TERM 2-MY NOTES ADULTH HEALTH NURSING CH.9 "Respiatory Disorders" Flashcards Preview

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Flashcards in TERM 2-MY NOTES ADULTH HEALTH NURSING CH.9 "Respiatory Disorders" Deck (633):
1

CARE OF THE PATIENT WITH RESPIRATORY DISORDERS

M

2

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

,

3

External respiration, or breathing, is the exchange of oxygen and carbon dioxide between the lung and the environment.
A)true
B)false

A

4

_______ respiration, or breathing, is the exchange of oxygen and carbon dioxide between the lung and the environment

External

5

The respiratory system works with the cardiovascular system to deliver oxygen to the cells, where it provides energy to carry out metabolism.
A)true
B)false

A

6

Internal respiration is the exchange of oxygen and carbon dioxide at the cellular level
A)true
B)falsE

A

7

_________ respiration is the exchange of oxygen and carbon dioxide at the cellular level

Internal respiration is the exchange of oxygen and carbon dioxide at the cellular level

8

UPPER RESPIRATORY TRACT

,

9

Air enters the respiratory tract through the nose. The air is filtered, moistened, and warmed as it enters the two nasal openings (nares) and travels to the nasal cavity.
A)true
B)false

A

10

The mucous membrane provides warmth and moisture and secretes 1 L of moisture every day.
A)true
B)false

A

11

Lateral to the nasal cavities are three scroll-like bones called turbinates or conchae, which cause the air to move over a larger surface area.
A)true
B)false

A

12

paranasal sinuses. They are called the frontal, maxillary, sphenoid, and ethmoid cavities. These are hollow areas that make the skull lighter and are believed to give resonance to the voice.
A)true
B)false

A

13

The pharynx, or throat (a tubular structure about 5 inches [13 em] long extending from the base of the skull to the esophagus and situated just in front of the vertebrae), is the passageway for both air and food.
A)true
B)false

A

14

the distal end of the pharynx are three subdivisions:
(1) nasopharynx (superior portion),
(2) oropharynx (posterior to mouth), and
(3) laryngopharynx (directly superior to larynx) .
A)true
B)false

A

15

eustachian tubes enter either side of the nasopharynx, connecting it to the middle ear.
A)true
B)false

A

16

The adenoids (pharyngeal tonsils) are in the nasopharynx, whereas the palatine tonsils are in the oropharynx.
A)true
B)false

A

17

larynx, or organ of voice, is supported by nine areas of cartilage and connects the pharynx with the trachea.
A)true
B)false

A

18

The largest area of cartilage is composed of two fused plates and is called the thyroid cartilage, or Adam's apple.
A)true
B)false

A

19

The epiglottis, a large leaf-shaped area of cartilage, protects the larynx when swallowing. It covers the larynx tightly to prevent food from entering the trachea and directs the food to the esophagus
A)true
B)false

A

20

The larynx contains the vocal cords.
A)true
B)false

A

21

The trachea, or windpipe, is a tubelike structure that extends approximately 4 1/3 inches (11 cm) to the midchest, where it divides into the right and left bronchi
A)true
B)false

A

22

The entire structure is lined with mucous membranes and tiny cilia (small, hairlike processes on the outer surfaces of small cells, which produce motion or current in a fluid) that sweep dust or debris upward toward the nasal cavity.
A)trachea
B)lungs

A

23

Sometimes, because of an airway obstruction, a physician performs a tracheostomy (a surgical opening into the trachea through which an indweLling tube may be inserted). Once this procedure is completed, the individual breathes through the tracheal opening rather than the nose. The opening is below the larynx, so air cannot pass over the vocal cords. The vocal cords cannot vibrate, and speech becomes physiologically impossible.
A)true
B) false

A

24

tracheostomy, The opening is below the larynx, so air cannot pass over the vocal cords. The vocal cords cannot vibrate, and speech becomes physiologically impossible.
A)true
B)false

A

25

LOWER RESPIRATORY TRACT

,

26

Because of this design, foreign objects that are aspirated generally enter the right bronchus.
A)true
B)false

A

27

The end structures of the bronchial tree are called alveoli
A)true
B)false

A

28

These saclike structures(alveoli) resemble a bunch of grapes. A single grapelike structure is called an alveolus.
A)true
B)false

A

29

MECHANICS OF BREATHING

,

30

lungs occupy almost all the thoracic cavity except the centermost area, the mediastinum, which contains the heart and the great vessels. This cavity, the interpleural space, is enclosed by the sternum, the ribs, and the thoracic vertebrae.
A)true
B)false

A

31

The lungs receive their blood supply, which comes directly from the heart, through the pulmonary arteries
A)true
B)false

A

32

The surface of each lung is covered with a thin, moist, serous membrane called the visceral pleura.
A)true
B)false

A

33

The walls of the thoracic cavity are covered with the same type of membrane called the parietal pleura.
A)true
B)false

A

34

When too much serous secretion is produced, fluid accumulates in the pleural space; this is called pleural effusion.
A)true
B)false

A

35

The physician may decide to remove the fluid by performing a thoracentesis-inserting a needlelike instrument into the pleural space and removing the fluid.
A)true
B)false

S

36

Respiratory Movements and Ranges

,

37

The normal range of respiration for an adult at rest is 12 to 20 breaths/min. This rate can be affected by many variables, including age, sex, activity, disease, and body temperature.
A)true
B)false

A

38

The respiratory rate is 40 to 60 breaths/min for a newborn, 22 to 24 breaths/min for an early school-age child, and 20 to 22 breaths/min for a teenager.
A)true
B)false

A

39

The normal range for women is higher than that for men
A)true
B)false

A

40

The medulla oblongata and pons of the brain are responsible for the basic rhythm and depth of respiration. The body's demands can modify the rhythm.
A)true
B)false

A

41

Chemoreceptors in the carotid and aortic bodies are specialized receptors. When stimulated by increasing levels of blood carbon dioxide, decreasing levels of blood oxygen, or increasing blood acidity, these receptors send nerve impulses to the respiratory centers, which in turn modify respiratory rates.
A)true
B)false

A

42

Carbon dioxide, which is present in the blood as carbonic acid, is considered the chemical stimulant for regulation of respiration. Therefore the more carbon dioxide in the blood, the more acidic the blood becomes.
A)true
B)false

A

43

After exhalation the blood becomes more alkaline. The normal pH of the blood is 7.35 to 7.45 a narrow range. Deviation from this range causes the patient to develop either acidosis or alkalosis.
A)true
B)false

A

44

ASSESSMENT OF THE RESPIRATORY SYSTEM

,

45

subjective data. During the interview, encourage the patient to describe any symptoms, such as shortness of breath, dyspnea on exertion, or cough.
A)true
B)false

A

46

Dyspnea, or difficulty breathing, is a subjective experience that only the patient can accurately describe.
A)true
B)false

A

47

Flaring nostrils indicate the patient is struggling to breathe, which is usually a late sign of respiratory distress
A)true
B)false

A

48

orthopnea (an abnormal condition in which a person must sit or stand to breathe deeply or comfortably).
A)true
B)false

A

49

adventitious sounds (abnormal sounds superimposed on breath sounds, including sibilant wheezes [formerly called simply wheezes], sonorous wheezes [formerly called rhonchi], crackles [formerly called rales], and pleural friction rubs.
A)true
B)false

A

50

Sibilant wheezes are musical, high-pitched, squeaking or whistling sounds, caused by the rapid movement of air through narrowed bronchioles.
A)true
B)false

A

51

Sonorous wheezes are low-pitched, loud, coarse, snoring sounds. They are often heard on expiration.
A)true
B)false

A

52

Crackles are short, discrete, interrupted crackling or bubbling sounds that are most commonly heard during inspiration.
A)true
B)false

A

53

Pleural friction rubs are low-pitched, grating or creaking lung sounds that occur when inflamed pleural surfaces rub together during respiration.
A)true
B)false

A

54

hypoxia (oxygen deficiency)
A)true
B)false

A

55

Adventitious Breath Sounds

,

56

Crackles (rales) Caused by fluid, mucus, or pus in the small airways and alveol
A)true
B)false

A

57

Fine crackles Found in diseases affecting bronchioles and alveoli.
A)true
B)false

A

58

Medium crackles,Associated with diseases of small bronchi.
A)true
B)false

A

59

Coarse crackles,Associated with diseases of small bronchi.
A)true
B)false

A

60

Sonorous wheezes (rhonchi),Caused by air moving through narrowed tracheobronchial passages (caused by secretions, tumor, spasm); cough may alter sound if caused by mucus in trachea or large bronchi.
A)true
B)false

A

61

Sibilant wheezes (wheezes),Caused by narrowed bronchioles; bilateral wheeze often result of bronchospasm; unilateral, sharply localized wheeze may result from foreign matter or tumor compression.
A)true
B)false

A

62

Pleural friction rub,Sound originates outside respiratory tree, usually caused by inflammation; over the lung fields it suggests pleurisy; over the pericardium it suggests pericarditis with a pericardia! friction rub. To distinguish the two, ask the patient to hold the breath briefly. If the rubbing sound persists, it is a pericardia! friction rub because the inflamed pericardia! layers continue rubbing together with each heartbeat; a pleural rub would stop when breathing stops.
A)true
B)false

A

63

LABORATORY AND DIAGNOSTIC EXAMINATIONS

,

64

CHEST ROENTGENOGRAM

,

65

This test gives information on alterations in size and location of the pulmonary structures and blood flow, and it identifies lesions, infiltrates, foreign bodies, or fluid.
A)CHEST ROENTGENOGRAM
B)false

A

66

chest radiograph also shows whether a disorder involves the lung parenchyma (the tissue of an organ, as distinguished from supporting or cotmective tissue) or the interstitial spaces.
A)true
B)false

A

67

Chest radiographs can confirm . pneumothorax, pneumonia, pleural effusion, and pulmonary edema
A)true
B)false

A

68

Any article of clothing containing metal (e.g., .a bra with metal hooks) or jewelry must be removed, since the metal produces a shadow on the film.
A)CHEST ROENTGENOGRAM
B)false

A

69

Signs and Symptoms of Hypoxia

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70

-Apprehension, anxiety, restlessness
• Decreased ability to concentrate
• Disorientation
• Decreased level of consciousness
• Increased fatigue
• Vertigo
• Behavioral changes
• Increased pulse rate; bradycardia as hypoxia advances
• Increased rate and depth of respiration; shallow, slow respirations as hypoxia progresses
• Elevated blood pressure; with continuing oxygen deficiency, decreased blood pressure
• Cardiac dysrhythmias
• Pallor
• Cyanosis (may not be present until hypoxia is severe)
• Clubbing
• Dyspnea

Truw

71

COMPUTED TOMOGRAPHY

,

72

Computed tomography (CT) scans of the lungs take pictures of small layers of pulmonary tissue, usually to identify a pulmonary lesion
A)true
B)false

A

73

the helical CT can scan the abdomen and chest in less than 30 seconds, the entire study can be performed with one breath-hold
A)true
B)false

A

74

Pulmonary angiography (pulmonary arteriography) uses a radiographic contrast material injected into the pulmonary arteries to permit visualization of the pulmonary vasculature.
A)true
B)false

A

75

Angiography is used to detect pulmonary embolism (PE) and a variety of congenital and acquired lesions of the pulmonary vessels
A)true
B)false

A

76

If the lung scan is normal, PE is ruled out.
A)true
B)false

A

77

Ventilation-perfusion (V/Q) scanning is used primarily to check for a PE. An intravenous (IV) radioisotope is given for the perfusion portion of the test, and the pulmonary vasculature is outlined and photographed.
A)true
B)false

