NUR 301 Prep U Week 1
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." 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 The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.
A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?
15-mm induration A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.
When preparing a chest drainage system, the nurse would fill the water seal chamber to which mark?
2 cm level The water seal chamber is filled with water to the 2 cm level. All other levels would be inappropriate to maintain adequate chest drainage.
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 Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
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 Pulmonary tuberculosis (TB) is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.
What dietary recommendations should a nurse provide a patient with a lung abscess?
A diet rich in protein For a patient with pleural effusion, a diet rich in protein and calories is pivotal. A carbohydrate-dense diet or diets with limited fat are not advisable for a patient with lung abscess.
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary. A total laryngectomy will result in a permanent stoma and total loss of voice. A partial laryngectomy involves the removal of one vocal cord. The voice is spared with the supraglottic laryngectomy. Removal of a portion of the vocal cord occurs with a hemilaryngectomy.
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. A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.
You are an ICU nurse caring for a client who was admitted with a diagnosis of smoke inhalation. You know 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.
Constant bubbling in the water seal of a chest drainage system indicates:
Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal, which show effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
A patient has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the patient about?
Amoxicillin-clavulanic acid (Augmentin) Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases (Chow et al., 2012). Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS (Chow et al., 2012).
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?
An antiviral agent such as acyclovir Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth. The blisters are commonly referred to as cold sores or fever blisters. Medications used in the management of herpes labialis include acyclovir (Zovirax) and valacyclovir (Valtrex), which help to minimize the symptoms and the duration or length of flare-up.
Which of the following types of hypoxia result from decreased hemoglobin concentration?
Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. Hypoxemic hypoxia is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. Histotoxic hypoxia occurs when a toxic substance, such as cyanide, interferes with the ability of tissues to use available oxygen.
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure. The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
The nurse is teaching a new surgical patient how to use an incentive spirometer. Which of the following should be included in the teaching plan?
Assume an upright position, if possible. The patient should assume an upright position if possible (sitting or semi-Fowler's). He or she should use the incentive spirometer every hour while awake. Breathing should be done using the diaphragm. The mouthpiece should be placed firmly in the mouth, the patient should breathe in deeply and slowly, holding each breath in for 3 to 4 seconds, and exhaling slowly.
Which of the following methods most resembles normal speech following a total laryngectomy?
Blom-Singer voice prosthesis The Blom-Singer voice prosthesis most resembles normal speech. With esophageal speech, patients compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. With electrolarynx, a battery-powered apparatus projects sound into the oral cavity. When the mouth forms words (articulation), the sounds from the electric larynx becomes audible words. Lip speaking is available during the immediate postoperative period. It does not resemble normal speech.
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 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 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.. The use of HEPA filters can reduce allergens, but they do not prevent lung cancer. Chest x-rays aid in detection of lung cancer but do not prevent it. Exposure to asbestos has been implicated as a risk factor, but cigarette smoking is the major risk factor.
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.
A patient is diagnosed with hypoxemic hypoxia. The nurse knows that the etiology directs medical and nursing interventions. Which of the following is the cause?
Decreased oxygen diffusion into the tissues Hypoxemic hypoxia is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. It may be caused by hypoventilation, high altitudes, ventilation-perfusion mismatch (as in pulmonary embolism), shunts in which the alveoli are collapsed and cannot provide oxygen to the blood (commonly caused by atelectasis), and pulmonary diffusion defects. It is corrected by increasing alveolar ventilation or providing supplemental oxygen.
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?
Developing a list of people with whom the client has had contact To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.
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.
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.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?
Edema of the upper airway An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, post operative bleeding, or a plugged tracheostomy tube.
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises. 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.
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 client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.
Ventilator-acquired pneumonia (VAP) is a type of hospital-acquired pneumonia (HAP) that is associated with which of the following interventions?
Endotracheal intubation VAP is a type of HAP that is associated with endotracheal intubation and mechanical ventilation. VAP is defined as pneumonia that develops in patients who have been receiving mechanical ventilation for at least 48 hours. Urinary catheterization, central line placement, and nasogastric suctioning are not associated with VAP.
You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.
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 patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?
