Chapter 23-chest and lower respiratory disorders
A nurse recognizes that a client with tuberculosis needs further teaching when the client states:
"The people I have contact with at work should be checked regularly."
Approximately what percentage of people who are initially infected with TB develop active disease?
10%
Which of the following is a potential complication of a low pressure in the endotracheal cuff?
aspiration pneumonia
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and assist in the diagnosis of an occupational lung disease?
black streaked sputum
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
impaired gas exchange
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?
institute isolation precautions-SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients.
A nurse reading a chart notes that the patient had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?
negative
A 73-year-old client is admitted to the pulmonology unit of the hospital with a pleural effusion, which was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?
5-15ml
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6-12 months
Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women?
Adenocarcinoma
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
B6
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?
Deficient knowledge (disease process and treatment regimen)
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?
My cough has changed from a dry cough to one with lots of sputum production.
The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS?
Rapid onset of severe dyspnea
A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct the client that he will be safe from infecting others approximately how long after initiation of the chemotherapy regimen?
Two to 3 weeks after initiation of bacteriocidal drugs
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?
acute respiratory distress syndrome
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
acute respiratory distress syndrome
you are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know that this client is at increased risk for which of the following?
acute respiratory distress syndrome
A 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
Which of the following interventions does a nurse implement for patients with empyema?
encourage breathing exercises
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
encourage increased fluid intake
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear?
decreased breath sounds
What dietary recommendations should a nurse provide a patient with a lung abscess?
diet rich in protein
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessment is significant in diagnosing this client with flail chest
paradoxical chest movement During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
record the observation
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 drain air from the space around the lung."