A

78

PULMONARY FUNCTION TESTING

,

79

PFTs include various procedures to obtain information on lung volume, ventilation, pulmonary spirometry, and gas exchange.
A)true
B)false

A

80

Lung volume tests refer to the volume of air that can be completely and slowly exhaled after a maximum inhalation (vital capacity).
A)true
B)false

A

81

Inspiratory capacity is the largest amount of air that can be inhaled in one breath from the resting expiratory level.
A)true
B)false

A

82

Total lung capacity is calculated to
determine the volume of air in the lung after a maximal inhalation
A)true
B)false

A

83

MEDIASTINOSCOPY

,

84

This is performed to gather a sample of lymph nodes for biopsy for tumor diagnosis. Because these lymph nodes receive lymphatic drainage from the lungs, they help diagnose malignant tumors.
A)MEDIASTINOSCOPY
B)false

A

85

LARYNGOSCOPY

,

86

Direct laryngoscopy requires local or general anesthesia and exposes the vocal cords with a laryngoscope passed down over the tongue.
A)LARYNGOSCOPY
B)false

A

87

BRONCHOSCOPY

,a

88

Bronchoscopy is performed by passing a bronchoscope into the trachea and bronchli
A)BRONCHOSCOPY
B)false

A

89

local anesthetic agent may be used, but an IV general anesthetic agent is usually given.
A)bronchyscopy
B)false

A

90

Nursing interventions for patients after bronchoscopy include

(1) keeping the patient on NPO (nothing by mouth) status until gag reflex returns, usually about 2 hours after the procedure;

(2) keeping the patient in a semi-Fowler's position and turning on either side to facilitate removal of secretions (unless the physician specifies another position);

(3) monitoring the patient for signs of laryngeal edema or laryngospasms, such as stridor or increasing dyspnea; and

(4) if lung tissue biopsy is taken, monitoring sputum for signs of hemorrhage (blood-streaked sputum is expected for a -few days after biopsy).

True

91

Guidelines for Sputum Specimen Collection

1 . Explain to the patient that the sputum must be brought up from the lungs. Patients who have difficulty producing sputum or who have tenacious sputum may be dehydrated. Encourage fluid intake.

2. Collect the sputum specimen before prescribed antibiotics are started.

3. Collect specimens before meals to avoid possible emesis from coughing.

4. Instruct patient to inhale and exhale deeply three times, then inhale swiftly, cough forcefully, and expectorate into the sterile sputum container. Usually early morning samples are collected on 3 consecutive days.

5. If the patient cannot raise sputum spontaneously, a hypertonic saline aerosol mist may help produce a good specimen. Instruct the patient to take several normal breaths of the mist, inhale deeply, cough, and expectorate.

6. Instruct patient to rinse mouth with water before expectorating into sterile specimen bottle to decrease sputum contamination.

7. Properly label and send to the laboratory without delay.

8. Sputum samples can also be obtained indirectly, such as with nasotracheal suctioning with a catheter or transtracheal aspiration. Take care to ensure that the suction catheters remain sterile. A physician's order must be obtained for endotracheal suctioning.

True

92

LUNG BIOPSY

,

93

Lung biopsy may be done transbronchially or as an open-lung biopsy. The purpose is to obtain tissue, cells, or secretions for evaluation.
A)LUNG BIOPSY
B)false

A

94

THORACENTESIS

,

95

Thoracentesis is the surgical perforation of the chest wall and pleural space with a needle for the aspiration of fluid for diagnostic or therapeutic purposes or for the removal of a specimen for biopsy.
A)true
B)false

A

96

Nursing interventions for the patient undergoing thoracentesis include explaining the procedure and obtaining a written consent. Try to relieve the patient's anxiety. The procedure is usually carried out in the patient's room. The patient sits on the edge of the bed with the head and arms resting on a pillow placed on an overbed table. If the patient cannot sit up, turn him or her to the unaffected side with the head of the bed elevated 30 degrees.
A)true
B)false

A

97

Nursing interventions for the patient with thoracentesis, Monitor vital signs, general appearance, and respiratory status throughout the procedure. Usually no more than 1300 mL of pleural fluid should be removed within a 30-minute period because of the risk of intravascular fluid shift with resultant pulmonary edema.
A)true
B)false

A

98

After thoracentesis, position the patient on the unaffected side. Label the specimen and send it immediately to the laboratory per physician's orders.
A)true
B)false

A

99

ARTERIAL BLOOD GASES

,

100

Arterial blood gas (ABC) testing yields definitive information on the patient's respiratory status and metabolic balance. The procedure is performed at the bedside. A heparinized syringe and needle are used to withdraw 3 to 5 mL of arterial blood, usually from the radial artery. Other possible sites include femoral or brachial arteries. After the sample is obtained, place direct pressure on the puncture site for a minimum of 5 minutes to prevent hematoma formation and blood loss.
A)ARTERIAL BLOOD GASES
B)false

A

101

If the patient is taking anticoagulants, maintain pressure for 20 minutes or longer until bleeding stops. Place the capped syringe in a basin of crushed ice and water to preserve the gas and pH levels of the specimen. Send the properly labeled specimen to the laboratory immediately.
A)ARTERIAL BLOOD GASES
B)false

A

102

PULSE OXIMETRY

,

103

Pulse oximetry is a noninvasive method of providing continuous monitoring of Sao2 (saturation of oxygen) for assessment of gas exchange.
A)true
B)false

A

104

An Sao2 of 90% to 100% is needed to adequately replenish oxygen in plasma.
A)true
B)false

A

105

An Sao2 of less than 70% is considered life threatening.
A)true
B)false

A

106

DISORDERS OF THE UPPER AIRWAY

,

107

EPISTAXIS

,

108

The underlying cause of epistaxis (bleeding from the nose) is congestion of the nasal membranes, leading to capillary rupture. This condition is frequently caused by injury and occurs more frequently in men.
A)True
B)false

A

109

Other causes include local irritation of nasal mucosa, such as dryness, chronic infection, trauma (e.g., injury, vigorous nose blowing, or nose picking), topical corticosteroid use, nasal spray abuse, or street drug use.
A)epistaxis
B)false

A

110

Bleeding may also be prolonged of a patient with a nose bleed, if the patient takes aspirin or nonsteroidal antiinflammatory drugs (NSAIDs).
A)true
B)False

A

111

Exsanguination (loss of blood to the point at which life can no longer be sustained) .
A)true
B)false

A

112

Assess the patient's blood pressure, temperature, pulse, respirations, and any evidence of hypovolemic shock. Severe bleeding results in a drop in blood pressure,
which may cause the bleeding to stop. Hypotension is a late sign of shock.
A)objective data for patient with epistaxis
B)false

A

113

A hemoglobin and hematocrit determination will aid in establishing an estimate of the blood loss.
A)true for epistaxis
B)false

A

114

Nursing interventions for a patient with epistaxis include keeping the patient quiet.

1.Place the patient in a sitting position, leaning forward, or in a reclining position with head and shoulders elevated.

2.Apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes.

3.Apply ice compresses to the nose and have the patient suck on ice.

4.Partially insert a small gauze pad into the bleeding nostril, and apply digital pressure if bleeding continues.

5.Monitor for signs and symptoms of hypovolemic shock.

True

115

Nursing diagnoses and interventions for the patient with epistaxis include but are not limited to the following:

,

116

Ineffective tissue perfusion, cerebral and/or cardiopulmonary, related to blood loss. A nursing intervention would be? Select all that apply
A)Assess vital signs and level of consciousness every 15 minutes and report any changes.
B)Document estimated blood loss.
C)give alcohol

A B

117

Risk for aspiration, related to bleeding, a nursing intervention would be?select all that apply
A)Elevate head of bed; place patient in Fowler's position with the head forward; encourage patient to let the blood drain from the nose.
B)Pinch nostrils; have the patient breathe through the mouth; apply ice compresses over the nose (however, the primary benefit of the application of ice is that it requires the patient to remain still); assist patient in clearing secretions.
C)Maintain airway patency.
D)Instruct patient to expectorate any blood or clots rather than swallow them, which could cause nausea and vomiting.

A B C D

118

To prevent recurrent hemorrhage, warn the patient not to blow the nose vigorously and to avoid dryness of the nose.
A)true for patient with epistaxis
B)false a

A

119

Encourage the patient to use a vaporizer and saline or nasal lubricants to keep nasal mucous membranes moist.
A)for patient with epistaxis
B)false

A

120

Advise the patient to avoid using aspirin-containing products or NSAIDs, and teach him or her to sneeze with the mouth open.
A)true for patient with epistaxis
B)false

A

121

DEVIATED SEPTUM AND NASAL POLYPS

,

122

Common conditions that cause nasal obstruction include nasal polyps or a deviated septum caused by congenital abnormality or, more likely, injury.
A)true
B)false

A

123

Nasal polyps are tissue growths on the nasal tissues that are frequently caused by prolonged sinus inflammation; allergies are often the underlying cause.
A)true
B)false

A

124

A septum that deviates from the midline can obstruct airway passages
A)true
B)false

A

125

stertorous (characterized by a harsh snoring sound)
A)true
B)false

A

126

Sinus radiographic studies depict the presence of shadowy sinuses when nasal polyps are present.
A)true
B)false

A

127

A shift of the nasal septum is evident with a septal defect
A)true
B)false

A

128

Nasoseptoplasty is the operation of choice to reconstruct, align, and straighten the deviated nasal septum.
A)true
B)false

A

129

nasal polypectomy is performed to remove the polyps. Actions include nasal packing to control bleeding for 24 hours, and then maintaining nasal mucosa hydration with nasal irrigation of saline or application of a light layer of petroleum jelly to the external nares to prevent drying
A)true
B)false

A

130

Medications include (1) corticosteroids (prednisone), which cause polyps to decrease or disappear; and (2) antihistamines for allergy signs and symptoms, to decrease congestion in both septal deviations and polyps.
A)true
B)false

A

131

Nursing diagnoses and interventions for the patient with deviated septum or nasal polyps include but are not limited to the following:

,

132

Ineffective airway clearance, related to nasal exudates. A nursing intervention would be? Select all that apply
A)Document patient's ability to clear secretions, and note respiratory status.
B)Elevate head of bed, and apply ice compresses to the nose to decrease edema, discoloration, discomfort, and bleeding.
C)Change nasal drip pad as needed, documenting color, consistency, and amount of exudates.

A B C

133

Risk for injury, related to trauma to bleeding site associated with vigorous nose blowing. A nursing intervention would be?select all that apply.
A)Assess and report exudates (as stated above).
B)Instruct patient against blowing nose in immediate postoperative period, since this could increase bleeding, edema, and ecchymosis.

