Iggy ch 31: patients with infectious respiratory problems
A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? a. "I am here to receive the yearly pneumonia shot again." b. "I am here to get my yearly flu shot again." c. "I should avoid large gatherings during cold and flu season." d. "I should cough into my upper sleeve instead of my hand."
a. "I am here to receive the yearly pneumonia shot again." The statement by the client, "I am here to receive the yearly pneumonia shot again" indicates a need for further teaching. The CDC recommends that adults older than 65 years be vaccinated with two vaccines, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax would have Prevnar 13 about a year or more later, but not annually. Older clients are encouraged to receive a flu shot annually because the vaccine is formulated annually, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. Recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.
The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? a. Arrange for a health care worker to observe the client take the medication. b. Give the client written instructions about how to take prescribed medications. c. Have the client repeat medication names and side effects. d. Instruct the client about the possible consequences of nonadherence.
a. Arrange for a health care worker to observe the client take the medication. The most effective action for the nurse to take to ensure that the client completes the treatment is to arrange for the client to be directly observed during therapy. The client is unlikely to adhere to long-term treatment unless closely supervised while taking medications. Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless and addicted to opiates would most likely be more concerned with obtaining drugs and shelter than with properly taking his or her medication.
An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first? a. Check the resident's oxygen saturation. b. Do a complete neurologic assessment. c. Administer the prescribed PRN lorazepam. d. Perform a mini mental status exam.
a. Check the resident's oxygen saturation. The nurse's first action is to assess the client's oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A common reason for sudden confusion in adult clients and those with spinal cord injury that may weaken respiratory muscles is hypoxemia caused by undiagnosed pneumonia or pulmonary embolism. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation, but this will take several minutes to complete. Administering lorazepam may mask symptoms of hypoxemia, delaying treatment. Benzodiazepine medications may cause a paradoxical reaction, or opposite effect, in some older clients, enhancing agitation. A mini mental status exam determines cognitive function and may give direction to the diagnosis of Alzheimer's or traumatic brain injury.
The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. a. Take a supplement containing B vitamins. b. Avoid alcohol containing beverages. c. Have kidney function tests monthly. d. Report changes in vision to the health care provider. e. Notify the health care provider for red-orange urine.
a. Take a supplement containing B vitamins. b. Avoid alcohol containing beverages. d. Report changes in vision to the health care providers. Teach the client to take a daily multiple vitamin that contains the B-complex vitamins while on this drug as deficiency may occur. These medications can cause liver damage, which is potentiated by alcohol. Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Contact lenses will also be stained and oral contraceptives will be less effective. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless and expected. Both isoniazid and pyrazinamide may cause liver failure. Side effects of major concern include jaundice, bleeding, and abdominal pain.
A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? a. "You will not spread the disease unless you stop taking your medication." b. "You will not pose an increased risk of disease to the people you have been living with." c. "You will have to take these medications for at least 1 year." d. "Your sputum may turn a rust color as your condition gets better."
b. "You will not pose an increased risk of disease to the people you have been living with." The nurse tells the client that he/she will not be contagious to the people he/she lives with. The people the client has been living with have already been exposed and need to be tested. They cannot become at higher risk simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. However, the risk for transmission is reduced after the infectious person has received proper drug therapy for 2 to 3 weeks, clinical improvement occurs, and acid-fast bacilli (AFB) in the sputum are reduced. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.
An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority? a. Corticosteroid b. Beta agonist c. Pneumococcal vaccine d. Antibiotic
b. Beta agonist The priority medication the nurse would expect the HCP to order is a beta-2 agonist or bronchodilator to help decrease bronchospasm and wheezing. This medication allows for adequate oxygenation by relaxing bronchial smooth muscle in the airways, and acts quickly to maintain airway patency. A corticosteroid will decrease airway swelling but takes many hours to days to become effective. A diagnosis of pneumonia has not been validated. However, if documented, the client should receive pneumococcal vaccine as an inpatient The anti-infective medication may be ordered after the cause of the symptoms is determined, but restoring adequate airway patency and reducing dyspnea take priority.
The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? a. Client with group A beta-hemolytic streptococcal pharyngitis who has stridor b. Client with pulmonary tuberculosis who is receiving multiple medications c. Client with sinusitis who has just arrived after having endoscopic sinus surgery d. Client with tonsillitis who has a thick-sounding voice and difficulty swallowing
b. Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Each state designates which tasks may be safely delegated and assigned to nursing team members. Depending on the state's nurse practice act, licensed practical/vocational nurses (LPNs/LVNs) and technicians may be trained and undergo competency verification related to the skill of peripheral IV insertion and assistance with infusions. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks (Infusion Nurses Society [INS], 2016; Weinstein & Hagle, 2014). Stridor, a harsh respiratory sound, is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful swallowing and respiratory assessment and monitoring by the RN.
