Med Surg Ch. 23 Lower Resp Tract Disorders
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?
"You must consume a diet rich in protein, such as chicken, fish, and beans." The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.
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:
1.4 L. 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.
Nursing instruction during postural drainage should include telling the patient to:
Change positions frequently and cough up secretions. Patients who lie supine will have secretions accumulate in the posterior lung sections, whereas upright patients will pool secretions in their lower lobes. By changing positions (see Fig. 10-2 in the text), secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.
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 Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client'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 help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.
A client reports dyspnea, fatigue, and having had a persistent productive cough for the last few months, which the client attributes to a bout with the flu. The nurse suspects that this client may have:
lung cancer. Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. The sputum is examined for malignant cells. Chest x-rays may or may not show a tumor. With pleurisy, the client's respirations become shallow secondary to excruciating pain. The client may have a dry cough, fatigue easily, and experience dyspnea. Fever, pain, and dyspnea are the most common symptoms of pleural effusion. Signs and symptoms of lung abscess include chills, fever, weight loss, chest pain, and a productive cough.
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 Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.
Which of the following is a potential complication of a low pressure in the endotracheal cuff?
Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.
What is the reason for chest tubes after thoracic surgery?
Draining secretions, air, and blood from the thoracic cavity is necessary. After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.
A client who has 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. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which intervention to improve oxygenation and provide comfort for the client?
Position the client in the prone position The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs.
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 When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. 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. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?
Daily doses of isoniazid, 300 mg for 6 months to 1 year All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
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.
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 Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. Bronchoalveolar cell cancer arises from the terminal bronchus and alveoli and usually grows slowly. Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Record the observation Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes.
The most diagnostic clinical symptom of pleurisy is:
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 nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer?
Symptoms often do not appear until the disease is well established. Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. Option A is correct, but it is not the best answer. Option B is incorrect because it is not a true statement. Option C is incorrect because lung cancer is not an infectious disease.
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to:
remove air from the pleural space. After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery: one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid.
Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?
staphylococcal pneumonia Complications include tracheobronchitis, bacterial pneumonia, and cardiovascular disease, however staphylococcal pneumonia is the most serious complication.
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C, and D are incorrect.
Which action by the nurse is most appropriate when a client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?
Apply a compression dressing to the area. Subcutaneous emphysema is a typical finding in clients after chest surgery. During surgery, the air within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted.
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 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.
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 When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
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 nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.
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 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 (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
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. 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.
Which is a true statement regarding severe acute respiratory syndrome (SARS)?
It is 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 clients 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 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 The size of the induration determines the significance of the reaction. A reaction 0-4 mm is not considered significant. A reaction ≥5 mm may be significant in people who are considered to be at risk. An induration ≥10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity.
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?
Tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).
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 Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
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. Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.
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:
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 client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply.
-Do not smoke, or quit smoking if currently smoking. -Wear appropriate protective equipment when around airborne irritants and dusts. The nurse may instruct clients that the following precautions may help prevent occupational lung disease: not smoking, wearing appropriate protective equipment when around airborne irritants and dusts, scheduling lung function evaluation with spirometry as recommended, becoming educated about lung diseases, and paying attention to risk evaluation of the workplace to identify risks for lung disease.