A B

134

Remind the patient to avoid nose blowing, vigorous coughing, or Valsalva's maneuver (holding the breath and bearing down as if straining during a bowel movement) for 2 days postoperatively. Remind the patient that facial ecchymosis and edema may persist for several days after surgery.
A)true
B)false

A

135

ANTIGEN-ANTIBODY ALLERGIC RHINITIS AND ALLERGIC CONJUNCTIVITIS (HAY FEVER)

,

136

atopic allergic conditions that result from antigenantibody reactions in the nasal membranes, nasopharnasopharynx, and conjunctiva from inhaled or contact allergens. Many infants, children, and adults have these seasonal or perennial conditions, which often result in absences from school and work.
A)ANTIGEN-ANTIBODY ALLERGIC RHINITIS AND ALLERGIC CONJUNCTIVITIS (HAY FEVER)
B)false

A

137

During the antigen-antibody reaction of rhinitis and conjunctivitis, ciliary action slows; mucosal gland secretion increases; leukocyte (eosinophil) infiltration occurs; and, because of increased capillary permeability and vasodilation, local tissue edema results.
A)true
B)false

A

138

Common allergens are tree, grass, and weed pollens; mold spores; fungi; house dusts; mites; and animal dander.
A)ANTIGEN-ANTIBODY ALLERGIC RHINITIS AND ALLERGIC CONJUNCTIVITIS (HAY FEVER)
B)false

A

139

The initial complaints of seasonal rhinitis and conjunctivitis include severe sneezing, congestion, pruritus, and lacrimation (watery eyes).
A)true
B)false

A

140

Cough, epistaxis, and headache may also occur. With ANTIGEN-ANTIBODY ALLERGIC RHINITIS AND ALLERGIC CONJUNCTIVITIS (HAY FEVER)
A)true
B)false

A

141

More chronic signs and symptoms include headache, severe nasal congestion, postnasal drip, and cough. If these are not treated, . chronic sufferers eventually develop secondary infections, such as otitis media, bronchitis, sinusitis, and pneumonia.
A)ANTIGEN-ANTIBODY ALLERGIC RHINITIS AND ALLERGIC CONJUNCTIVITIS (HAY FEVER)
B)false

A

142

In allergic rhinitis, on physical examination the mucosa of the turbines is usually pale because of venous engorgement, which is in contrast to the erythema of viral rhinitis.
A)true
B)false

A

143

Perennial use of antihistamines, intranasal corticosteroids, and leukotriene receptor antagonists such as zafirlukast (Accolate) or montelukast (Singulair) is recommended.
A)ANTIGEN-ANTIBODY ALLERGIC RHINITIS AND ALLERGIC CONJUNCTIVITIS (HAY FEVER)
B)false

A

144

Lodoxamide (Alomide) four times a day is the recommended treatment for mild to moderately severe allergic conjunctivitis
A)true
B)false

A

145

Pressure headaches may require opioid analgesics until signs and symptoms are relieved.
A)true
B)false

A

146

Hot packs over facial sinuses offer relief if headache is related to sinus congestion.
A)true
B)false

A

147

OBSTRUCTIVE SLEEP APNEA

,

148

Obstructive sleep apnea (OSA) is characterized by partial or complete upper airway obstruction during sleep, causing apnea and hypopnea
A)true
B)false

A

149

Apnea is the cessation of spontaneous respirations;
A)true
B)false

A

150

hypopnea is abnormally shallow and slow respirations
A)true
B)false

A

151

Airflow obstruction occurs when the tongue and the soft palate fall backward and partially or completely obstruct the pharynx.
A)true
B)false

A

152

During the apneic period, the patient experiences severe hypoxemia (decreased Pao2) and hypercapnia (increased Paco2). These changes are ventilatory stimulants and cause the patient to partially awaken.
A)true
B)false

A

153

Apnea and arousal cycles occur repeatedly, as many as 200 to 400 times during 6 to 8 hours of sleep.
A)true
B)false

A

154

Clinical manifestations of sleep apnea include frequent awakening at night, insomnia, excessive daytime sleepiness, and witnessed apneic episodes
A)true
B)false

A

155

Other symptoms include morning headaches (from hypercapnia, which causes vasodilation of cerebral blood vessels), personality changes, and irritability
A)OBSTRUCTIVE SLEEP APNEA
B)false

A

156

Risk factors for OSA include the following:
A)Male gender: About twice as many men as women have OSA.
B)incidence increases with age over 65 years, probably because of weight gain and loss of pharyngeal muscle strength.
C)Nasal conditions: Nasal allergies, polyps, or septal deviation decrease the diameter of the pharynx
D)Receding chin: A person with a receding chin may not have enough room in the pharynx for the tongue, thus contributing to obstruction.
E)Pharyngeal structural abnormalities: A person with OSA may have enlarged tonsils, an elongated uvula, an especially long tongue, or a soft palate that rests on the base of the tongue. Any of these structural abnormalities can impinge on the airway

A B C D E

157

Diagnosis of sleep apnea is made during sleep with the use of polysomnography. Electrodes are placed on the patient's scalp, mandibular area, and lateral area of the eyelids.
A)true
B)false

A

158

Instruct the patient to avoid sedatives and alcoholic beverages for 3 to 4 hours before sleep. Referral to a weight loss program may help, since excessive weight exacerbates symptoms.
A)OBSTRUCTIVE SLEEP APNEA
B)false

A

159

Symptoms resolve in half of the patients with OSA who use an oral appliance during sleep that brings the mandible and tongue forward to enlarge the airway space, thereby preventing airway occlusion.
A)true
B)false

A

160

In patients with more severe symptoms, nasal continuous positive airway pressure (nCPAP) may be used
A)OBSTRUCTIVE SLEEP APNEA
B)false

A

161

The blower is adjusted to maintain sufficient positive pressure (5 to 15 em H20) in the airway during inspiration and expiration to prevent airway collapse.
A)true OSA
B)false

A

162

A technologically more sophisticated therapy, bilevel positive airway pressure (BiPAP), capable of delivering higher pressure during inspiration (when the airway is most likely to be occluded) and lower pressure during expiration, may be helpful and is better tolerated.
A)true, OSA
B)false

A

163

Although nCPAP is highly effective, compliance is poor even if symptoms of sleep apnea are relieved.
A)true
B)false

A

164

The most common procedures are uvulopalatoplasty, pharyngoplasty (UPP, UPPP, or UP3) and genioglossal advancement and hyoid myotomy (GAHM)
A)true
B)false

A

165

UPPER AIRWAY OBSTRUCTION

,

166

Upper airway obstruction is precipitated by a recent respiratory event, such as trallffiatic injury to the airway or surrounding tissues
A)true
B)false

A

167

Common airway obstructions include choking on food; dentures; aspiration of vomitus or secretions; and, the most common airway obstruction in an unconscious person, the tongue.
A)true
B)false

A

168

Altered physiology includes any condition that could produce airway obstruction, such as laryngeal spasm caused by tetany resulting from hypocalcemia. Another cause may be laryngeal edema caused by injury.
A)UPPER AIRWAY OBSTRUCTION
B)false

A

169

objective data includes prompt assessment for the classic sign of choking in which the patient places a hand over throat. Also monitor for signs of hypoxia (an inadequate, reduced tension of cellular oxygen; see Box 9-1), cyanosis (slightly bluish, -grayish, slatelike, or dark pmple discoloration of the skin resulting from excessive amounts of deoxygenated hemoglobin in the blood), stertorous respirations, and wheezing or stridor (harsh, high-pitched sollllds during respiration, caused by obstruction).
A)UPPER AIRWAY OBSTRUCTION
B)false

A

170

As hypoxia progresses, the respiratory centers in the brain (medulla oblongata and pons) are depressed, resulting in bradycardia and shallow, slow respirations.
A)UPPER AIRWAY OBSTRUCTION
B)false

A

171

The most immediate nursing intervention is opening the airway and restoring patency. This may be accomplished by properly repositioning the patient's head and neck, or it may require further maneuvers.
A)UPPER AIRWAY OBSTRUCTION
B)false

A

172

The head-tilt/ chin-Lift tedmique recommended by the American Heart Association minimizes further damage in the presence of a suspected cervical neck fracture. With a foreign body. airway obstruction, the Heimlich maneuver is used.
A)UPPER AIRWAY OBSTRUCTION
B)false

A

173

Nursing diagnoses and interventions for the patient with an airway obstruction include but are not limited to the following:

,

174

Ineffective airway clearance, related to obstruction in airway. A nursing intervention would be. Select the all that apply
A) Reestablish and maintain secure airway.
B)Administer oxygen as ordered.
C)Suction as needed and assess patient's ability to mobilize secretions.
D)Monitor vital signs and breath sounds closely.

A B C D

175

Risk for aspiration, related to partial airway obstruction. Nursing intervention would be.
A)Monitor respiratory rate, rhythm, and effort.
B)Assess patient's ability to swallow secretions by elevating the head of the bed.
C)Assess and document breath sounds
D)Facilitate optimal airway and functional swallowing by elevating head of bed.
E)Note amount, color, and characteristics of secretions
F)Suction as needed.

A B C D E F

176

CANCER OF THE LARYNX

,

177

The incidence appears to be correlated to prolonged tobacco use (cigarettes, pipes, cigars, chewing tobacco, smokeless tobacco) and heavy alcohol use, chronic laryngitis, vocal abuse, and family history.
A)CANCER OF THE LARYNX
B)false

A

178

Because of the increase in the number of women who are heavy smokers, their incidence of carcinoma of the larynx is increasing
A)true
B)false

A

179

Progressive or persistent hoarseness is an early sign. Any person who is hoarse longer than 2 weeks should seek medical treatment.
A)CANCER OF THE LARYNX
B)false

A

180

Signs of metastasis to other areas include pain in the larynx radiating to the ear, difficulty swallowing (dysphagia), a feeling of a lump in the throat, and enlarged cervical lymph nodes.
A)CANCER OF THE LARYNX
B)false

A

181

Complaints of referred pain to the ear (otalgia) and difficulty breathing (dyspnea) or swallowing should be noted.
A)CANCER OF THE LARYNX
B)false

A

182

objective data includes examining sputum for blood (hemoptysis, or blood expectorated from the respiratory tract)
A)CANCER OF THE LARYNX
B)false

A

183

Visual examination of the larynx with direct laryngoscopy, with a fiberoptic scope, is done to determine the presence of laryngeal cancer.
A)true
B)false

A

184

partial laryngectomy is done to remove the diseased vocal cord and possibly a portion of thyroid cartilage. This requires placement of a temporary tracheostomy, which is closed when the edema has decreased.
A)true
B)false

A

185

Because the patient can no longer breathe through the nose, the sense of smell is lost.
A)true
B)false

A

186

The voice is also absent once the larynx is removed.
A)true
B)false

A

187

Because of neck and facial disfigurement and loss of voice, a thorough psychosocial assessment and resultant interventions are beneficial
A)true
B)false

A

188

Encourage communication through writing and facial and hand gestures.
A)CANCER OF THE LARYNX
B)false

A

189

Many cities have a Lost Chord Club or a New Voice Club, whose members are willing to visit hospitalized patients.
A)CANCER OF THE LARYNX
B)false

A

190

A speech therapist should meet with the patient after a total laryngectomy to discuss voice restoration options, including a voice prosthesis, esophageal speech, and an electrolarynx.
A)true
B)false

A

191

Nursing diagnoses and interventions for the patient with a tracheostomy include but are not limited to the following:

,

192

Ineffective airway clearance, related to secretions or obstruction. A nursing interventions be.
A)Provide tracheostomy care according to protocol; ensure the availability of emergency equipment (oxygen and tracheostomy tray). B)Offer small, frequent feedings, and give liquid or pureed food as tolerated to avoid choking.
C)Suction secretions as needed.
D)Teach patient stoma protection.
E)Assess respiratory rate and characteristics every 1 to 2 hours.
F)Auscultate lung sounds, monitor Sao2 every 4 hours
G)Elevate head of bed 30 degrees or higher.
H)Turn patient and encourage coughing and deep breathing every 2 to 4 hours.
I)Auscultate lung sounds.
J)Provide constant humidity.
K)Suction tracheostomy tube as needed, using aseptic technique; instruct patient to inhale as catheter is advanced.
L)Clean inner cannula of tracheostomy tube every 2 to 4 hours and as needed, using a solution of normal saline and hydrogen peroxide.
M)Suction trachea as needed.

