NURS 401 PrepU Ch. 23 Management of patients with Chest and Lower Respiratory Tract Disorders (Brunner & Suddarth)
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? "Chest tubes provide a route for medication instillation to the lung." "The tube will drain air from the space around the lung." "Chest tube will allow air to be restored to the lung." "The tube will drain secretions from the lung."
"The tube will drain air from the space around the lung."
On auscultation, which finding suggests a right pneumothorax? Bilateral inspiratory and expiratory crackles Absence of breath sounds in the right thorax Inspiratory wheezes in the right thorax Bilateral pleural friction rub
Absence of breath sounds in the right thorax Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
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 Tracheobronchitis Bronchitis Lung cancer
Acute respiratory distress syndrome Explanation: 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.
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? Aspiration Drug ingestion Chemical irritation Direct lung damage
Chemical irritation Explanation: 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 nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? Nonproductive cough and abdominal pain Hypertension and lack of fever Bradypnea and bradycardia Chest pain and dyspnea
Chest pain and dyspnea Explanation: As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.
A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement? "I am going to have a tuna fish sandwich for lunch." "It is all right if I have a grilled cheese sandwich with American cheese." "It is fine if I eat sushi with a little bit of soy sauce." "It is all right if I drink a glass of red wine with my dinner."
Correct response: "It is all right if I have a grilled cheese sandwich with American cheese." Explanation: Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.
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? Pleural friction rub Sibilant wheezes Crackles in the lung bases Low-pitched rhonchi during expiration
Crackles in the lung bases Explanation: 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 admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient? Syncope Dyspnea Hypertension Ascites
Dyspnea Explanation: 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? Nonproductive cough and normal temperature Sore throat and abdominal pain Hemoptysis and dysuria Dyspnea and wheezing
Dyspnea and wheezing Explanation: 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.
What are the most common symptoms of PE?
Dyspnea, tachypnea
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. Place client on bed rest. Offer nutritious snacks 2 times a day. Give antibiotics as ordered.
Encourage increased fluid intake. Explanation: 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 in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate? "A large amount of fluid has accumulated in your lungs and made it difficult to breathe." "Fluid has built up between your lungs and the lining that surrounds your lungs." "Bacteria have entered the fluid surrounding your lungs and these bacteria must be eliminated." "The small air sacs that make up your lungs have become infected."
Fluid has built up between your lungs and the lining that surrounds your lungs." Explanation: A pleural effusion is characterized by an accumulation of fluid in the pleural space. This excess fluid is not located in the lung tissue itself or in the alveoli. A pleural effusion is not normally infectious in etiology.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Impaired gas exchange Ineffective tissue perfusion (cardiopulmonary) Anxiety Decreased cardiac output
Impaired gas exchange Explanation: 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.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Ineffective airway clearance. Risk for falls. Impaired tissue integrity. Ineffective breathing pattern.
Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? Pain in the feet Coolness to lower extremities Localized calf tenderness Decreased urinary output
Localized calf tenderness Explanation: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? pH Partial pressure of arterial carbon dioxide (PaCO2) Partial pressure of arterial oxygen (PaO2) Bicarbonate (HCO3-)
Partial pressure of arterial oxygen (PaO2) Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.
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? Inspiratory crackles Cyanosis Rapid onset of severe dyspnea Bilateral wheezing
Rapid onset of severe dyspnea Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: Negative Nonreactive Not significant Significant
Significant Explanation: An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.
Arterial blood gas analysis would reveal which value related to acute respiratory failure? pH 7.35 PaO2 80 mm Hg PaCO2 32 mm Hg pH 7.28
pH 7.28 Explanation: Acute respiratory failure 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 greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
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 pH 7.36, PaCO2 32 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.35, PaCO2 48 mm Hg
pH 7.28, PaO2 50 mm Hg Explanation: 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 nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.36, PaCO2 32 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.35, PaCO2 48 mm Hg
pH 7.28, PaO2 50 mm Hg Explanation: 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.
The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for? Emphysema Pleurisy Atelectasis Pneumonia
Atelectasis Explanation: In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).
The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema? Elevated myoglobin levels Elevated troponin levels Elevated white blood count Elevated B-type natriuretic peptide (BNP) levels
Elevated B-type natriuretic peptide (BNP) levels Explanation: Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema.
