Chapter 23

A nurse is caring for client after thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?

"Client is becoming agitated and complains of pleuritic pain."

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range?

2.0 to 2.5

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. This client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?f

6 to 12 months

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that the client is at increased risk for which of the following?

Acute respiratory distress syndrome

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Aspiration pneumonia

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing

Which interventions does a nurse implement for clients with empyema?

Encourage breathing exercises

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:

Asbestos

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

Streptococcus pneumoniae

A client involved in a motor vehicle crash suffered a penetrating injury to the chest wall and was brought to the emergency department. The nurse assesses the client for which clinical manifestation that would indicate the presence of a pneumothorax?

Sucking sound at the site of injury

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?

Blood-tinged sputum

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states he must:

Continue to take antibiotics for the entire 10 days

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Progressive loss of lung function associated with chronic disease

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Tension pneumothorax

The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?

Classes at community centers to teach about smoking cessation strategies

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

The nursing instructor is teaching students about types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally?

Large cell carcinoma

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

Acute respiratory distress syndrome

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

Acute respiratory distress syndrome (ARDS)

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?

Apply airtight dressing

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

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

Crackles in the lung bases

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

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail chest

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?

Ineffective breathing pattern

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

Initiate oxygen therapy

A client with suspected acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions

A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?

Negative

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

Pleural effusion

A client who 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. chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Pneumothorax

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

Rapid onset of severe dyspnea

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

See if there are leaks in the system

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

Stabbing pain during respiratory movement

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse?

The employee enters the room wearing a gown, gloves, and a mask

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

The tissues give a crackling sensation when palpated

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6

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?

Chemical irritation

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Cough or change in chronic cough