ALL THE ABOVE

193

Impaired communication, verbal, related to removal of larynx, nursing intervention would be.
A)Provide patient with implements for communication, including pencil, paper, Magic slate; picture books, or electronic voice device. B)Keep call signal by patient's hand at all times.
C)If possible, ask patient questions that require only a yes or no response to avoid fatigue and frustration.
D)Refer patient to local support groups and the local chapter of the American Cancer Society.
F)Assist with speech rehabilitation.
G)Review instructions about esophageal and electroesophageal speech.
H)Reinforce need for regular follow-up with speech pathologist and surgeon after discharge.

All the above

194

Explain techniques of airway maintenance, such as oxygen usage, deep breathing, and coughing.
A)true
B)false

A

195

ACUTE RHINITIS

,

196

Acute rhinitis (or acute coryza), known as the common cold, is an inflammatory condition of the mucous membranes of the nose and accessory sinuses. It is typically characterized by edema of the nasal mucous membrane.
A)true
B)false

A

197

Signs and symptoms usually are evident within 24 to 48 hours after exposure
A)acute rhinitis
B)false

A

198

Sinus congestion causes increased sinus drainage, leading to postnasal drip. The postnasal drip causes throat irritation, headache, and earache.
A)true
B)false

A

199

Most people with colds contaminate their hands when coughing or sneezing, thus contaminating everything they touch. Others become infected when touching the telephone, computer, or anything else that has been touched by the person with a cold.
A)true
B)false

A acute rhinitis

200

Subjective data include the patient's complaints of sore throat, dyspnea, and congestion of varying duration.
A)acute rhinitis
B)false

A

201

Nursing interventions are aimed at promoting comfort. Such measures include encouraging fluids and applying warm, moist packs to sinuses.
A)acute rhinitis
B)false

A

202

Nursing diagnoses and interventions for the patient with acute rhinitis include but are not limited to the following:

,

203

Ineffective airway clearance, related to nasal exudates, a nursing intervention would be?select all that apply
A)Encourage fluids to liquefy secretions and aid in their expectoration.
B)Use vaporizer to moisten mucous membranes and prevent further irritation.

A B

204

Health-seeking behaviors: illness prevention, related to preventing exacerbation or spread of infection, a nursing intervention would be? Select all that apply.
A)Remind patient and family of health maintenance behaviors to decrease risk of illness, such as adequate fluid and nutritional management and sufficient rest.
B)Teach importance of hygiene measures to decrease spread of infection.

A B

205

Instruct the patient to limit exposure to others during the first 48 hours and to check the temperature every 4 hours.
A)acute rhinitis
B)false

A

206

ACUTE FOLLICULAR TONSILLITIS

,

207

Acute follicular tonsillitis can be an acute inflammation of the tonsils. It is the result of an airborne or foodborne bacterial infection, often streptococci.
A)true
B)false

A

208

It appears to be most common in school-age children. Signs and symptoms of tonsillitis include sore throat, fever, chills, and anorexia. The tonsils become enlarged and often contain purulent exudate.
A)Acute follicular tonsillitis
B)false

A

209

subjective data includes monitoring the severity of throat pain and the possibility of referred pain to the ears. Note headache or joint pain.
A)Acute follicular tonsillitis
B)false

A

210

Collection of objective data includes a visual examination that shows increased throat secretions and enlarged, erythematous tonsils
A)Acute follicular tonsillitis
B)false

A

211

Throat cultures identify the causative microorganism, most commonly 13-hemolytic streptococci.
A)Acute follicular tonsillitis
B)false

A

212

An elective tonsillectomy and adenoidectomy (T&A), where the tonsils and adenoids are surgically excised, is performed in people who have recurrent attacks of tonsillitis
A)true
B)false

A

213

Medications used in tonsillitis include analgesics and antipyretics (e.g., acetaminophen) and antibiotic .agents (e.g., penicillin). Warm saline gargles are also beneficial.
A)true
B)false

A

214

One of the primary nursing goals for acute tonsillitis is to provide meticulous oral care, which promotes comfort and assists in combating infection.
A)true
B)false

A

215

Postoperative care for tonsillectomy includes maintaining IV fluids until the nausea subsides, at which time the patient may begin drinking ice cold clear liquids.
A)true
B)false

A

216

The diet is advanced to custard and ice cream and then to a normal diet as soon as possible. Apply an ice collar to the neck for comfort and to reduce bleeding by vasoconstriction.
A)after tonsils are removed
B)false

A

217

Nursing diagnoses and interventions for the patient with acute follicular tonsillitis include but are not limited to the following:

,

218

Pain, related to inflammation and irritation of the pharynx, a nursing intervention would be? Select all that apply

A)Assess degree of pain and need for analgesics.
B)Document effectiveness of medication, and offer analgesic as ordered.
C)Maintain bed rest, and promote rest.
D)Offer warm saline gargles, ice chips, and ice collar as needed.

A B C D

219

Risk for deficient flujd volume, related to inability to maintain usual oral intake because of painful swallowing, a nursing intervention would be? Select all that apply
A)Assess hydration status by noting mucous membranes, skin turgor, and urinary output.
B)Encourage Popsicles, ice chjps, and increased oral intake; cold liquids, sherbet, and ice cream are best tolerated; carbonated drinks may be taken if patient tolerates; avoid offering citrus juices because they may burn the throat.

A B

220

Risk for aspiration, related to postoperative bleeding, a nursing intervention would be? Select all that apply.
A)Maintain patent airway; keep patient lying on side as much as possible to prevent aspiration.
B)Observe for vomiting of dark brown fluid; patient may have "swallowed" blood during surgery.
C)Watch for frequent swallowing, which may indicate bleeding; check frequently with flashlight to see if blood is trickling down posterior pharynx.

A B C

221

Tell the patient to avoid attempting to clear the throat immediately after surgery (may initiate bleeding) and to avoid coughing, sneezing, or vigorous nose blowing for 1 to 2 weeks
A)true after tonsils are removed
B)false

A

222

Most surgeons no longer prescribe aspirin for pain after tonsillectomy, since it increases the tendency to bleed; acetaminophen or another aspirin substitute is usually ordered
A)true
B)false

A

223

Analgesics are usually given orally in liquid form. Remind the patient to avoid overexertion, and make certain that the patient and the family know how to reach the physician in case of increased pain, fever, or bleeding.
A)true after tonsils are removed
B)false

A

224

LARYNGITIS

,

225

Laryngeal inflammation is a common disorder that can be either chronic or acute. Acute laryngitis may cause severe respiratory distress in children younger than 5 years of age because the relatively small larynx is subject to spasm when irritated or infected and readily becomes partially or totally obstructed
A)LARYNGITIS
B)rhinitis

A

226

Acute laryngitis often accompanies viral or bacterial infections. Other causes include excessive use of the voice or inhalation of irritating fumes.
A)true
B)false

A

227

Chronic laryngitis is usually associated with inflammation of laryngeal mucosa or edematous vocal cords.
A)true
B)false

A

228

Subjective data include the patient reporting progressive hoarseness and a cough that may be productive or may be dry and nonproductive. Attempt to identify any precipitating factors such as excessive voice use or exposure to inhaled irritants
A)laryngitis
B)rhinitis

A

229

Collection of objective data includes evaluating the patient's voice quality and the characteristics (color, consistency, and amount) of sputum produced.
A)laryngitis
B)rhinitis

A

230

Laryngoscopy reveals abnormalities (edema, drainage) of vocal cords and erythematous laryngeal mucosa.
A)true
B)false

A

231

General interventions include use of warm or cool mist inhalation via vaporizer. Encourage the patient to rest the voice by limiting verbal communication.
A)laryngitis
B)rhinitis

A

232

Nursing diagnoses and interventions for the patient with laryngitis include but are not limited to the following:

,

233

Pain, related to pharyngeal irritation, a nursing intervention would be?select all that apply
A)Assess level of pain, and offer medications to promote comfort.
B)Use steam inhalation as ordered.
C)Instruct patient on the importance of resting the voice.

A B C

234

Impaired communication, verbal, related to edematous vocal cord, a nursing intervention would be? Select all that apply
A)Instruct patient on the importance of resting the voice.
B)Provide other means for communication (written word, gestures).
C)Anticipate patient's needs whenever possible.

A B C

235

PHARYNGITIS

,

236

Pharyngitis is usually viral but can be caused by 13-hemolytic streptococci, staphylococci, or other bacteria. There is increased evidence of gonococcal pharyngitis caused by the gram-negative diplococcus Neisseria gonorrhoeae.
A)true
B)false

A

237

A severe form of acute pharyngitis often is referred to as strep throat because the streptococcus organism is commonly the cause. This . disorder is contagious for 2 or 3 days after the onset of signs and symptoms.
A)true
B)false

A

238

Pharyngitis manifests itself clinically by a dry cough, tender tonsils, and enlarged cervical lymph glands.
A)true
B)false

A

239

Subjective data include any reported pharyngeal discomfort, fever, or difficulty swallowing.
A)Pharyngitis
B)rhinitis

A

240

Collection of objective data includes palpating for enlarged, edematous glands and associated tenderness and noting elevated temperature.
A)Pharyngitis
B)rhinitis

A

241

Two throat swabs are obtained so a culture can be performed if the rapid strep screen test is negative
A)pharyngitis
B)rhinitis

A

242

Commonly ordered medications include antibiotics, such as penicillin or erythromycin, to (1) treat severe infections; or (2) prevent superimposed infections, particularly in people who have a history of rheumatic fever or bacterial endocarditis.
A)pharyngitis
B)rhinitis

A

243

Nursing diagnoses and interventions for the patient with pharyngitis include but are not Limited to the following:

,

244

Impaired oral mucous membrane, related to edema, a nursing intervention would be?select all that apply
A)Provide warm saline gargles to promote comfort.
B)Assess level of pain and provide meclications as ordered.
C)Encourage oral intake of fluids.
D)Offer frequent oral care.

A B C F

245

Deficient fluid volume, risk for, related to decreased oral intake as a result of painful swallowing, a nursing intervention would be?select all that apply
A)Observe and record patient's hydration status.
B)Monitor 1&0 and patient's temperature.
C)Maintain IV therapy if indicated.

A B C

246

SINUSITIS

,

247

Sinusitis can be chronic or acute, involving any sinus area, such as maxillary or frontal. This infection can be either viral or bacterial in origin and often is a complication of pneumonia or nasal polyps. The underlying pathophysiology begins with an upper respiratory tract infection that leads to a sinus infection.
A)SINUSITIS
B) pharyngitis

A

248

The patient with sinusitis often complains of a constant, severe headache with pain and tenderness in the particular sinus region, and often has purulent exudate.
A)true
B)false

A

249

Subjective data include patient reporting decreased appetite or nausea. The patient may also complain of generalized malaise, headache, diminished sense of smell, and pain in the sinus region when bending forward
A)sinusitis
B)rhinitis

A

250

Purulent nasal secretions, elevated temperature, facial congestion, and eyelid edema are often noted
A)objective data for sinusitis
B)false

A

251

Sinus radiographic studies are frequently done to depict cloudy or fluid-filled sinus cavities.
A)sinusitis
B)false

A

252

A common surgical procedure to relieve chronic maxillary sinusitis, the Caldwell-Luc operation, is a radical antrum operation involving the creation of an incision under the lip to remove diseased mucosal and bone tissue.
A)true
B)false

A

253

Steam inhalation and warm, moist packs facilitate drainage and promote comfort
A)sinusitis
B)false

A

254

Nursing diagnoses and interventions for the patient with sinusitis include but are not limited to the following:

,

255

Ineffective breathing pattern, related to nasal congestion, a nursing intervention would be?select all that apply
A)Assess respiratory status frequently, noting any changes; mouth breathing may be necessary because of nasal airway and sinus discomfort.
B)false

A

256

Pain, related to sinus congestion, a nursing intervention would be?select all that apply
A)Document comfort level.
B)Assess need for analgesics, and document patient response.
C)Elevate head of bed to promote drainage of secretions
D)Apply warm, moist packs four times a day to promote secretion drainage and provide relief.

