Final
You are the hospice nurse caring for a client with pulmonary fibrosis who wants to die at home. The client is having difficulty breathing. The family asks why it is so hard for the client to breathe. What would be the nurse's best response? a) "The dying no longer have the energy to breathe." b) "This is normal when a person is near the end of their life." c) "The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe. d) "The disease is making your loved one retain carbon dioxide, so there is not enough room in the blood for adequate oxygen."
"The fibrosis of the lungs makes the lungs stiff, which makes it harder to breathe. Explanation: Decreased surfactant, fibrosis, edema, and atelectasis (alveolar collapse) affect lung compliance. Greater pressure gradients are needed when lungs are stiff. Options A, B, and D are incorrect because the information given to the family is incorrect
A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is: a) 3 L. b) 1.4 L. c) unspecified. d) 2 L.
1.4 L. Correct Explanation: Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily.
Emphysema is described by which of the following statements? a) A disease of the airways characterized by destruction of the walls of overdistended alveoli b) Chronic dilatation of a bronchus or bronchi c) Presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years d) A disease that results in a common clinical outcome of reversible airflow obstruction
A disease of the airways characterized by destruction of the walls of overdistended alveoli Explanation: Emphysema is a category of COPD. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.
Which of the following would be LEAST likely to contribute to a case of hospital-acquired pneumonia? a) A highly virulent organism is present. b) A nurse washes her hands before beginning patient care. c) Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. d) Host defenses are impaired.
A nurse washes her hands before beginning patient care. Explanation: HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? a) A puncture at the radial artery b) The pleural surfaces c) A catheter in the arm vein d) The trachea and bronchi
A puncture at the radial artery Explanation: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
On auscultation, which finding suggests a right pneumothorax? a) Absence of breath sounds in the right thorax b) Inspiratory wheezes in the right thorax c) Bilateral pleural friction rub d) Bilateral inspiratory and expiratory crackles
Absence of breath sounds in the right thorax Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
Your client is scheduled for a bronchoscopy to visualize the larynx, trachea, and bronchi. What precautions would you recommend to the client before the procedure? a) Avoid sedatives or narcotics as they depress the vagus nerve. b) Avoid atropines as they dry the secretions. c) Practice holding the breath for short periods. d) Abstain from food for at least 6 hours before the procedure.
Abstain from food for at least 6 hours before the procedure. Explanation: For at least 6 hours before bronchoscopy, the client must abstain from food or drink to decrease the risk of aspiration. Risk is increased because the client receives local anesthesia, which suppresses the reflexes to swallow, cough, and gag. The client receives medications before the procedure. Typically, atropine is given to dry secretions and a sedative or narcotic is given to depress the vagus nerve. The client may need to hold his or her breath for short periods during lung scans and for bronchoscopy
A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. The nurse knows this would probably be a) Albuterol b) Atrovent c) Isuprel d) Foradil
Albuterol Explanation: Short-acting beta2-adrenergic agonists include albuterol, levalbuterol, and pirbuterol. They are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They are used to relax smooth muscle.
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? a) Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. b) Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. c) Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. d) Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Correct Explanation: In secondary pulmonary arterial hypertension, alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Therefore options A, B, and C are incorrect.
A 55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse a) Explains to the client not to eat or drink before the spirometry test b) Asks the client, "What are your allergies?" c) States that various blood tests must also be done d) Tells the client that arterial blood gas is performed after spirometry testing
Asks the client, "What are your allergies?" Explanation: Spirometry testing includes use of a bronchodilator and then further testing. The nurse needs to assess for allergies first. The client does not need to be NPO prior to spirometry testing. Venous blood work may be done for clients younger than 45 years old, to check for a deficiency in alpha 1-antitrypsin. Arterial blood gases, if ordered, are obtained prior to spirometry testing.
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time? a) Perform mouth care. b) Assess for a cough reflex. c) Call dietary services to send the client's tray now. d) Assess for bowel sounds.
