility testing · Complete blood count · Complete history and physical examination · A chest radiograph · A repeat multiple-puncture skin test
Drug susceptibility testing Complete history and physical examination A chest radiograph
For a client with pleural effusion, what does chest percussion over the involved area reveal? · Fluid presence · Friction rub · Dullness over the involved area · Absent breath sounds
Dullness over the involved area
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? · Sore throat and abdominal pain · Dyspnea and wheezing · Hemoptysis and dysuria · Nonproductive cough and normal temperature
Dyspnea and wheezing
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? · Make sure that a thoracotomy tube is linked to open chest drainage. · Encourage coughing to mobilize secretions. · Assist with positioning the client on the right side. · Restrict intravenous fluids for at least 24 hours.
Encourage coughing to mobilize secretions.
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? · Encourage increased fluid intake. · Offer nutritious snacks 2 times a day. · Give antibiotics as ordered. · Place client on bed rest.
Encourage increased fluid intake.
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? · Have the patient lie in a supine position during the use of the spirometer. · Encourage the patient to try to stop coughing during and after using the spirometer. · Encourage the patient to take approximately 10 breaths per hour, while awake. · Inform the patient that using the spirometer is not necessary if the patient is experiencing pain.
Encourage the patient to take approximately 10 breaths per hour, while awake.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Maintaining a cool room temperature Elevating the head of the bed 30 degrees Turning the client every 2 hours Encouraging increased fluid intake
Encouraging increased fluid intake
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? · Use of a cooling blanket · Incentive spirometry · Endotracheal suctioning · Encouragement of coughing
Endotracheal suctioning
A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to: · Use the spirometer twice every hour. · Expect coughing when using the spirometer properly. · Inhale and exhale rapidly with the spirometer. · Maintain a supine position to use the spirometer.
Expect coughing when using the spirometer properly.
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movements, chest protrudes and comes to a point. movement when removing the patient's shirt. What does the nurse know that this finding indicates? · Pneumothorax · Flail chest · ARDS · Tension pneumothorax
Flail chest
The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client? · How to take prophylactic antibiotics correctly · How to splint the incision when coughing · How to milk the chest tubing · How to manage the need for fluid restriction
How to splint the incision when coughing
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? · Hyperoxemia, hypocapnia, and hyperventilation · Hypercapnia, hypoventilation, and hypoxemia · Hypotension, hyperoxemia, and hypercapnia · Hyperventilation, hypertension, and hypocapnia
Hypercapnia, hypoventilation, and hypoxemia
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority? · Impaired gas exchange · Ineffective airway clearance · Infection risk · Acute pain
Impaired gas exchange
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? · Impaired gas exchange · Anxiety · Decreased cardiac output Ineffective tissue perfusion (cardiopulmonary
Impaired gas exchange
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? · Risk for trauma related to endotracheal intubation and cuff pressure · Impaired gas exchange related to ventilator setting adjustments · Risk for infection related to endotracheal intubation and suctioning · Impaired physical mobility related to being on a ventilator
Impaired gas exchange related to ventilator setting adjustments
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? · Promote the strengthening of the client's diaphragm · Promote more efficient and controlled ventilation and to decrease the work of breathing · Promote the client's ability to take in oxygen · Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? · Decreased level of consciousness (LOC) · Increased blood pressure · Increased restlessness · Decreased heart rate
Increased restlessness
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: · Impaired tissue integrity. · Ineffective breathing pattern. · Risk for falls. · Ineffective airway clearance.
Ineffective airway clearance.
A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? · Excess fluid volume · Acute pain · Activity intolerance · Ineffective breathing pattern
Ineffective breathing pattern
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? · Intubate the client and control breathing with mechanical ventilation · Increase oxygen administration · Administer a large dose of furosemide (Lasix) IVP stat · Schedule the client for pulmonary surgery
Intubate the client and control breathing with mechanical ventilation
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? · It increases the respiratory rate to improve oxygenation. · It will prevent the alveoli from overexpanding. · It will assist with widening the airway. · It prolongs exhalation.
It prolongs exhalation.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A change in the oxygen concentration without resetting the oxygen level alarm An ET cuff leak A disconnected ventilator circuit Kinking of the ventilator tubing
Kinking of the ventilator tubing
A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? · Measure the client's oxygen saturation. · Have the client perform incentive spirometry. · Determine whether the client can now perform forced expiratory technique (FET). · Percuss the client's lungs and thorax.
Measure the client's oxygen saturation.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? · Keep the tracheostomy tube plugged at all times. · Monitor the pressure in the cuff at least every 8 hours · Deflate the cuff overnight to prevent tracheal tissue trauma. · Inflate the cuff to the highest possible pressure in order to prevent aspiration.
Monitor the pressure in the cuff at least every 8 hours
The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? · Disconnect the system and get another. · Place the head of the patient's bed flat. · Notify the physician. · Milk the chest tube.