A B C D

257

DISORDERS OF THE LOWER AIRWAY

,

258

ACUTE BRONCHITIS

,

259

Usually acute bronchitis is secondary to an upper respiratory tract infection, but it can be related to exposure to inhaled irritants
A)ACUTE BRONCHITIS
B)false

A

260

Inflammation of the trachea and bronchial tree causes congestion of the mucous membranes, which results in retention of tenacious secretions. These secretions can become a culture medium for bacterial growth
A)true
B)false

A

261

Acute bronchitis manifests itself with symptoms such as a productive cough, diffuse rhonchi and wheezes, dyspnea, chest pain, and low-grade temperature.
A)true
B)false

A

262

Subjective data include the patient's complaints of feeling poorly and experiencing headache and aching tightness in the chest.
A)acute bronchitis
B)rhinitis

A

263

Collection of objective data includes monitoring vital signs frequently, checking breath sounds, and noting the presence of wheezes or basilar crackles.
A)acute bronchitis
B)rhinitis

A

264

chest radiographic examination to ensure clear lung fields and a sputum specimen to determine the presence of associated bacterial infections.
A)acute bronchitis
B)false

A

265

Such actions include placing the patient on bed rest to conserve energy, using a vaporizer to add humidity to inhaled air, and increasing fluid intake
A)interventions for acute bronchitis patients
B)false

A

266

Nursing diagnoses and interventions for the patient with acute bronchitis include but are not limited to the following:

,

267

Risk for infection, related to retained pulmonary secretions, a nursing intervention would be? Select all that apply
A)Assess for signs and symptoms of infection: fever, dyspnea, color and characteristics of sputum production.
B)Administer antipyretics and antibiotics as ordered.

A B

268

Ineffective airway clearance, related to tenacious pulmonary secretions, a nursing intervention would be?select all that apply
A)Assess patient's ability to move secretions; also note any increase in retained pulmonary secretions.
B)Facilitate airway clearance by elevating head of bed and liquefying secretions by use of humidifier and adequate fluid intake (3000 to 4000 mL/day).
C)Suction as needed.
D)When offering fluids, avoid dairy products, which tend to produce more tenacious secretions.

A B C D

269

Instruct the patient on measures that will prevent exacerbation or recurrence of infection. Such measures include increasing oral fluid intake, incorporating rest periods between activities, and recognizing the signs that may indicate worsening infection (purulent sputum and increased dyspnea)
A)patient with acute bronchitis
B)false

A

270

LEGIONNAIRES' DISEASE

,

271

This organism thrives in water reservoirs, such as in air conditioners, humidifiers, and whirlpool spas. It is transmitted through airborne routes. The Legionella microbe can progress in two different forms: influenza or legionnaires' disease
A)LEGIONNAIRES' DISEASE
B)false

A

272

The disease progresses rapidly (less than 1 week) and can result in respiratory failure, renal failure, bacteremic shock, and ultimately death
A)LEGIONNAIRES' DISEASE
B)false

A

273

Collection of subjective data includes noting the patient's complaints of dyspnea, headache, and chest pain on inspiration
A)LEGIONNAIRES' DISEASE
B)false

A

274

Objective data include many significant signs associated with this infectious process. A significantly elevated temperature (102° to 105° F (38.8° to 40.5° C1) bears close watching and may require immediate interventions. The patient also has a nonproductive cough with difficult and rapid breathing. Auscultation of lungs reveals crackles or wheezes. Because of the high fever and extreme respiratory effort, tachycardia and signs of shock may be present. Hematuria may develop, indicative of renal impairment.
A)LEGIONNAIRES' DISEASE
B)false

A

275

Diagnostic tests to confirm L. pneumophila infection are cultures of blood, sputum, and pulmonary tissue or fluid. Chest radiographic.
A)LEGIONNAIRES' DISEASE
B)false

A

276

To control and compensate for impaired and ineffective respiratory function, the patient requires oxygen therapy, possibly even mechanical ventilation. The patient needs adequate IV fluid therapy to maintain hydration and electrolyte status.
A)LEGIONNAIRES' DISEASE
B)false

A

277

Maintain the patient on bed rest, and monitor 1&0.
A)LEGIONNAIRES' DISEASE
B)false

A

278

Nursing diagnoses and interventions for the patient with legionnaires' disease include but are not limited to the following:

,

279

Ineffective tissue perfusion, cardiopulmonary or renal, related to lack of oxygen, a nursing intervention would be?select all that apply
A)Monjtor and report signs and symptoms of impending shock (decreased blood pressure and increased pulse).
B)Administer vasopressor drugs as ordered.
C)Maintain hydration status and urinary output.
D)Assess changes in level of consciousness.
E)Assist with acute hemodialysis if indkated.

A B C D E

280

Ineffective breathing pattern related to respiratory failure, a nursing intervention would be? Select all that apply
A)Assess signs and symptoms of respiratory failure
B)Note respiratory rate, rhythm, and effort.
C)Be alert for cyanosis and dyspnea.
D)Assist with oxygen therapy or mechanical ventilation as ordered
E)Facilitate optimal ventilation; place patient in semi-Fowler's position if tolerated; suction as needed.
F)Have patient cough and deep breathe every 2 hours if able.
G)Identify associated factors, such as ineffective airway clearance, pain, and altered level of consciousness.

A B C D E F G

281

SEVERE ACUTE RESPIRATORY SYNDROME

,

282

Severe acute respiratory syndrome (SARS) is an infection caused by a coronavirus. The virus spreads by dose contact between people, most likely via droplets in the air. It is possible that SARS may also spread by touching contaminated objects.
A)true
B)false

A

283

A chest radiograph is ordered to diagnosis
A)Severe acute respiratory syndrome (SARS) B)false

A

284

The infection control nurse must notify the local public health department. Respiratory isolation with meticulous hand hygiene is carried out to prevent the spread of SARS. When the patient's respiratory status returns to baseline, he or she is discharged home. The patient can go out in public and return to work 10 days after the fever has resolved and respiratory symptoms are improving or absent
A)true
B)false

A

285

ANTHRAX

,

286

Anthrax infection is caused by the spore-forming bacterium Bacillus anthricis.
A)true
B)false

A

287

In humans, anthrax gains a foothold when spores enter the body via the skin, intestines, or lungs. It is not contagious by person-to-person contact, so treating family members and others in contact with an infected person is not recommended unless they were exposed to the same source of infection.
A)true
B)false

A

288

Three Types of Anthrax

1.Cutaneous anthrax, the most common type, occurs after bacteria or spores enter the skin through a cut or abrasion. Within several days of exposure, a pruritic reddened macule or papule develops, followed by vesicle formation. The lesion resembles an insect bite at first, until black eschar appears at the center of the lesion and the site becomes edematous. Although a patient may develop bacteremia if the organism enters his or her bloodstream, cutaneous anthrax is rarely fatal if it is treated with antibiotics

2.Gastrointestinal anthrax, the least common type, occurs after ingestion of the organism in contaminated, undercooked food. Spores can germinate in the mouth, the esophagus, the stomach, or the small and large intestines, causing ulcers. Inflammation of the gastrointestinal tract can cause nausea, vomiting, fever, abdominal pain, and diarrhea. Unless treated early, a patient may die from sepsis

3.Inhalational anthrax, seen in global germ warfare, is the most deadly type. It develops when . spores are inhaled deeply into the lungs. Immune cells sent to fight the lung infection carry some bacteria back to the lymph system, which spreads the infection to other organs.

Initial symptoms of inhalational anthrax resemble those of the common cold or influenza, except that the patient usually does not develop an increased amount of thin, clear nasal exudate.

True

289

A chest x-ray helps differentiate inhalational anthrax from pneumonia.
A)true
B)false

A

290

Antibiotic treatment is indicated for anyone diagnosed with anthrax or exposed to anthrax spores. For both . children and adults, dprofloxacin (Cipro) has been considered the treatment of choice for all three forms of anthrax because of concerns that genetically engineered anthrax strains might resist older antibiotics
A)true
B)false

A

291

The Centers for Disease Control and Prevention (CDC) recommend a 60-day course of therapy to ensure eradication of inactive spores and bacteria.
A)true for anthrax
B)false

A

292

TUBERCULOSIS

,

293

TB is a chronic pulmonary and extrapulmonary (outside of the lung) infectious disease acquired by inhalation of a dried droplet nucleus containing a tubercle bacillus, coughed or sneezed into the air by a person whose sputum contains virulent (capable of producing disease) tubercle bacilli, and inhaled into the alveolar structure of the hmg.
A)true
B)false

A

294

It most commonly affects the respiratory system, but other parts of the body such as gastrointestinal and genitourinary tracts, bones, joints, nervous system, lymph nodes, and skin may become infected
A)TB
B)false

A

295

TB infection is characterized by mycobacteria in the tissue of a host who is free of clinical signs and symptoms and who demonstrates the presence of antibodies against the mycobacteria.
A)true
B)false

A

296

TB disease is manifested as pathologic and functional signs and symptoms indicating destructive activity of mycobacteria in host tissue
A)true
B)false

A

297

TB has been particularly prevalent among people infected with the human immunodeficiency virus (HIV)
A)true
B)false

A

298

Hospitals are a high-risk setting for TB transmission, and health care workers are at high occupational risk for TB infection. Until recently the vulnerability of hospital workers to TB infection had not been emphasized. This complacency is changing with the wide publicity accompanying the increase in TB
A)true
B)false

A

299

They will have a positive tuberculin skin test, and chest radiographs will be negative. These people still retain a lifelong risk of developing reactivation of TB if the immune system is compromised.
A)true, ppl with TB
B)false

A

300

Subjective data include the patient reporting loss of muscle strength and weight loss.
A)TB
B)false

A

301

Diagnostic evaluation includes the tuberculin skin test (Mantoux), using purified protein derivative (PPD), to identify people infected with the TB organism. A positive reaction indicates infection 2 to 10 weeks after exposure to the tubercle bacillus. To read the test 48 to 72 hours later, measure and record the subsequent induration (an area of hardened tissue); do not measure the erythema (redness). A negative reaction is less than 5 mm. If the patient is infected with TB (whether active or dormant), lymphocytes recognize the PPD antigen in the skin test and cause a local indurated reaction.
A)TB
B)false

A

302

Drug therapy is the mainstay of TB treatment.
A)true
B)false

A

303

In general, infants and young children with pulmonary TB do not require isolation precautions because they rarely cough and their bronchial secretions contain few AFB, compared with adults with pulmonary TB.
A)true
B)false

A

304

If TB is suspected, immediately ask permission to place the patient in AFB isolation precautions. These . precautions include the use of isolation rooms with a negative air pressure so that air flows into, rather than out of, the room. Keep doors and windows closed to maintain airflow control. Room air should be exhausted directly to the outside and not recirculated to other rooms.
A)true
B)false

A

305

Also included in AFB isolation precautions is the use of high-efficiency particulate respiration masks (because AFB particles pass through standard masks)
A)intervention for TB
B)false

A

306

Nursing diagnoses and interventions for the patient with TB include but are not limited to the following:

,

307

Ineffective breathing pattern, related to pulmonary infection process, a nursing intervention would be?select all that apply
A)Monitor breathing for evidence of dyspnea or signs and symptoms of pneumothorax.
B)Evaluate degree of respiratory effort and assist as needed.
C)Assess expectorated sputum for hemoptysis.
D)Help immobile patient to turn, cough, and deep breathe every 2 to 4 hours to prevent pooling of secretions.

