Pellico Ch. 10: Nursing Management: Patients With Chest and Lower Respiratory Tract Disorders

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? a) 15-mm induration b) Reddened area c) 5-mm induration d) A blister

a) 15-mm induration Rationale: 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.

What is the reason for chest tubes after thoracic surgery? a) Draining secretions, air, and blood from the thoracic cavity is necessary. b) Chest tubes allow air into the pleural space. c) Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. d) Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

a) Draining secretions, air, and blood from the thoracic cavity is necessary. Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.

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? a) Encourage increased fluid intake. b) Place client on bed rest. c) Offer nutritious snacks 2 times a day. d) Give antibiotics as ordered.

a) Encourage increased fluid intake. Rationale: 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 Class 1 with regards to TB indicates a) Exposure and no evidence of infection. b) Disease that is not clinically active. c) Latent infection with no disease. d) No exposure and no infection

a) Exposure and no evidence of infection. Rationale: 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.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? a) Impaired gas exchange b) Imbalanced nutrition: Less than body requirements c) Impaired oral mucous membranes d) Activity intolerance

a) Impaired gas exchange Rationale: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.

Which of the following terms refers to lung tissue that has become more solid in nature due to a collapse of alveoli or an infectious process? a) Empyema b) Consolidation c) Bronchiectasis d) Atelectasis

b) Consolidation Rationale: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.

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: a) Ineffective breathing pattern. b) Ineffective airway clearance. c) Impaired tissue integrity. d) Risk for falls.

b) Ineffective airway clearance. Rationale: 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.

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? a) Myocardial infarction (MI) b) Pneumothorax c) Pulmonary embolism d) Heart failure

b) Pneumothorax Rationale: 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 asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: a) test stimulates a reddened response in some clients and requires a second test in 3 months. b) skin test doesn't differentiate between active and dormant tuberculosis infection. c) area of redness is measured in 3 days and determines whether tuberculosis is present. d) presence of a wheal at the injection site in 2 days indicates active tuberculosis.

b) Skin test doesn't differentiate between active and dormant tuberculosis infection. Rationale: 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.

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? a) 2 to 4 months b) 1 to 3 weeks c) 6 to 12 months d) 3 to 5 days

c) 6 to 12 months Rationale: 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.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a) A client who is receiving acetaminophen (Tylenol) for pain b) A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago c) A client with a nasogastric tube d) A client who ambulates in the hallway every 4 hours

c) 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. 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 cause of histotoxic hypoxia? a) Fungi b) Virus c) Cyanide d) Bacteria

c) Cyanide Rationale: Histotoxic hypoxia occurs when a toxic substance, such as cyanide, interferes with the ability of the tissues to use available oxygen. The other options are not potential causes of histotoxic hypoxia.

Ventilator-acquired pneumonia (VAP) is a type of hospital-acquired pneumonia (HAP) that is associated with which of the following interventions? a) Urinary catheterization b) Central line placement c) Endotracheal intubation d) Nasogastric suctioning

c) Endotracheal intubation Rationale: 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.

A 73-year-old client was admitted to the pulmonology unit with a pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. Which of the following primary conditions would most likely have caused the pleural effusion? a) Emphysema b) Sleep apnea c) Heart failure d) Asthma

c) Heart failure Rationale: Pleural effusion may be a complication of pneumonia, lung cancer, TB, pulmonary embolism, and CHF.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperoxemia, hypocapnia, and hyperventilation b) Hypotension, hyperoxemia, and hypercapnia c) Hypercapnia, hypoventilation, and hypoxemia d) Hyperventilation, hypertension, and hypocapnia

c) Hypercapnia, hypoventilation, and hypoxemia Rationale: 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? a) Decreased cardiac output b) Anxiety c) Impaired gas exchange d) Ineffective tissue perfusion (cardiopulmonary)

c) 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. 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.

The physician orders a patient to have 2 L/min of oxygen per nasal cannula. When calculating the correct FiO2 for this setting, which of the following would be correct? a) 36% b) 40% c) 32% d) 28%

d) 28% Rationale: The correct calculation of a FiO2 for 2 L would be 28%. Three liters per minute equals 32% FiO2; 4 L/min equals 36% FiO2; and 5 L/min equals 40% FiO2.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Sore throat and abdominal pain c) Hemoptysis and dysuria d) Dyspnea and wheezing

d) Dyspnea and wheezing Rationale: 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.

The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure? a) Sudden onset in client who had compromised lung function b) Insidious onset in client who had compromised lung function c) Insidious onset in client who had normal lung function d) Sudden onset in client who had normal lung function

d) Sudden onset in client who had normal lung function Rationale: Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy? a) Vitamin D b) Vitamin E c) Vitamin C d) Vitamin B6

d) Vitamin B6 Rationale: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.