NU 310 Chapter 23: Management of Patients with Chest and Lower Respiratory 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."
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?
"You should switch to wearing your glasses while taking this medication." (Rationale: The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.)
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?
0 to 4 mm
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?
6 to 12 months
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 (Rationale: 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)
What dietary recommendations should a nurse provide a client with a lung abscess?
A diet rich in protein (Rationale: For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.)
Which would be least likely to contribute to a case of hospital-acquired pneumonia?
A nurse washes her hands before beginning client care. (Rationale: 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)
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?
A positive reaction indicates that the client has been exposed to the disease.
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
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
Which type of lung cancer is the most prevalent among both men and women?
Adenocarcinoma (presents more peripherally as masses or nodules and often metastasizes)
Which action should the nurse take first in caring for a client during an acute asthma attack?
Administer bronchodilator as ordered.
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 (Rationale: 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 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
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?
Classes at community centers to teach about smoking cessation strategies (Rationale: Lung cancer is directly correlated with heavy cigarette smoking, and the most effective approach to reducing lung cancer in the community is to help the citizens stop smoking)
A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Cough or change in chronic cough
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
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 (Rationale: 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 right-sided 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.)
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
Encourage increased fluid intake.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake (Rationale: increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration)
The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?
Fit all employees with protective masks.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange (Rationale: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival.)
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 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 (Rationale: 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 identifies which finding to be most consistent prior to the onset of acute respiratory distress?
Normal lung function (Rationale: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.)
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?
Paradoxical chest movement (Rationale: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement)
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?
Rapid onset of severe dyspnea (usually occurs less than 72 hours after the precipitating event)
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?
Receiving vaccinations
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?
Shortness of breath (Rationale: Early signs and symptoms of pulmonary sarcoidosis may include dyspnea, cough, hemoptysis, and congestion. Generalized symptoms include anorexia, fatigue, and weight loss.)
Chest Tube Assessment Acronym STOP
Site, Tubing, Output, Patency
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 (Rationale: 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.)
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?
Streptococcus pneumoniae
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. (Rationale: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg.)
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6 (pyridoxine)
What is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process?
consolidation
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg (Rationale: ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.)
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as
pleural effusion (Rationale: Fluid accumulating within the pleural space is called a pleural effusion)
Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as
primary drug resistance
What does a positive Mantoux test indicate?
production of an immune response (Rationale: The Mantoux test is based on the antigen/antibody response and will show a positive reaction after an individual has been exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria.)