A B C D

308

Risk for infection, (patient contacts), related to viable M. tuberculosis in respiratory secretions, a nursing intervention would be?select all that apply
A)Obtain specimen for culture (incorrect collection and handling may destroy or contaminate specimen, thus interfering with diagnostic results).
B)Employ AFB isolation until antimicrobial therapy is successfully initiated for sputum-positive patients to prevent transmission of organisms.
C)Employ drainage and secretion precautions until wounds from patient with extrapulmonary TB stop draining to prevent transmission of organism
D)Instruct the patient to cough and sneeze into tissue and properly dispose of it to prevent organism transmission.

A B C D

309

Emphasize the need to report hemoptysis, dyspnea, vertigo, or chest pain. Remind the patient to maintain adequate fluid and nutritional intake.
A)true for TB patients
B)false

A

310

Cultural Considerations Tuberculosis

,

311

-Tuberculosis in the United States tends to be a disease of the older population, urban poor, minority groups, and patients with acquired immunodeficiency syndrome.

• At all ages the incidence of tuberculosis among nonwhites is at least twice that of whites.

• Ethnic groups that have a high incidence of tuberculosis include foreign-born people from Asia, Africa, and Latin America.

• Southeastern Asian, Haitian, and Hispanic immigrants have incidence rates of tuberculosis similar to those of the countries from which they came.

True

312

High-Risk Groups to Screen for Tuberculosis

,

313

-People infected with the human immunodeficiency virus

• Close contacts

-People with conditions that increase the risk of active TB after infection, such as silicosis, diabetes, chronic renal failure, history of gastrectomy, weight 10% below ideal body weight, prolonged corticosteroid or other immunosuppressive therapy, some hematologic disorders (e.g., leukemia and lymphomas). and other malignancies

• People born in countries with a high prevalence of TB

-Substance abusers, such as alcoholics, intravenous drug users, and cocaine or crack users

• Residents of long-term care facilities. nursing homes, prisons, mental institutions, homeless shelters, and other congregate housing settings

True

314

Medications for Respiratory Disorders

,

315

Azatadine (Optimine);
A)antihistamine-blocks allergic response
B)false

A

316

Corticosteroids: Prednisone (Deltasone),
methylprednisolone (Medrol), hydrocortisone (Cortef)
A)anitinflammtory agent
B)false

A

317

Epinephrine (Adrenalin, others)
A)Beta1- and beta2- receptor agonist;
causes bronchodilation and cardiac stimulation; alpha1-agonist activity may cause
vasoconstriction
B)false

A

318

Oxymetazoline (Afrin, others)
A)Vasoconstrictor, used for nasal congestion
B)false

A

319

Theophylline (Accurbron, Bronkodyl, Theo-Dur) (Aminophylline is a salt of theophylline.)
A)Bronchodilator
B)false

A

320

PNEUMONIA

,

321

Pneumorua is an inflammatory process of the respiratory bronchioles and the alveolar spaces that is caused by an infection. It can also be caused by oversedation, inadequate ventilation, or aspiration
A)true
B)false

A

322

Pneumonia can occur in any season but is most common during winter and early spring
A)true
B)false

A

323

pneumorua is more common among infants and older adults.
A)true
B)false

A

324

Pneumorua is often caused by aspiration of infected materials into the distal bronchioles and alveoli.
A)true
B)false

A

325

Aspiration pneumonia is frequently called necrotizing pneumonia because of the pathologic changes in the lungs. Aspiration pneumonia occurs most commonly as a result of aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure, drugs, alcohol, anesthesia, acute infection, or shock. Aspiration pneumonia may be acquired through foreign body aspiration or may follow aspiration of toxic materials, such as gasoline or kerosene.
A)true
B)false

A

326

The causative agents of bacterial aspiration pneumonia includeS. au reus, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aerugilrosa, and Proteus specie
A)true
B)false

A

327

A productive cough is common; color and consistency of sputum vary depending on the type of pneumonia present. Severe chills, elevated temperature, and increased heart and respiratory rates may accompany the painful, productive cough
A)true for pneumonia
B)false

A

328

Streptococcal, pneumococcal: Sudden onset; chest pain; chills; fever; headache; cough; rust-colored t-sputum; crackles and possibly friction rub; hypoxenlia as blood is shunted away from area of consolidation; cyanosis; area of consolidation visible on chest radiograph; sputum culture needed to determine causative agen
A)true
B)false

A

329

Haemophilus: Commonly follows upper respiratory tract infection; low-grade fever; croupy cough; malaise; arthralgias; yellow or green sputum
A)true
B)false

A

330

Mycoplasmal: Gradual onset; headache; fever; malaise; chills; cough severe and nonproductive; decreased breath sounds and crackles; chest radiograph clear; white blood cell count normal
A)true
B)false

A

331

Viral: Signs and symptoms generally mild; cold symptoms; headache; anorexia; myalgia (tenderness or pain in muscles); irritating cough that produces mucopurulent or bloody sputum; bronchopneumonic type of infiltration on chest radiograph; white blood cell count usually normal; rise in antibody titers
A)true pneumonia
B)false

A

332

Subjective data include the patient's description of the onset and duration of cough. The patient may complain of fever and night sweats
A)pneumonia
B)false

A

333

Perform auscultation; the patient will have crackles on inspiration and possibly a pleural effusion.
A)objective data for a patient with pneumonia
B)false

A

334

Blood and sputum cultures help identify organisms.
A)pneumonia
B)false

A

335

Chest radiographic studies reveal changes in density, primarily in the lower lobes.
A)pneumonia
B)false

A

336

White blood cell count is normal or even low in viral or mycoplasmal pneumonia, whereas it is elevated in bacterial pneumonia
A)true
B)false

A

337

Leukocytosis is found in the majority of patients with bacterial pneumonia,
A)true
B)false

A

338

Encourage patients to cough and breathe deeply to maximize ventilatory capabilities.
A)patient with pneumonia
B)false

A

339

Currently viral pneumonia has no definitive treatment. Analgesics and antipyretics (acetaminophen or aspirin), expectorants, and bronchodilators are often prescribed. Humidification with a humidifier or a nebulizer if secretions are tenacious and copious is useful.
A)true
B)false

A

340

Pneumococcal vaccine is indicated primarily for the individual considered at risk who

(1) has chronic illnesses such as lung and heart disease and diabetes mellitus,
(2) is recovering from a severe illness,
(3) is 65 years of age or older, or
(4) is in a nursing home or other long-term care facility.

True

341

Nursing strategies are aimed at helping the patient conserve energy. Allow rest periods and facilitate optimal air exchange by placing the patient in a high Fowler's position.
A) pneumonia.
B)false

A

342

Place the patient on the side with the "good lung down." This position benefits those with unilateral pulmonary disease, including unilateral pneumonia.
A)true
B)false

A

343

Studies have revealed that hypoxia worsened when patients were placed on their back or side with the affected (sick) lung down.
A)true
B)false

A

344

If the patient is unable to expectorate secretions, assist with appropriate measures (such as coughing, positioning, suctioning, and liquefying secretions)
A)true
B)false

A

345

Promptly administer bronchodilators, mucolytics, and expectorants as prescribed to dilate bronchioles and remove secretions.
A)true
B)false

A

346

Provide hydration to liquefy secretions and replace fluids. Fluid intake of at least 3 L/ day is im. portant in the supportive treatment of pneumonia. If oral intake cannot be maintained, IV administration of fluids and electrolytes may be necessary for the acutely ill patient. Fluid intake must be individualized for patients with heart failure.
A)true
B)false

A

347

An intake of at least 1500 calories per day should be maintained to provide energy for the patient's increased metabolic processes
A)true
B)false

A

348

Nursing diagnoses and interventions for the patient with pneumonia include but are not limited to the following:

,

349

Ineffective breathing pattern, related to inflammatory process and pleuritic pain, a nursing intervention would be? Select all that apply
A)Assess ventilation, including breathing rate, rhythm, and depth; chest expansion; and presence of respiratory distress such as dyspnea, shortness of breath, nasal flaring, pursed-lip breathing, or prolonged expiratory phase and use of accessory muscles.
B)Auscultate lungs for crackles, wheezes, and pleural friction rub.
C)Maintain patient in position that facilitates ventilation (head of bed in semiFowler's position or sitting and leaning forward on overbed table).

A B C

350

lmpaired gas exchange, related to alveolarcapillary membrane changes secondary to inflammation , a nursing intervention would be?select all that apply
A)Assess patient to identify signs (e.g., restlessness, disorientation, and irritability) that may indicate the body's response to altered blood gas states (hypoxia).
B)If necessary and with physician consultation, administer oxygen by nasal cannula or Venturi mask to maintain oxygen saturations above 90%.
C)Carefully monitor body temperature, which may fluctuate due to alterations in metabolism or infection.

A B C

351

Teach the patient and the family about

(1) deep breathing and coughing techniques and the use of an incentive spirometer;
(2) the importance of handwashing to prevent the spread of the disease;
(3) prescribed medications such as antibiotics, including the purpose, action, dosage, frequency of administration, and side effects;
(4) the specific type of pneumonia the patient has, treatment, anticipated response, possible complications, and probable disease duration;
(5) the importance of conswning large quantities of fluid;
(6) adaptive exercise and rest techniques; and
(7) the availability of pneumococcal vaccine

True

352

Health Promotion Pneumonia

,

353

Encourage the individual at risk for pneumonia (e.g., the chronically ill, older adult) to obtain both influenza and pneumococcal vaccines
A)true
B)false

A

354

Turn and reposition the patient at least every 2 hours to facilitate adequate lung expansion and to discourage pooling of secretions
A)true
B)false

A

355

The patient who has difficulty swallowing (e.g., stroke patient) needs assistance in eating, drinking, and taking medication to prevent aspiration.
A)true
B)false

A

356

Aspiration pneumonia can occur as a result of nasogastric tube feedings. Always check for correct placement and keep the head of bed elevated to 30 degrees.
A)true
B)false

A

357

Be careful to avoid overmedication with opioids or sedatives, which can cause a depressed cough reflex and accumulation of fluid in the lungs.
A)true
B)false

A

358

Before providing food or fluids, ensure the gag reflex has returned to the patient who had local anesthesia to the throat.
A)true
B)false

A

359

Life Span Considerations Older Adults Respiratory Disorder

,

360

Generalized signs and symptoms such as lethargy, disorientation, dyspnea, tachypnea, chills, chest pain, and vomiting, as well as an unexpected exacerbation of coexisting conditions, should be viewed with suspicion because they may indicate pneumonia in the older adult
A)true
B)false

A

361

Adequate hydration is important for the older person with pneumonia. It helps liquefy secretions and promotes expectoration
A)true
B)false

A

362

Many older adults have difficulty expectorating. This slows resolution of congestion and increases the difficulty of obtaining sputum specimens. Because deep breathing and coughing are difficult, the older person may require suctioning to remove respiratory secretions. Perform this with caution, since too-frequent suctioning can stimulate increased production of secretions.
A)true
B)false

A

363

Drier mucous membranes and decreased number of cilia affect the older individual's ability to humidify inhaled air and trap debris. This increases the risk for inflammation and irritation of the upper respiratory tract.
A)true
B)false