Notify the physician.
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? · Chest pain on inspiration · Clubbing of fingers and toes · Paradoxical chest movement · Respiratory acidosis
Paradoxical chest movement
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? · Clamp the chest tube immediately. · Secure the chest tube with tape. · Place the end of the chest tube in a container of sterile saline. · Apply an occlusive dressing and notify the physician.
Place the end of the chest tube in a container of sterile saline.
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? · Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide · Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula · Puts on clean gloves; removes and discards the soiled dressing in a biohazard container · Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? · Heart failure · Myocardial infarction (MI) · Pulmonary embolism · Pneumothorax
Pneumothorax
The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? · Exercise tolerance tests · Pulmonary function studies · Arterial blood gas values · Chest x-ray
Pulmonary function studies
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections? Receiving vaccinations Mobilizing early Using incentive spirometry Using prescribed opioids
Receiving vaccinations
The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? Removal from oxygen, tube, and then ventilator Removal of the tube, oxygen, and then ventilator Removal from oxygen, ventilator, and then tube Removal from the ventilator, tube, and then oxygen
Removal from the ventilator, tube, and then oxygen
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? · Ensuring that humidified oxygen is always introduced through the tube · Checking the cuff pressure every 6 to 8 hours · Deflating the cuff before removing the tube · Routinely deflating the cuff
Routinely deflating the cuff
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? · Respiratory rate of 16 breaths/minute · Oxygen saturation of 93% · Blood pressure remains stable · Runs of ventricular tachycardia
Runs of ventricular tachycardia
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? Shortness of breath Headache Fever Weight loss
Shortness of breath
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: · Nonreactive · Negative · Significant · Not significant
Significant
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Fever and chills Dullness or flatness on percussion over areas of collected fluid Dyspnea and coughing Stabbing pain during respiratory movement
Stabbing pain during respiratory movement
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? · Suction the client's artificial airway. · Check for an apical pulse. · Increase the oxygen percentage. · Ventilate the client with a handheld mechanical ventilator.
Suction the client's artificial airway.
The nurse is caring for a client with a diagnosis of pleurisy. The client begins reporting right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What is the nurse's best action? · Teach the client to splint the rib cage · Teach the client pursed lip breathing · Teach the client deep-breathing and coughing exercises · Contact the respiratory therapist promptly
Teach the client to splint the rib cage
A mediastinal shift occurs in which type of chest disorder? · Traumatic pneumothorax · Cardiac tamponade · Simple pneumothorax · Tension pneumothorax
Tension pneumothorax
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? · The patient is in a hypermetabolic state. · The patient is having a myocardial infarction. · The patient is hypoxic from suctioning. · The patient is having a stress reaction.
The patient is hypoxic from suctioning.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? · The client has a pneumothorax. · The system is functioning normally. · The chest tube is obstructed. · The system has an air leak.
The system has an air leak.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? · Absence of bloody drainage in the anterior/upper tube · Bloody drainage is observed in the collection chamber. · Skin around tube is pink. · The tissues give a crackling sensation when palpated.
The tissues give a crackling sensation when palpated.
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? · To assist with mechanical ventilation · To remove air from the pleural space · To monitor bleeding around the lungs · To drain copious sputum secretions
To remove air from the pleural space
A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? · Reposition the endotracheal tube. · Manually ventilate the client. · Troubleshoot to identify the malfunction. · Notify the respiratory therapist.
Troubleshoot to identify the malfunction.
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? · Use a prescribed analgesic. · Turn onto the affected side. · Use a heat or cold application. · Avoid using a pillow while splinting.
Turn onto the affected side.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? · Using strict hand hygiene · Turning the client every 4 hours to prevent fatigue · Keeping the head of the bed at 15 degrees or less · Providing oral hygiene daily
Using strict hand hygiene
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? · Suction control chamber · Air-leak chamber · Collection chamber · Water-seal chamber
Water-seal chamber
A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan? · Wearing a gown and gloves when providing direct care · Instructing the client to wear a mask at all times · Wearing a disposable particulate respirator that fits snugly around the face · Keeping the door to the client's room open to observe the client
Wearing a disposable particulate respirator that fits snugly around the face
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: · milk the chest tube every 2 hours. · report fluctuations in the water-seal chamber. · encourage coughing and deep breathing. · clamp the chest tube once every shift.
encourage coughing and deep breathing.
A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: · keeping his airway patent. · encouraging him to perform activities of daily living (ADLs). · preventing him from developing an infection. · helping him communicate.
keeping his airway patent.
What does a positive Mantoux test indicate? · production of an immune response · active immunity to tuberculosis · development of full-blown tuberculosis · an active case of tuberculosis
production of an immune response
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows · drainage. · tissue sloughing. · redness and induration. · bruising.
redness and induration.
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to: · remove fluid from the lungs. · administer IV medication. · remove air from the pleural space. · ventilate the client.
remove air from the pleural space.