Assess for a cough reflex. Explanation: Before a bronchoscopy procedure, the nurse will administer preoperative medications, usually atropine and a sedative. These are prescribed to inhibit vagal stimulation, suppress the cough reflex, sedate the client, and relieve anxiety. After the procedure, it is important that the client take nothing by moth until the cough reflex returns. This is because the preoperative medication impairs the protective laryngeal reflex and swallowing for several hours. Once the client demonstrates a cough reflex or the nurse positively assesses one, then the nurse may offer ice chips and fluids
A critical-care nurse is caring for a postoperative patient following lung surgery. The patient has a shallow, monotonous respiratory pattern and is reluctant to cough. What may the patient may be at an increased risk for? a) Atelectasis b) Aspiration c) Increased oxygen saturation d) Malnutrition
Atelectasis Correct Explanation: The reluctance to cough is likely due to poor pain control. A shallow, monotonous respiratory pattern places the patient at an increased risk of developing atelectasis. The patient would not be at increased risk for increased oxygen saturation, aspiration, or malnutrition
Which of the following is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)? a) Occupational exposure b) Genetic abnormalities c) Air pollution d) Cigarette smoking
Cigarette smoking Explanation: Pipe, cigar and other types of tobacco smoking are also risk factors for COPD. While a risk factor, occupational exposure is not the most important risk factor for development of COPD. Air pollution is a risk factor for development of COPD, but it is not the most important risk factor
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Administering pain medications, frequent repositioning, and limiting fluid intake b) Administering oxygen, coughing, breathing deeply, and maintaining bed rest c) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer d) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Correct Explanation: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? a) Assess the radial pulse. b) Assist the client to lie down. c) Count the rate of respirations. d) Inquire if there have been any stressful visitors.
Count the rate of respirations. Correct Explanation: Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.
Which of the following is a late sign of hypoxia? a) Restlessness b) Cyanosis c) Somnolence d) Hypotension
Cyanosis Explanation: Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
An 81-year-old client is recovering in your hospital unit from a bout with empyema. Because of her condition, you implement an intervention to promote healing and oxygenation. What intervention do you implement? a) Institute droplet precautions. b) Do not allow visitors with a respiratory infection. c) Encourage breathing exercises. d) Place suspected clients together.
Encourage breathing exercises.
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema? a) Place suspected patients together. b) Do not allow visitors with respiratory infection. c) Institute droplet precautions. d) Encourage breathing exercises.
Encourage breathing exercises. Explanation: The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.
Which of the following exposures accounts for the majority of cases with regard to risk factors for chronic obstructive pulmonary disease (COPD)? a) Exposure to tobacco smoke b) Passive smoking c) Ambient air pollution d) Occupational exposure
Exposure to tobacco smoke Explanation: Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors but do not account for the majority. (less)
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hypotension, hyperoxemia, and hypercapnia b) Hypercapnia, hypoventilation, and hypoxemia c) Hyperventilation, hypertension, and hypocapnia d) Hyperoxemia, hypocapnia, and hyperventilation
Hypercapnia, hypoventilation, and hypoxemia Correct Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems
In which stage of COPD is the forced expiratory volume (FEV) less than 30%? a) II b) I c) 0 d) III
III Explanation: Stage III patients demonstrate an FEV less than 30% with respiratory failure or clinical signs of right heart failure. Stage II patients demonstrate an FEV of 30% to 80%. Stage I is mild COPD with an FEV less than 70%. Stage 0 is characterized by normal spirometry
Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? a) Varicella b) Hepatitis B c) Influenza d) Human papilloma virus (HPV)
Influenza Explanation: Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for women ages 9 to 26
A client has intermittent asthma attacks. Which of the following therapies does the nurse teach the client to use at home when experiencing an asthma attack? a) Oxygen therapy b) Inhaled cromolyn sodium (Intal) c) Inhaled albuterol (Ventolin) d) Oral theophylline (Theo-Dur)
Inhaled albuterol (Ventolin) Explanation: For intermittent asthma, the preferred treatment is with an inhaled short-acting beta2-agonist. The other treatments are for persistent asthma.
Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders? a) Manage decreased energy levels b) Manage respiratory distress c) Aid the caregivers of the client d) Ensure adequate rest periods
Manage decreased energy levels Explanation: In addition to the nursing management of individual tests, patients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these patients, breathing may in some way be compromised. Energy levels may be decreased. For that reason, explanations should be brief yet complete and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress
Which of the following terms is used to describe the inability to breathe easily except in an upright position? a) Hemoptysis b) Orthopnea c) Hypoxemia d) Dyspnea
Orthopnea Patients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.
When assessing a client, which adaptation indicates the presence of respiratory distress? a) Productive cough b) Respiratory rate of 14 breaths per minute c) Sore throat d) Orthopnea
Orthopnea Correct Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.