The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? a. Bradycardia b. Confusion c. Eupnea d. Pale skin
b. Confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Symptoms of pneumonia include flushing, not pale skin, anxiety, chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, not bradycardia, dyspnea, tachypnea not eupnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Crackles, wheezing may be heard over areas of fluid, decreased breath sounds are present and wheezing may be heard where the airways are narrowed by exudate.
A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? a. Administer levofloxacin (Levaquin) 500 mg IV. b. Draw aerobic and anaerobic blood cultures. c. Give lorazepam (Ativan) as needed for agitation. d. Refer to social worker for alcohol counseling.
b. Draw aerobic and anaerobic blood cultures. The nurse would first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed. Getting cultures to identify the causative organism before initiating an antibiotic could affect the results of the culture and the type of antibiotic used. Levofloxacin, an antibiotic, is a priority intervention, and would be done after cultures are drawn. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action. Other interventions to help control the agitation may be tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.
The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? a. Avoiding public gatherings at all times b. Early recognition and quarantine of affected persons c. Vaccinating community members with pneumonia vaccine d. Widespread distribution of antiviral drugs
b. Early recognition and quarantine of affected persons Early recognition and quarantine of affected persons is the best way to prevent outbreaks of pandemic influenza. The recommended approach to disease prevention consists of quick recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings need to be avoided only in the case of widespread outbreak of influenza in the community. A vaccine (Vepacel) is available in case of H5N1 outbreaks, but is stockpiled and not part of general influenza vaccination. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.
The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. a. Breast cancer survivors b. Those in the local prison c. Homeless adults d. Recent immigrants to the United States e. Those who have received bacille Calmette-Guérin (BCG) vaccine
b. Those in the local prison c. Homeless adults d. Recent immigrants to the United States The groups the nurse plans to educate include those adults who live in crowded areas such as prisons and homeless shelters, and those who are recent immigrants to the USA. Other groups at higher risk for tuberculosis include those who abuse injection drugs or alcohol and those groups of lower socioeconomic status. Breast cancer survivors who are no longer undergoing immunocomprising therapy have the same risk as the general population. Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.
The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? a. Client with bacterial pneumonia and a cough productive of green sputum b. Client with neutropenia and pneumonia caused by Candida albicans c. Client with possible H5N1 influenza who currently has epistaxis d. Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)
c. Client with possible H5N1 influenza who currently has epistaxis A client with possible tuberculosis or H5N1 avian influenza would be admitted to the negative-airflow room to prevent airborne transmission of organisms from the client room to other clients/staff and areas of the hospital. A client with bacterial pneumonia does not require a negative-airflow room but should have airborne or Droplet Precautions in place. A client with neutropenia may be in a regular room with an emphasis on handwashing. The client with a right empyema who also has a chest tube and a fever would have Contact Precautions in place but does not require a negative-airflow room.
The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? a. Completing the antibiotic medication regimen b. Taking pain medications every 4 to 6 hours c. Contacting the health care provider (HCP) if drooling occurs d. Using warm saline gargles and irrigations
c. Contacting the health care provider (HCP) if drooling occurs The most important point to teach the client is to notify the HCP if signs of drooling develop. Clients with peritonsillar abscesses are at risk for airway obstruction due to swelling, manifested by drooling. It is also important to tell the client to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but these are not priority issues.
The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? a. Hemoglobin A1C b. Culture and Sensitivity report c. Evaluating pneumonia vaccine status d. Ensuring education to cough into the upper sleeve
c. Evaluating pneumonia vaccine status The Joint Commission's National Client Safety Goals (NPSGs) and core measures are client-safety oriented and recommends that all inpatients need to have their pneumonia vaccination status evaluated and, if needed, be vaccinated during that admission. It is important to provide diabetes education and assist the client in understanding the role of A1C in diabetes management, but that is not a core measure related to this situation. A culture and sensitivity may be performed, but is not a requirement or core measure. Coughing into the upper sleeve is a technique the center for disease control (CDC) recommends to prevent transmission and reduce the spread of disease.