A

364

Kyphosis and calcification of costal cartilage are common changes. These restrict expansion of the thoracic cavity and lead to a barrel-chested appearance.
A)true
B)falseness

A

365

Intercostal muscles and the diaphragm lose elasticity, resulting in a decreased ability to breathe deeply and cough. -
A)true
B)false

A

366

The elasticity of airways and alveoli decreases, alveoli thicken, and pulmonary blood flow decreases, resulting in an increased risk for impaired gas exchange.
A)true
B)false

A

367

Inactivity and immobility increase the risk of stasis pooling of respiratory secretions. This increases the risk of pneumonia.
A)true
B)false

A

368

PLEURISY

,

369

Pleurisy is an in.flam.mation of the visceral and parietal pleura. Pleurisy can be caused by either a bacterial or viral infection. The underlying physiologic change is an inflammation of any portion of the pleura.
A)PLEURISY
B)false

A

370

more frequently is a complication of pneumonia, pulmonary infarctions, viral infections of the intercostal muscles, pleural trauma, or early stages of TB or lung tumor.
A)PLEURISY
B)false

A

371

One of the first symptoms of pleurisy may be a sharp inspiratory pain, often radiating to the shoulder or abdomen of the affected side. The pain is caused by stretching of the inflamed pleura. If pleural effusion develops, pain subsides and fever and dry cough occur.
A)true
B)false

A

372

Subjective data include the patient's complaint of chest pain on inspiration. The patient may also report an elevated temperature.
A)pleurisy
B)false

A

373

Prescribed medications may include antibiotics (penicillin) to combat the infection and analgesics (meperidine [Demerol] or morphine) to decrease pain when the patient takes deep breaths and coughs. Antipyretics (acetaminophen) are used for fever. Oxygen may be administered.
A)pleurisy
B)false

A

374

Position the patient comfortably on the affected side to splint the chest, and apply heat to the area.
A)pleurisy
B)false

A

375

Nursing diagnoses and interventions for the patient with pleurisy include but are not limited to the following:

,

376

Pain, related to stretching of the pulmonary pleura as a result of fluid accumulation, a nursing intervention would be?select all that apply
A)Assess patient's pain level and need for analgesics; administer as needed, documenting effectiveness
B)Assist with splinting affected side when patient coughs and deep breathes.

A B

377

Impaired gas exchange, related to pain on inspiration and expiration, a nursing intervention would be? Select all that apply
A)Assess patient's level of consciousness, noting any increase in restlessness or disorientation, which may indicate ineffective breathing.
B)Auscultate lungs for wheezes, crackles, and pleural friction rub.
C)Reposition patient every 2 hours to prevent pooling of secretions and to promote optimal lung expansion.
D)Elevate head of bed to facilitate optimal ventilation.

A B C D

378

Teach the patient to effectively cough every 2 hours and to splint the affected side.
A) pleurisy
B)false

A

379

PLEURAL EFFUSION/EMPYEMA

,

380

If the fluid becomes infected, it is called empyema, which is the accumulation of pus in a body cavity, especially the pleural space
A)true
B)false

A

381

In acute empyema the affected area is inflamed with a thin layer of fluid. If this goes untreated, the fluid . thickens and the pleura becomes scarred and fibrosed, losing its elasticity
A)true
B)false

A

382

Pleural effusion is generally associated with other disease processes, such as pancreatitis, cirrhosis of the liver, pulmonary edema, congestive heart failure, kidney disease, or carcinoma involving altered capillary permeability.
A)true
B)false

A

383

Empyema is usually seen as a result of bacterial infection, as in pneumonia, TB, or blunt chest trauma.
A)true
B)false

A

384

Subjective data include patient complaints of dyspnea and air hunger. The patient may also report fear and anxiety related to decreased levels of oxygen.
A)PLEURAL EFFUSION/EMPYEMA
B)false

A

385

Collection of objective data in both pleural effusion and empyema includes assessment of signs and symptoms of respiratory distress, such as nasal flaring, tachypnea, and decreased breath sounds
A)PLEURAL EFFUSION/EMPYEMA
B)false

A

386

Effusions or pleural fluid will be evident on chest radiographic examination
A)true
B)false

A

387

Usually this condition requires a thoracentesis to remove fluid from the pleural space. A possible danger from this procedure is removing fluid too rapidly; less than 1300 to 1500 mL at one time is recommended.
A)PLEURAL EFFUSION/EMPYEMA
B)false

A

388

chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation
A)PLEURAL EFFUSION/EMPYEMA
B)false

A

389

Under normal conditions, intrapleural pressure is below atmospheric pressure
A)true
B)false

A

390

If intrapleural pressure becomes equal to atmospheric pressure, the lungs will collapse.
A)true
B)false

A

391

One catheter is inserted through a stab wound in the anterior chest wall; this is referred to as the anterior tube. It removes air from the pleural space.

The second tube, the posterior tube, is inserted through a stab wound in the posterior chest. It is primarily for the drainage of serosanguineous fluid or purulent exudate.

The posterior (lower) tube may be larger in diameter than the anterior (upper) tube to prevent it from becoming occluded with exudate or clots

True

392

General nursing measures include placing the patient on bed rest. If the patient is receiving oxygen therapy, provide frequent oral care to keep mucous membranes moist. Also encourage effective coughing and deep breathing techniques and respiratory treatments. If the patient has had a thoracentesis, apply a large sterile dressing and assess it for drainage, noting the color and amount.
A)PLEURAL EFFUSION/EMPYEMA
B)false

A

393

A patient with a chest tube in place is usually positioned on the unaffected side to keep the tube from becoming kinked; however, the patient may assume any position of comfort in bed
A)PLEURAL EFFUSION/EMPYEMA
B)false

A

394

There is no contraindication to ambulation with a chest tube in place, as long as the water-seal bottle remains below the level of the chest.
A)true
B)false

A

395

Never elevate the drainage system to the level of the patient's chest, since this would cause fluid to drain back into the pleural cavity.
A)true
B)false

A

396

Facilitate coughing and deep-breathing procedures at least every 2 hours and auscultate breath sounds frequently.
A)true
B)false

A

397

Be careful to keep tubing as straight as possible and coiled loosely. Do not let the patient lie on it. Tubing should never be placed over the side rails.
A) true
B)false

A

398

Nursing diagnoses and interventions for the patient with pleural effusion or empyema include but are not limited to the following:

,

399

lmpaired gas exchange, related to ineffective breathing pattern, a nursing intervention would be?select all that apply
A)Assess for changes in level of consciousness, such as disorientation, restlessness, or irritability, since these may indicate increasing hypoxia as a result of ineffective breathing.
B)Monitor ABGs and pulse oximetry.
C)Encourage coughing and deep breathing to remove secretions and facilitate lung expansion.
D)Assess for atelectasis.
E)Encourage increasing activity level when fever is reduced.

A B C D E

400

Guidelines for Care of Patient with Chest Tubes and Water-Seal Drainage

,

401

Any change in the quantity or characteristics of drainage (e.g., clear yellow to serosanguineous) should be reported to the physician and recorded. Record output on chart.
A)true
B)false

A

402

If bubbling increases, there may be an air leak.
A)true
B)false

A

403

Encourage the patient to breathe deeply periodically to facilitate lung expansion, and encourage range-of-motion exercises to the shoulder on the affected side
A)true
B)false

A

404

Do not strip or milk chest tubes routinely because this increases pleural pressures.
A)true
B)false

A

405

If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal.
A)true
B)false

A

406

Chest tubes are not clamped routinely. Clamps with rubber protection are kept at the bedside for special procedures such as changing the chest drainage system and assessment before removal of chest tubes
A)true
B)false

A

407

ATELECTASIS

,

408

Atelectasis (the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and oxygen) occurs from occlusion of air (blockage) to a portion of the lung.
A)true
B)false

A

409

All or part of the lung collapses, usually as a result of hypoventilation (the condition in which the amount of air that enters the alveoli and takes part in gas exchange is not adequate for the body's metabolic needs), which then leads to bronchial obstruction caused by mucus accumulation
A)ATELECTASIS
B)false

A

410

The patient displays dyspnea, tachypnea (an abnormally rapid rate of breathing), pleural friction rub, restlessness, hypertension, and elevated temperature.
A)ATELECTASIS
B)false

A

411

Subjective data include patient complaints of severe shortness of breath (dyspnea) requiring much effort, which results in fatigue. The patient may also verbalize a feeling of air hunger and resulting anxiety.
A)ATELECTASIS
B)rhinitis

A

412

Objective data include decreased breath sounds and crackles on auscultation. Assess vital signs frequently because tachycardia and hypertension are present at first, followed by hypotension and bradycardia.
A)ATELECTASIS
B)rhinitis

A

413

Serial chest radiographic studies can detect ATELECTASIS
A)true
B)false

A

414

Incentive spirometry 10 times every hour while awake helps provide visual feedback of respiratory effort. Respiratory therapy with oxygen is ordered
A)for patients with ATELECTASIS
B)false

A

415

Prescribed medications may include bronchodilators (albuterol) to facilitate secretion removal, antibiotics to prevent infection, and mucolytic agents (acetylcysteine [Mucomyst]) to reduce viscosity of secretions. A bronchoscope can be used to remove a thick, tenacious secretion or a mucous plug.
A)for a patient with ATELECTASIS
B)false

A

416

Postoperatively, remind patients to cough, breathe deeply, use their incentive spirometer, and change positions every 1 to 2 hours. Effective coughing is . essential in mobilizing secretions.
A)for patients with ATELECTASIS
B)false

A

417

If secretions are present in the respiratory passages, deep breathing and use of the incentive spirometer often will move them up to stimulate the cough reflex, and then they can be expectorated
A)for patients with ATELECTASIS
B)false

A

418

Administer analgesics to relieve pain and increase the patient's ability to carry out respiratory exercises and to clear airway passages. Provide emotional support. Encourage early ambulation.
A)for patients with ATELECTASIS
B)false

A

419

Nursing diagnoses and interventions for the patient
with atelectasis include but are not limited to the
following:

,

420

Ineffective airway clearance, related to inability to dear secretions, a nursing intervention would be?select all the above
A)Assess patient's ability to move secretions, and assist if needed.
B)Encourage use of incentive spirometer 10 times every hour while awake.
C)Encourage coughing and deep breathing every 1 to 2 hours while awake.
D)Encourage adequate hydration to liquefy secretions.
E)Auscultate breath sounds frequently, documenting and reporting any changes.
F)Assess color, consistency, and amount of secretions removed via either coughing or suction.

A B C D E F

421

Ineffective coping, related to invasive medical regimen, a nursing intervention would be?select all the apply
A)Assess the patient's ability to comply with the prescribed regimen and to cooperate with caregivers.
B)Identify patient's emotional support systems.