A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first: a) Oxygen therapy through a non-rebreather mask b) Normal saline 0.9% at 100 mL/hr intravenously c) Oral fluid of at least 2500 mL/day d) Intravenous magnesium sulfate
Oxygen therapy through a non-rebreather mask Explanation: The description is consistent with status asthmaticus. The client has not responded to treatment. Oxygen saturation is low. As oxygenation is the priority per Maslow's hierarchy of needs, oxygen therapy would be supplied first. Then, the nurse would initiate intravenous fluids and magnesium sulfate. Last, the nurse would encourage the client to drink fluids to prevent dehydration.
A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following? a) Hemothorax b) Consolidation c) Pleural effusion d) Pneumothorax
Pleural effusion Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature due to collapse of alveoli or infectious process
Which of the following terms means an increase in the red blood cell concentration in the blood? a) Bronchitis b) Emphysema c) Polycythemia d) Asthma
Polycythemia Explanation: Polycythemia is an increase in the red blood cell concentration in the blood. Emphysema is a disease of the airways characterized by destruction of the walls of overdistended alveoli. Asthma is a disease with multiple precipitating mechanisms resulting in a common clinical outcome of reversible airflow obstruction.
Which of the following terms means an increase in the red blood cell concentration in the blood? a) Bronchitis b) Emphysema c) Polycythemia d) Asthma
Polycythemia Correct Explanation: Polycythemia is an increase in the red blood cell concentration in the blood. Emphysema is a disease of the airways characterized by destruction of the walls of overdistended alveoli. Asthma is a disease with multiple precipitating mechanisms resulting in a common clinical outcome of reversible airflow obstruction
You are caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when you will allow the patient to drink fluids? a) Absence of nausea b) Ability to demonstrate deep inspiration c) Presence of a cough and gag reflex d) Ability to speak
Presence of a cough and gag reflex Explanation: After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? a) Progressive loss of lung function associated with chronic disease b) Sudden loss of lung function associated with chronic disease c) Progressive loss of lung function with history of normal lung function d) Sudden loss of lung function with history of normal lung function
Progressive loss of lung function associated with chronic disease Explanation: In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)? a) Pulse oximetry b) Sputum studies c) Arterial blood gas analysis d) Pulmonary function testing
Pulse oximetry Explanation: Pulse oximetry is a noninvasive method of continuously monitoring SaO2. Measurements of blood pH of arterial oxygen and carbon dioxide tensions are obtained when managing patients with respiratory problems and adjusting oxygen therapy as needed. This is an invasive procedure. Pulmonary function testing assesses respiratory function and determines the extent of dysfunction. Sputum studies are done to identify if any pathogenic organisms or malignant cells are in the sputum
Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections? a) Using prescribed opioids b) Mobilizing early c) Using incentive spirometry d) Receiving vaccination
Receiving vaccination Explanation: Identifying the patients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages patients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances? a) Metabolic alkalosis b) Respiratory acidosis c) Metabolic acidosis d) Respiratory alkalosis
Respiratory acidosis Correct Explanation: Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid-base imbalances would not correlate with COPD
Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client? a) Watery sputum b) Respiratory distress c) Masses in pleural space d) Loss of consciousness
Respiratory distress Explanation: After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.
When developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated? a) Smoking cessation b) Cholesterol management c) Weight reduction d) Cancer prevention
Smoking cessation Explanation: The most important risk factor for the development of COPD is cigarette smoking. The effects of cigarette smoke are complex and lead to the development of COPD in approximately 15% to 20% of smokers. Tobacco smoke irritates the airways and, in susceptible individuals, results in mucus hypersecretion and airway inflammation
A client is being sent home with oxygen therapy. The nurse instructs that a) Smoking or a flame is dangerous near oxygen. b) The client should raise the flow of oxygen if shortness of breath increases. c) The client will not be able to travel with oxygen. d) Oxygen is addictive and its use must be decreased.
Smoking or a flame is dangerous near oxygen. \The nurse should cautions the client against smoking or using a flame near oxygen. Oxygen is not addictive. Clients can travel with portable oxygen systems. Teaching also includes the proper flow of oxygen. (less)
Which of the following results in decreased gas exchange in older adults? a) The elasticity of the lungs increases with age. b) The alveolar walls contain fewer capillaries. c) The alveolar walls become thicker. d) The number of alveoli decreases with age.