A local hunter is admitted to the intensive care unit with a diagnosis of fulminant stage inhalation anthrax. Which assessment findings does the nurse anticipate is present? Select all that apply. a. Sore throat b. Rhinorrhea c. Harsh cough d. Stridor e. Low grade fever
c. Harsh cough d. Stridor The ICU nurse expects to find this client exhibiting a harsh cough and stridor. Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). The fulminant phase of inhalation anthrax begins after the client feels a little better and includes high fever, sudden onset of severe illness, including respiratory distress, hematemesis (bloody vomit), dyspnea, diaphoresis, stridor, chest pain, and cyanosis. When infection occurs through the lungs, the disease is nearly 100% fatal without treatment (CDC, 2015b). Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). Symptoms take up to 8 weeks to develop after exposure (Chart 31-4).The prodromal stage occurs early in the course of illness and includes low-grade fever, fatigue, mild chest pain, and a dry, harsh cough. It is not accompanied by upper respiratory symptoms of sore throat or rhinitis.
A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? a. Contact the health care provider for tuberculosis (TB) medications. b. Perform a TB skin test. c. Place a respiratory mask on the client. d. Test all family members for TB.
c. Place a respiratory mask on the client. The nurse's first action is to place a respiratory mask on the client. The concern is that this client has a high risk for TB having recently immigrated from overseas. Client with symptoms consistent with TB should be considered infectious until the disease is ruled out. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. Tell the client that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.
The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? a. "Handwashing is the best way to prevent transmission." b. "I should avoid kissing and shaking hands." c. "It is best to cough and sneeze into my upper sleeve." d. "The intranasal vaccine can be given to everybody in the family."
d. "The intranasal vaccine can be given to everybody in the family." Further teaching is needed when the client states that the intranasal vaccine can be given to everybody in the family. The intranasal flu vaccine is approved for adult clients up to age 49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.
The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? a. Ensures that the client is wearing a mask b. Informs the visitor that the client cannot receive visitors at this time c. Provides a particulate air respirator to the visitor d. Provides the visitor with a surgical mask
d. Provides the visitor with a surgical mask Because the visitor is entering the client's isolation environment, the visitor must wear a mask. The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator which is typically used for TB, H5N1 influenza, or SARS.
The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client? a. "Whooping" after a cough b. Hemoptysis c. Mild cold-like symptoms d. Severe coughing spasms
d. Severe coughing spasms Clients with pertussis will have severe coughing spasms. Paroxysms of coughing will often be followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing exhibited by children with pertussis. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.
An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? a. Ensure that ED staff members receive oseltamivir (Tamiflu). b. Administer IM influenza vaccination. c. Place the client in a negative air pressure room. d. Start an IV line and begin intravenous hydration.
d. Start an IV line and begin intravenous hydration. The nurse's first priority is to start an IV line and begin intravenous hydration. Elderly clients with influenza symptoms can develop dehydration quickly because of fever, vomiting and possible diarrhea. Initiating intravenous rehydration is a priority to maintain tissue perfusion. The ED staff would have received annual seasonal influenza vaccine, however if not, they can be given antiviral agents. A negative airflow room is not required in the ED, however a mask would be worn. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority as it takes weeks for full immunity to develop.
The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. a. The client states she will complete the entire dose of antibiotic prescribed. b. The client reports fatigue and malaise. c. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). d. The client has been afebrile for 48 hours.
d. The client has been afebrile for 48 hours. A positive outcome been afebrile for 48 hours. Expected outcomes to treatment include negative blood and sputum cultures, normal WBC count and differential, and absence of fever. Fatigue may persist for several weeks. The normal WBC count is 5000-10,000 mm3 (5-10 × 109/L). A WBC count of 16,000 mm3 (16 × 109/L) indicates infection. The client stating compliance with treatment is positive, but is not an objective measurement of eradicating the infecting organism.
A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? a. Combination medication therapy is effective in eliminating cough and fever. b. Combination medication therapy improves adherence. c. Combination medication therapy has fewer side effects, particularly liver damage. d. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.
d. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms. The nurse tells the client that multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission. As the disease responds to treatment, the symptoms will decrease, but they are not eliminated. Combination drug therapy does not improve adherence to drug therapy. Isoniazid, rifampin, and pyrazinamide may cause liver damage.
The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client? a. Keeping the door to the client room closed b. Performing oral care after suctioning the oropharynx c. Washing hands and donning gloves prior to the procedure d. Wearing a disposable particulate mask respirator
d. Wearing a disposable particulate mask respirator The most important infection control precaution the nurse must take before suctioning a client is to wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. The door to the room needs to be closed during care of the client with SARS and other instances of airborne precautions. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure.