Chapter 28 Lower Respiratory Problems Flashcards
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
a. Weak, nonproductive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
a. Weak, nonproductive cough effort
The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
a. vesicular breath sounds.
b. increased tactile fremitus.
c. dry, nonproductive cough.
d. hyperresonance to percussion.
b. increased tactile fremitus.
Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Educate the patient about the need for fluid restrictions.
c. Encourage the patient to wear the nasal oxygen cannula.
d. Instruct the patient on the pursed lip breathing technique.
a. Assist the patient to splint the chest when coughing.
Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse?
a. “I will call the doctor if I still feel tired after a week.”
b. “I will need to use home oxygen therapy for 3 months.”
c. “I will continue to do the deep breathing and coughing exercises at home.”
d. “I will schedule two appointments for the pneumonia and influenza vaccines.”
c. “I will continue to do the deep breathing and coughing exercises at home.”
Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk?
a. Turn and reposition immobile patients at least every 2 hours.
b. Place patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in patients who are immunosuppressed.
d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
b. Place patients with altered consciousness in side-lying positions.
The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient coughs up small amounts of green mucus.
c. The patient’s white blood cell (WBC) count is 9000/µl.
d. Increased tactile fremitus is palpable over the right chest.
c. The patient’s white blood cell (WBC) count is 9000/µl.
The normal WBC count indicates that the antibiotics have been effective.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take?
a. Repeat the tuberculin skin testing.
b. Teach about the reason for the blood tests.
c. Obtain consecutive sputum specimens from the patient for 3 days.
d. Instruct the patient to expectorate three specimens as soon as possible.
c. Obtain consecutive sputum specimens from the patient for 3 days.
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative.
d. Three sputum smears for acid-fast bacilli are negative.
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB
a. demonstrates correct use of a nebulizer.
b. washes dishes and personal items after use.
c. covers the mouth and nose when coughing.
d. reports daily to the public health department.
c. covers the mouth and nose when coughing.
Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis?
a. “Your urine, sweat, and tears will be orange colored.”
b. “Read a newspaper daily to check for changes in vision.”
c. “Take vitamin B6 daily to prevent peripheral nerve damage.”
d. “Call the health care provider if you notice any hearing loss.”
a. “Your urine, sweat, and tears will be orange colored.”
Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication.
When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops
a. yellow-tinged skin.
b. changes in hearing.
c. orange-colored sputum.
d. thickening of the fingernails.
a. yellow-tinged skin.
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Educating the patient about the long-term impact of TB on health
b. Giving the patient written instructions about how to take the medications
c. Teaching the patient about the high risk for infecting others unless treatment is followed
d. Arranging for a daily noontime meal at a community center and giving the medication then
d. Arranging for a daily noontime meal at a community center and giving the medication then
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
a. Ask the patient whether medications have been taken as directed.
b. Discuss the need to use some different medications to treat the TB.
c. Schedule the patient for directly observed therapy three times weekly.
d. Educate about using a 2-drug regimen for the last 4 months of treatment.
a. Ask the patient whether medications have been taken as directed.
The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
a. use and side effects of isoniazid (INH).
b. standard four-drug therapy for TB.
c. need for annual repeat TB skin testing.
d. bacille Calmette-Guérin (BCG) vaccine.
a. use and side effects of isoniazid (INH).
The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member
a. washes the hands before entering the patient’s room.
b. hands the patient a tissue from the box at the bedside.
c. puts on a surgical face mask before visiting the patient.
d. brings food from a “fast-food” restaurant to the patient.
c. puts on a surgical face mask before visiting the patient.
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient’s room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease?
a. Teach about symptoms of lung disease.
b. Treat workers who inhale dust particles.
c. Monitor workers for shortness of breath.
d. Require the use of protective equipment.
d. Require the use of protective equipment.
Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about
a. computed tomography (CT) screening for lung cancer.
b. options for smoking cessation.
c. reasons for annual sputum cytology testing.
d. erlotinib (Tarceva) therapy to prevent tumor risk.
b. options for smoking cessation.
Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.
A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have radiation than surgery.” Which response by the nurse is most appropriate?
a. “Are you afraid that the surgery will be very painful?”
b. “Did you have bad experiences with previous surgeries?”
c. “Surgery is the treatment of choice for stage I lung cancer.”
d. “Tell me what you know about the various treatments available.”
d. “Tell me what you know about the various treatments available.”
More assessment of the patient’s concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, “Surgery is the treatment of choice” is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient’s reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?
a. Administer the prescribed PRN morphine.
b. Assist the patient to deep breathe and cough.
c. Milk the chest tube gently to remove any clots.
d. Tape the area around the insertion site of the chest tube.
a. Administer the prescribed PRN morphine.
The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
A patient with newly diagnosed lung cancer tells the nurse, “I think I am going to die pretty soon.” Which response by the nurse is best?
a. “Would you like to talk to the hospital chaplain about your feelings?”
b. “Can you tell me what it is that makes you think you will die so soon?”
c. “Are you afraid that the treatment for your cancer will not be effective?”
d. “Do you think that taking an antidepressant medication would be helpful?”
b. “Can you tell me what it is that makes you think you will die so soon?”
The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about
a. a large air leak in the water-seal chamber.
b. 400 mL of blood in the collection chamber.
c. complaint of pain with each deep inspiration.
d. subcutaneous emphysema at the insertion site.
b. 400 mL of blood in the collection chamber.
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.
A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about
a. paradoxic chest movement.
b. the complaint of chest wall pain.
c. a heart rate of 110 beats/minute.
d. a large bruised area on the chest.
a. paradoxic chest movement.
Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for
a. emergency pericardiocentesis.
b. stabilization of the chest wall with tape.
c. administration of an inhaled bronchodilator.
d. insertion of a chest tube with a chest drainage system.
d. insertion of a chest tube with a chest drainage system.
The patient’s history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient’s clinical manifestations are not consistent with these problems
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to
a. document the presence of a large air leak.
b. obtain and attach a new collection device.
c. notify the surgeon of a possible pneumothorax.
d. take no further action with the collection device.
d. take no further action with the collection device.
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.