The alveolar walls contain fewer capillaries. Explanation: Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age, and number of alveoli does not decrease with age
The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration? a) To move CO2 out of the atmospheric air and into the expired air b) To exchange atmospheric air between the blood and the cells c) To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells d) To move O2 out of the atmospheric air and into the retained air
To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells Explanation: The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells
Which of the following would not be considered a primary symptom of COPD? a) Cough b) Sputum production c) Dyspnea on exertion d) Weight gain
Weight gain Correct Explanation: COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea on exertion. Weight loss is common with COPD.
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: a) propranolol (Inderal). b) albuterol (Proventil). c) morphine. d) alprazolam (Xanax).
albuterol (Proventil). Explanation: The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation
A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: a) assist the client to a sitting position on the edge of the bed, leaning over the bedside table. b) place the client supine in the bed, which is flat. c) raise the arm on the side of the client's body on which the physician will perform the thoracentesis. d) raise the head of the bed to a high Fowler's position.
assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Explanation: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.
A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: a) diminished or absent breath sounds on the affected side. b) muffled or distant heart sounds. c) tracheal deviation to the unaffected side. d) paradoxical chest wall movement with respirations.
diminished or absent breath sounds on the affected side. Explanation: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.
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: a) empyema. b) lobar pneumonia. c) Pneumocystis carinii pneumonia. d) infected chest tube wound site.
empyema. Correct Explanation: 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
The classification of Stage I of COPD is defined as a) mild COPD. b) very severe COPD. c) severe COPD. d) at risk for COPD.
mild COPD. Correct Explanation: Stage I is mild COPD. Stage 0 is at risk for COPD. Stage III is severe COPD. Stage IV is very severe COPD.
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as a) pleural friction rub. b) sonorous wheezes. c) sibilant wheezes. d) crackles.
pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration.
The term for the volume of air inhaled and exhaled with each breath is a) tidal volume. b) vital capacity. c) residual volume. d) expiratory reserve volume.
tidal volume. Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation
The diagnosis of pulmonary hypertension associated with chronic obstructive pulmonary disease (COPD) is suspected when which of the following is noted? Select all that apply. a) Enlarge of central pulmonary arteries b) Right ventricular enlargement c) Elevated plasma brain natriuretic peptide (BNP) d) Left ventricular hypertrophy e) Dyspnea and fatigue disproportionate to pulmonary function abnormalities
• Dyspnea and fatigue disproportionate to pulmonary function abnormalities • Right ventricular enlargement • Elevated plasma brain natriuretic peptide (BNP) • Enlarge of central pulmonary arteries Explanation: The diagnosis of pulmonary hypertension associated with COPD is suspected in patients complaining of dyspnea and fatigue that appear to be disproportionate to pulmonary function abnormalities. Enlargement of the central pulmonary arteries on the chest X-ray, echocardiogram suggestive of right ventricular enlargement, and elevated plasma BNP may be present.
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. a) Maintain an open airway. b) Encourage deep breathing exercises. c) Monitor and record hourly intake and output. d) Monitor pulmonary status as directed and needed. e) Regularly assess the client's vital signs every 2 to 4 hours.
• Encourage deep breathing exercises. • Monitor pulmonary status as directed and needed. • Regularly assess the client's vital signs every 2 to 4 hours. Correct Explanation: Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. Maintainin an open airway is appropriate for improving the client's airway clearance. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance
After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options. a) Reduce airway obstruction b) Alter smooth muscle tone c) Decrease alveolar ventilation d) Increase oxygen distribution
• Reduce airway obstruction • Alter smooth muscle tone • Increase oxygen distribution Correct Explanation: Bronchodilators relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Substernal pain b) Dyspnea c) Fatigue d) Bradycardia e) Mood swings
• Substernal pain • Dyspnea • Fatigue Correct Explanation: Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity
A client with asthma has developed obstruction of the airway. Which of the following does the nurse understand as having potentially contributed to this problem? Choose all that apply. a) Thick mucus b) Airway remodeling c) Swelling of bronchial membranes d) Destruction of the alveolar wall
• Thick mucus • Swelling of bronchial membranes • Airway remodeling Explanation: As asthma becomes more persistent, inflammation progresses and airway edema, mucus hypersecretion, and formation of mucus plugs can occur. Airway remodeling may occur in response to chronic inflammation, causing further airway narrowing. Destruction of the alveolar wall does not occur with asthma.