A patient is postoperative day 3 following major bowel surgery and has been reluctant to ambulate since being admitted from postanesthetic recovery 2 days ago. As a result, the patient has developed atelectasis and is now being treated for this problem. When administering the patient's bronchodilator by nebulizer, what teaching should the nurse provide? "If you can practice 'huffing' while your nebulizer is running, it will help the medication reach your lungs." "Try to avoid coughing until your nebulizer has finished." "Try to breathe through your nose to ensure that you get as much benefit as possible from your medication." "If possible, take slow, deep breaths while your nebulizer is running."
"If possible, take slow, deep breaths while your nebulizer is running." Explanation: During nebulizer therapy, the patient breathes through the mouth, taking slow, deep breaths, and then holds the breath for a few seconds. The patient is encouraged to cough during the treatment, which assists in increasing intrathoracic pressure and promoting secretion expectoration. Huffing may be of benefit, but slow deep breaths are a priority.
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Influenza is the major cause of death in the United States." "Influenza vaccine will prevent typical pneumonias." "Viruses like influenza are the most common cause of pneumonia." "Getting the flu can complicate pneumonia."
"Viruses like influenza are the most common cause of pneumonia." Explanation: Influenza type A is the most common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.
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 history of smoking two packs of cigarettes per day until quitting 2 years ago A client who ambulates in the hallway every 4 hours A client with a nasogastric tube A client who is receiving acetaminophen (Tylenol) for pain
A client with a nasogastric tube Explanation: 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.
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Tachypnea Increased PaO2 Unresponsive arterial hypoxemia Diminished alveolar dilation
Correct response: Unresponsive arterial hypoxemia Explanation: 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.
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Elevating the head of the bed 30 degrees Turning the client every 2 hours Maintaining a cool room temperature Encouraging increased fluid intake
Encouraging increased fluid intake Explanation: 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 atelectasis, but will not adequately mobilize thick 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.
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 Sudden loss of lung function associated with chronic disease Progressive loss of lung function with history of normal lung function Sudden loss of lung function with history of normal lung function
Progressive loss of lung function associated with chronic disease Explanation: In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.
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? Pseudomonas aeruginosa Streptococcus pneumoniae Staphylococcus aureus Mycobacterium tuberculosis
Streptococcus pneumoniae Explanation: 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 nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? Hemoptysis Tachypnea Cough Syncope
Tachypnea Explanation: 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).
A mediastinal shift occurs in which type of chest disorder? Traumatic pneumothorax Simple pneumothorax Cardiac tamponade Tension pneumothorax
Tension pneumothorax Explanation: A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.
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 consolidation. hemothorax. pneumothorax. pleural effusion.
pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.
The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. Using elastic stockings, especially when decreased mobility would promote venous stasis Instructing the client to move the legs in a "pumping" exercise Applying a sequential compression device Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day Encouraging a liberal fluid intake
Correct response: Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device Explanation: The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.
A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply. prescribed opioids incentive spirometry hand antisepsis vaccinations
Correct response: vaccinations hand antisepsis Explanation: A powerful weapon against the spread of communicable disease is effective and frequent handwashing. The pneumococcal vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by S. pneumoniae.
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? Hemorrhage Lung contusion Fibrotic changes in lungs Damage to surrounding tissues
Fibrotic changes in lungs explanation: 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 victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? Cardiac tamponade Flail chest Pulmonary contusion Simple pneumothorax
Flail chest Explanation: When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner 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 exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.
The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? Positive end-expiratory pressure (PEEP) Intermittent positive pressure-breathing (IPPB) Incentive spirometry Bronchoscopy
Incentive spirometry Explanation: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as PEEP, continuous or intermittent positive pressure-breathing (IPPB), or bronchoscopy may be used.
A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? Chronic obstructive pulmonary disease (COPD) Pulmonary tuberculosis Pulmonary hypertension Empyema
Pulmonary hypertension Explanation: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.
A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? Empyema Pulmonary hypertension Pulmonary tuberculosis Chronic obstructive pulmonary disease (COPD)
Pulmonary hypertension Explanation: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss.
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Insidious onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had normal lung function Sudden onset of lung impairment in a client who had compromised lung function
Sudden onset of lung impairment in a client who had normal lung function Explanation: In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Providing oral hygiene daily Using strict hand hygiene Turning the client every 4 hours to prevent fatigue Keeping the head of the bed at 15 degrees or less
Using strict hand hygiene Explanation: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: area of redness is measured in 3 days and determines whether tuberculosis is present. presence of a wheal at the injection site in 2 days indicates active tuberculosis. test stimulates a reddened response in some clients and requires a second test in 3 months. skin test doesn't differentiate between active and dormant tuberculosis infection.
skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: 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.