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: · area of redness is measured in 3 days and determines whether tuberculosis is present. · skin test doesn't differentiate between active and dormant tuberculosis infection. · test stimulates a reddened response in some clients and requires a second test in 3 months. · presence of a wheal at the injection site in 2 days indicates active tuberculosis.
skin test doesn't differentiate between active and dormant tuberculosis infection.
Which is a potential complication of a low pressure in the endotracheal tube cuff? · Pressure necrosis · Aspiration pneumonia · Tracheal bleeding · Tracheal ischemia
Aspiration pneumonia
How should the nurse best assess whether a client receiving oxygen therapy is hypoxemic? Assess the client's level of consciousness (LOC). Review the client's hemoglobin, hematocrit, and red blood cell levels. Assess the client's extremities for signs of cyanosis. Assess the client using pulse oximetry.
Assess the client using pulse oximetry.
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? · When bronchospasms occur · Immediately before a meal · At bedtime · When secretions have mobilized
At bedtime
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? · Have the patient cough. · Assess the CO2 level to determine if the patient requires suctioning. · Have the patient inform the nurse of the need to be suctioned. · Auscultate the lung for adventitious sounds.
Auscultate the lung for adventitious sounds.
For a client with an endotracheal (ET) tube, which nursing action is the most important? · Auscultating the lungs for bilateral breath sounds · Monitoring serial blood gas values every 4 hours · Providing frequent oral hygiene · Turning the client from side to side every 2 hours
Auscultating the lungs for bilateral breath sounds
What assessment method would the nurse use to determine the areas of the lungs that need draining? · Auscultation · Arterial blood gas (ABG) levels · Chest X-ray · Inspection
Auscultation
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? · 1 to 3 weeks · 2 to 4 months · 6 to 12 months · 3 to 5 days
6 to 12 months
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 58 mm Hg 120 mm Hg 84 mm Hg 45 mm Hg
84 mm Hg
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 · hemothorax. · pneumothorax. · pleural effusion. · consolidation.
pleural effusion.
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient? · "The physician can give you eye drops to prevent any problems." · "Only wear your contact lenses during the day and take them out in the evening before bed." · "There are no significant problems with wearing contact lenses." · "You should switch to wearing your glasses while taking this medication."
"You should switch to wearing your glasses while taking this medication."
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside? · An Ambu bag · A bottle of sterile water · A set of hemostats · An incentive spirometer
A bottle of sterile water
What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? · A client requires permanent ventilation. · A client has a respiratory rate of 10 breaths per minute. · A client has respiratory acidosis. · A client exhibits symptoms of dyspnea.
A client requires permanent ventilation.
Which would be least likely to contribute to a case of hospital-acquired pneumonia? · A nurse washes her hands before beginning client care. · Host defenses are impaired. · Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. · A highly virulent organism is present.
A nurse washes her hands before beginning client care.
The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? · Elevated troponin levels · Elevated B-type natriuretic peptide (BNP) levels · Elevated white blood count · Elevated myoglobin levels
Elevated B-type natriuretic peptide (BNP) levels
On auscultation, which finding suggests a right pneumothorax? · Bilateral pleural friction rub · Absence of breath sounds in the right thorax · Bilateral inspiratory and expiratory crackles · Inspiratory wheezes in the right thorax
Absence of breath sounds in the right thorax
The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension? · Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. · Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. · Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. · Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? · Bradypnea · Productive cough · Blood-tinged sputum · Respiratory alkalosis
Blood-tinged sputum
A nurse should include what instruction for the client during postural drainage? · Remain in each position for 30 to 45 minutes for best results. · Lie supine to rest the lungs. · Sit upright to promote ventilation. · Change positions frequently and cough up secretions.
Change positions frequently and cough up secretions.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Contacts the respiratory therapy department to report the ventilator is malfunctioning Continues assessing the client's respiratory status frequently Changes the setting on the ventilator to increase breaths to 14 per minute Consults with the physician about removing the client from the ventilator
Continues assessing the client's respiratory status frequently
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? · Medications to assist the patient with sleep at night · Surgery to remove the tonsils and adenoids · Continuous positive airway pressure (CPAP) · Bi-level positive airway pressure (BiPAP)
Continuous positive airway pressure (CPAP)
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? · Assessing the client's temperature every 8 hours · Wearing gloves during all client contact · Placing the client in respiratory isolation · Monitoring the client's fluid intake and output
Placing the client in respiratory isolation
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? · The client exhibits restlessness and confusion. · The client exhibits bronchial breath sounds over the affected area. · The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. · The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? · Negative-pressure · Volume-controlled · Time-cycled · Pressure-cycled
Volume-controlled
Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and a rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza? · staphylococcal pneumonia · viral pneumonia · tracheobronchitis · cardiovascular disease
staphylococcal pneumonia
