chapter 23 Respiratory prepu
Which action should the nurse take first in caring for a client during an acute asthma attack? Send for STAT chest x-ray. Administer bronchodilator as ordered. Obtain arterial blood gases. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.
Administer bronchodilator as ordered.
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? Vitamin D Vitamin E Vitamin B6 Vitamin C
Vitamin B6
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? Damage to surrounding tissues Fibrotic changes in lungs Lung contusion Hemorrhage
Fibrotic changes in lungs
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: Not significant Significant Negative Nonreactive
Significant
What dietary recommendations should a nurse provide a patient with a lung abscess? A diet low in calories A diet with limited fat A carbohydrate-dense diet A diet rich in protein
A diet rich in protein
The nurse assesses a patient with pneumonia and notes bronchial breath sounds over consolidated lung areas. Which of the following breath sounds are diagnostic for pneumonia? Select all that apply. Crackles Egophony Wheezes Percussion dullness Friction rubs Whispered pectoriloquy
Crackles Egophony Percussion dullness Whispered pectoriloquy
A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient'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 assist the patient to breathe easier? Schedule the patient for pulmonary surgery Administer a large dose of furosemide (Lasix) IVP stat Increase oxygen administration Intubate the patient and control breathing with mechanical ventilation
Intubate the patient and control breathing with mechanical ventilation
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 Inspiratory crackles Bilateral wheezing Cyanosis
Rapid onset of severe dyspnea
A patient admitted to the hospital following a motor vehicle crash has suffered a flail chest. A nurse assesses the patient for what most common clinical manifestation of flail chest? Cyanosis Hypertension Wheezing Paradoxical chest movement
Paradoxical chest movement
Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? Streptococcal TB Pneumocystis Fungal
Pneumocystis
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication? 9 mm 5 to 6 mm 7 to 8 mm 0 to 4 mm
0 to 4 mm The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.
Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 75 and75 60 and 60 50 and 50 80 and 80
50 and 50
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? 3 to 5 days 1 to 3 weeks 2 to 4 months 6 to 12 months
6 to 12 months
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true? A negative reaction always excludes the diagnosis of TB. A positive reaction indicates that the client has been exposed to the disease. The PPD can be read within 12 hours after the injection. A positive reaction indicates that the client has active tuberculosis (TB).
A positive reaction indicates that the client has been exposed to the disease
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Auscultate breath sounds bilaterally every 4 hours. Instruct the client to breathe into a paper bag. Encourage the client to deep-breathe and cough every 2 hours. Administer oxygen by nasal cannula as ordered.
Administer oxygen by nasal cannula as ordered. When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.
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? Clean the wound and leave open to the air. Apply direct pressure to the wound. Apply vented dressing. Apply airtight dressing.
Apply airtight dressing. The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted.
A 65-year-old client who works construction, and has been demolishing an older building,is diagnosed with pneumoconiosis. The nurse is aware that his lung inflammation is most likely caused by exposure to which of the following? Asbestos Silica Pollen Coal dust
Asbestos
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 Blood-tinged sputum Respiratory alkalosis Productive cough
Blood-tinged sputum The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.
Nursing instruction during postural drainage should include telling the patient to: Lie supine to rest the lungs. Change positions frequently and cough up secretions. Sit upright to promote ventilation. Remain in each position for 30 to 45 minutes for best results.
Change positions frequently and cough up secretions.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Syncope Hypertension Dyspnea Ascites
Dyspnea Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of rightsided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.
Which of the following interventions does a nurse implement for patients with empyema? Place suspected patients together Institute droplet precautions Do not allow visitors with respiratory infection Encourage breathing exercises
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? Give antibiotics as ordered. Encourage increased fluid intake. Place client on bed rest. Offer nutritious snacks 2 times a day.
Encourage increased fluid intake.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Turning the client every 2 hours Encouraging increased fluid intake Maintaining a cool room temperature Elevating the head of the bed 30 degrees
Encouraging increased fluid intake
You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? Negative Homan's sign Pain in the calf Inability to dorsiflex Pain in the feet
Pain in the calf
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 Hyperventilation, hypertension, and hypocapnia Hypercapnia, hypoventilation, and hypoxemia Hypotension, hyperoxemia, and hypercapnia
Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Ineffective tissue perfusion (cardiopulmonary) Impaired gas exchange Anxiety Decreased cardiac output
Impaired gas exchange
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? Administer analgesics as ordered. Perform nasopharyngeal suctioning. Administer a heparin bolus and begin an infusion at 500 units/hour. Initiate oxygen therapy.
Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Obtain a sputum specimen for enzyme immunoassay testing. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Institute isolation precautions. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour.
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. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
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 Positive Borderline Uncertain
Negative The size of the induration determines the significance of the reaction. A reaction of 0-4 mm is not considered to be significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? Putting on an individually fitted mask when entering the client's room Instructing the client to wear a mask at all times Keeping the door to the client's room open to observe the client Wearing a gown and gloves when providing direct care
Putting on an individually fitted mask when entering the client's room
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 a kink has developed in the tubing. See if the wall suction unit has malfunctioned. See if the chest tube is clogged. See if there are leaks in the system
See if there are leaks in the system
The nurse is providing discharge instructions to a patient with pulmonary sarcoidosis. The nurse concludes that the patient understands the information if the patient correctly states which of the following early signs of exacerbation? Shortness of breath Weight loss Fever Headache
Shortness of breath Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.
The most diagnostic clinical symptom of pleurisy is: Fever and chills. Dyspnea and coughing. Dullness or flatness on percussion over areas of collected fluid. Stabbing pain during respiratory movements.
Stabbing pain during respiratory movements The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Pulmonary contusion Flail chest Tension pneumothorax Cardiac tamponade
Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
After a patient has undergone a series of diagnostic tests for tuberculosis, the diagnosis is confirmed by: A positive multiple-puncture skin test. A chest radiograph. Repeated Mantoux tests that yield indurations of 10 mm or greater. The ELISA test.
The ELISA test.
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: maintain fluid intake of 40 oz (1,200 ml) per day. follow up with the physician in 2 weeks. continue to take antibiotics for the entire 10 days. turn and reposition himself every 2 hours.
continue to take antibiotics for the entire 10 days.
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: lobar pneumonia. Pneumocystis carinii pneumonia. empyema. infected chest tube wound site.
empyema Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.
A Class 1 with regards to TB indicates no exposure and no infection. latent infection with no disease. disease that is not clinically active. exposure and no evidence of infection.
exposure and no evidence of infection. Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active.
Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)? Hypothermia will occur constipation usually develops it is the most contagious during the second week of illness It is spread by fecal contamination
it is the most contagious during the second week of illness Based on available information, SARS is most likely to be contagious only when symptoms are present, and patients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.35, PaCO2 48 mm Hg
pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.