Group A, beta-hemolytic streptococcus The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).
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 The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
Which of the following is the priority nursing diagnosis for the patient undergoing a laryngectomy?
Ineffective airway clearance The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but they are not the priority diagnosis.
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is
Ineffective airway clearance related to excess mucus production All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.
The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation?
Initial washing of hands after cleaning inner cannula. The client should wash the hands before any care of the surgical site, particularly cleansing of the inner cannula. The other activities are appropriate outcomes for a client following laryngectomy.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?
Laryngeal cancer Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.
Sniffling, nasal discharge, coughing, and sneezing...young Patrick Lee presents at your local free clinic with the above symptoms, which are keeping him awake at night, interrupting his feedings and are making him (and his mother) miserable. After the physician's exam, he is diagnosed with rhinovirus - a common virus. How many strains of this virus cause coryza?
More than 100 Rhinitis is inflammation of the nasal mucous membranes. It also is referred to as the common cold or coryza. Rhinitis may be acute, chronic, or allergic, depending on the cause. The most common cause is the rhinovirus, of which more than 100 strains exist.
You are caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Mucopurulent sputum For a client with lung cancer, a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders but are not considered indicative of lung cancer.
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for
Nuchal rigidity Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.
When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of hypoxemia?
PaO2 < 60 mm Hg Hypoxemia is a decrease in the arterial oxygen content or arterial oxygen tension (partial pressure of oxygen = PaO2) and is measured by arterial blood gas analysis (ABG) or pulse oximetry (POX). Hypoxemia is defined as a PaO2 of less than 60 mm Hb and/or a POX of less than 90%. When administering oxygen to a patient, a nurse must keep in mind that oxygen transport to the tissues is not dependent solely on the arterial oxygen content.
You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Pain in the calf When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
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?
Pleural effusion 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.
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.
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 In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease.
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?
Putting on an individually fitted mask when entering the client's room Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.
Which of the following is a complication of low cuff pressure on an endotracheal tube?
Risk of aspiration Low cuff pressure can increase the risk of aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.
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 Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.
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.
You are presenting about upper respiratory infections at an educational event for a local community group. What should you be sure to include regarding cold tablets containing antihistamines?
They decrease discomfort temporarily. Some cold tablets contain antihistamines that thicken the nasal secretions. Although this action may temporarily decrease the discomfort of profuse nasal secretions, thickened secretions can block the drainage openings of the sinus cavity, leading to the failure of the sinuses to drain adequately. Aspirin prolongs bleeding.
The nurse is caring for a patient with suspected ARDS with a pO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?
Unresponsive arterial hypoxemia Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure ( Dushianthan, Grott, Postle, et al., 2011).
Which of the following interventions regarding nutrition is implemented for patients who have undergone laryngectomy?
Use enteral feedings after the procedure Enteral feedings are used 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration. When oral intake resumes, the nurse offers small amounts of thick liquids. Following a laryngectomy, the patient may experience anorexia related to a diminished sense of taste and smell. Excess zinc can impair the immune system and lower the levels of high-density lipoproteins ("good" cholesterol). Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended.
A nurse is assigned to care for a patient with COPD. The doctor has ordered oxygen at 6 L/min. Which of the following does the nurse need to obtain to give the O2?
Venturi mask The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. It is used primarily for patients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive.
Which vitamin is usually administered 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.
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?
When the patient has less than 30 mL for 2 consecutive days Wound drains, inserted during surgery, may be in place to assist in removal of fluid and air from the surgical site. Suction also may be used, but cautiously, to avoid trauma to the surgical site and incision. The nurse observes, measures, and records drainage. When drainage is less than 30 mL/day for 2 consecutive days, the physician usually removes the drains.
A Class 1 with regards to TB indicates
exposure and no evidence of infection. Class 1 is exposure, but no evidence of infection. Class 0 is no exposure and no infection. Class 2 is a latent infection, with no disease. Class 4 is disease, but not clinically active.
Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is
primary drug resistance Primary drug resistance to one of the first-line antituberculotic agents is people who have not had previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in patients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:
skin test doesn't differentiate between active and dormant tuberculosis infection. The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.