A B

422

PNEUMOTHORAX

,

423

Pneumothorax is a collection of air or gas in the pleural space, causing the lung to collapse. It can be secondary to a ruptured bleb on the lung surface (as in emphysema) or a severe coughing episode. It can be caused by a penetrating chest injury that punctures the pleural lining, fractured ribs, or injury to the pleura from insertion of a subclavian catheter.
A)PNEUMOTHORAX
B)false

A

424

When the pleural space is penetrated, air enters, thus interrupting the normal negative pressure. Consequently the lung cannot remain fully inflated
A)PNEUMOTHORAX
B)false

A

425

The patient may be seen with a recent chest injury. He or she will have decreased breath sounds on the affected side and a sudden, sharp, pleuritic chest pain with dyspnea. The patient may be diaphoretic and exhibit an increased heart rate, tachypnea, and dyspnea.
A)PNEUMOTHORAX
B)false

A

426

Normal chest movements on the affected side cease. With a pneumothorax resulting from penetrating injury, a sucking soWld is heard on inspiration.
A)true
B)false

A

427

As the intrathoracic pressure increases, cardiac output is altered because of decreased venous return and compression of the great vessels.
A)true
B)false

A

428

Collection of subjective data includes reporting a precipitating respiratory condition such as COPD, a recent penetrating chest injury, or severe coughing episode. The patient may complain of chest pain, shortness of breath of sudden onset, and feelings of anxiety associated with air hWlger.
A)PNEUMOTHORAX
B)false

A

429

Chest radiographic examination shows the presence of pneumothorax.
A)true
B)false

A

430

Surgery may be done to insert a chest tube (thoracotomy). The chest tube is inserted in the fifth and sixth intercostal spaces at the midaxillary line. The chest tube is attached to a water-seal drainage system
A)PNEUMOTHORAX
B)false

A

431

Heimlich valve, which is typically used as a stopgap measure until chest tube therapy can be started. The valve attaches to a chest tube and is inserted into the chest. As the patient exhales, air and fluid drain through the valve into a plastic bag. When the patient inl1ales, however, the flexible tubing in the valve collapses, preventing secretions and air from reentering the pleura.
A)PNEUMOTHORAX
B)false

A

432

Monitor blood pressure and place the patient in a high Fowler's position to promote airway clearance and lung expansion. Control pain by administering appropriate analgesics, but avoid the use of respiratory depressants.
A)a patient with pneumothorax
B)false

A

433

Nursing diagnoses and interventions for the patient
with pneumothorax include but are not limited to the
following:

,

434

Ineffective breathing pattern, related to nonfunctioning lung, a nursing intervention would be?select all that apply
A) Assess respiratory rate and rhythm, and note any signs of respiratory distress, such as dyspnea, use of accessory muscles, nasal flaring, and anxiety.
B)Provide chest tube care, maintaining secure placement.
C)Facilitate ventilation by elevating head of bed, and administer oxygen as ordered.
D)Suction as needed to remove secretions.
E)Encourage adaptive breathing tedmiques to decrease respiratory effort.
F)Encourage rest periods interspersed with activities.

A B C D F

435

Fear, related to feeling of air hunger, a nursing intervention would be?select all that apply
A)Assess patient's feelings of fear related to health concerns and feeling of air hunger.
B)Identify positive coping methods, and support their use.
C)Determine support systems available to patient.

A B C

436

Instruct the patient to limit exposure to people who may have infections, such as upper respiratory tract infection or influenza. Advise . the patient to not smoke but to drink a lot of fluids, to avoid fatigue and strenuous activity, and to report any signs and symptoms of recurrence (e.g., chest pain, dif.ficulty breathing, or fever) to the physician.
A)PNEUMOTHORAX
B)false

A

437

LUNG CANCER

,

438

Approximately 87% of lung tumors are linked to cigarette smoking. A history of smoking, especially for 20 years or more, is considered to be a prime risk factor.
A)LUNG CANCER
B)false

A

439

Occupational exposures, such as asbestos, radon, and uranium, are also risk factors.
A)lung cancer
B)false

A

440

Many studies suggest the importance of certain antioxidant vitamins, especially vitamins A and E, reduce the risk of developing lung cancer
A)true
B)false

A

441

Studies report that an increased intake of fruits; green and yellow vegetables; and perhaps micronutrients such as total carotenoids, beta-carotene, and vitamins can significantly lower the risk of lung cancer in cigarette smokers as well as nonsmokers
A)true
B)false

A

442

If the peripheral lesion perforates the pleural space, pleural effusion and severe pain will occur.
A)true
B)false

A

443

Central lesions originate from a larger branch of the brondtial tree. These lesions cause obstruction and erosion of the bronchus. Signs and symptoms are cough, hemoptysis, dyspnea, fever, and chills. Auscultation may reveal wheezing on the affected side. Phrenic nerve involvement causes paralysis of the diaphragm.
A)lung cancer
B)false

A

444

Subjective data include the patient's complaints of a chrortic cough and of hoarseness. The patient may also . report weight loss and extreme fatigue. Interview the patient regarding a family history, especially a history of cigarette smoking and of exposure to occupational irritants.
A)lung cancer
B)false

A

445

Invasion of the superior vena cava causes edema of the neck and face and is called superior vena cava syndrome.
A)true
B)false

A

446

Chest radiographic studies and spiral CT scan of the chest are used to identify the location and size of the tumor.
A)lung cancer
B)false

A

447

Both a lobectomy and a segmental resection require chest tube insertion with water-seal drainage to facilitate lung reexpansion
A)true
B)false

A

448

Encourage the use of incentive spirometry. Explain the importance of changing position (to prevent atelectasis) and exercising the legs and feet (to prevent deep-vein thrombosis [DVT]). Administer supplemental oxygen and monitor oxygen saturation levels.
A)true
B)false

A

449

If a patient has chest tubes to water-seal drainage, assess for patency, and record the amount, color, and consistency of drainage. Carefully assess lung sounds and record findings. Assess vital signs frequently. After checking routine postoperative vital signs, check the patient every 2 hours until he or she is stable, and then every 4 hours.
A)true
B)false

A

450

Prescribed medications are primarily antineoplastic agents to prevent or reduce tumor growth.
A)true
B)false

A

451

Nursing diagnoses and interventions for the patient
with lung cancer include but are not limited to the
following:

,

452

Ineffective airway dearance, related to lung surgery, a nursing intervention would be?select all that apply
A)FacUitate optimal breathing by placing patient in a sitting position.
B)Assist with position changes frequently.
C)Promote coughing and deep breathing, providing necessary splinting.
D)Encourage early ambulation to mobilize secretions.
E)Encourage use of an incentive spirometer.

A B C D E

453

Fear, related to cancer, treatment, and prognosis, a nursing intervention would be?select all that apply
A)Monitor changes in communication patterns with others. B)Monitor expression of feelings, such as worthlessness, anxiety, powerlessness, abandonment, or exhaustion.
C)Listen and accept expressions of anger without taking it personally.
D)Encourage patient to identify problem, redefine the situation, obtain needed information, generate alternatives, and focus on solutions.

A B C D

454

Teach the patient effective coughing techniques.
A)true
B)false

A

455

Encourage the patient to eat a diet high in protein and calories. Instruct the patient and the family regarding signs and symptoms that could indicate recurrence of metastasis, such as fatigue, weight loss, increased coughing or hemoptysis, central nervous system changes, and arm or shoulder pain
A)lung cancer interventions
B)false

A

456

Home Care Considerations Lung Cancer

,

457

If the patient with lung cancer smokes, teach her or him that stopping smoking can improve pulmonary function, minimize postoperative complications, decrease the risk of pneumonia, and improve appetite during treatment.
A)true
B)false

A

458

Instruct the patient and the family to contact the physician if symptoms such as hemoptysis, dysphagia, chest pain, and hoarseness develop.
A)true
B)false

A

459

PULMONARY EDEMA

,

460

Pulmonary edema is an accumulation of serous fluid in interstitial lung tissue and alveoli resulting from the following (Lewis et a!., 2007):

• Severe left ventricular failure resulting from a weakened myocardium due to a myocardial infarction. The most common cause of pulmonary edema is left-sided heart failure.

• Hypoalbuminemia, hepatic disease, and nutritional disorders.

• Rapid administration of IV fluids (packed red blood cells, plasma, or fluids).

• Altered capillary permeability of lungs: inhaled toxins, inflammation (e.g., pneumonia), severe hypoxia, near drowning.

• Opioid overdose.

,

461

Cardiogenic pulmonary edema usually accompanies underlying cardiac disease in which the failure of the left ventricle causes pooling of fluid to back up into the left atrium and into pulmonary veins and capillaries.
A)true
B)false

A

462

The most common cause of pulmonary edema is increased capillary pressure from left ventricular failure.
A)true
B)false

A

463

The primary signs and symptoms of pulmonary edema are dyspnea and related breathing disturbances. Labored respirations; tachypnea; tachycardia; cyanosis; and, especially, pink (or blood-tinged), frothy sputum are the most obvious signs. The patient may also exhibit restlessness or agitation because of tl1e altered tissue perfusion and resulting hypoxia and respiratory failure.
A)true
B)false

A

464

Collection of objective data involves assessing for signs of respiratory distress, including nasal flaring and sternal retractions with inspiration; rapid, stertorous respirations; hypertension; tachycardia; restlessness; and disorientation. On auscultation the nurse will most likely hear wheezing and crackles
A)PULMONARY EDEMA
B)false

A

465

The patient may have a sudden gain weight because of fluid retention; decreased urinary output as a result of retained fluid in the pulmonary vasculature; and a productive cough of frothy, pink sputum.
A)objective data of pulmonary edema
B)false

A

466

Medications include diuretics to reduce alveolar and systemic edema by increasing urinary output (furosemide [Lasix]).
A)true
B)false

A

467

Patients are also given an opioid analgesic, usually morphine sulfate, to decrease respiratory rate; lower the anxiety level; reduce venous return; and dilate both the pulmonary and systemic blood vessels, thus improving the exchange of gases.
A)true
B)false

A

468

IV nitroprusside (Nipride) is a potent vasodilator that improves myocardial contraction and reduces pulmonary congestion. Because of its effects on the vascular system, it is the drug of choice for the patient with pulmonary edema
A)true
B)false

A

469

This includes assessment of respiratory status and frequent monitoring of cardiac status, I&O, vital signs, ABGs, pulse oximetry, and electrolyte values.
A)nursing intervention of pulmonary edema
B)false

A

470

Facilitate optimal air exchange by placing the patient in a high Fowler's position. Maintain a patent IV line (saline . block) for administering prescribed IV medications. IV fluids are usually withheld to prevent adding even more fluid to the overloaded patient
A)interventions for pulmonary edema
B)false

A

471

Nursing diagnoses and interventions for the patient
with pulmonary edema include but are not limited to
the following:

,

472

Impaired gas exchange, related to excess fluid in pulmonary vessels interfering with oxygen diffusion, nursing intervention would be?select all that apply
A)Be alert to any signs indicating altered ventilation, such as restlessness, irritability, disorientation, or apprehension.
B)Monitor ABGs and notify physician of any change.
C)Frequently monitor vital signs, including cardiac rhythm.
D)Administer oxygen therapy as ordered and document patient response.
E)Administer diuretics, bronchodilators, morphine sulfate, cardiotonic glycosides, and other medications as ordered.

A B C D E

473

Excess fluid volume, related to altered tissue permeability, a nursing intervention would be?select all that apply
A)Assess indicators of patient's fluid volume status, such as breath sounds and skin turgor.
B)Monitor l&O accurately.
C)Monitor electrolyte values closely, and notify physician of alterations
D)Administer diuretics as ordered, and note patient response.
E)Weigh patient daily on same scale at same time of day with same amount of bed linen and patient clothing.
F)Provide low-sodium diet to prevent excess fluid retention.

A B C D E F

474

Instruct the patient and the family about a low-sodium diet and refer them to a dietitian for follow-up. Emphasize the signs and symptoms to observe that would indicate alteration in health, such as productive cough (noting the color and characteristics of sputum), activity intolerance, or dyspnea.
A)intervention for pulmonary edema
B)false

A

475

PULMONARY EMBOLISM

,

476

The most common pulmonary perfusion abnormality, pulmonary embolism (PE), is caused by the passage of a foreign substance (blood clot, fat, air, tumor tissue, or amniotic fluid) into the pulmonary artery or its branches, with resulting obstruction of the blood supply to lung tissue and subsequent collapse.
A)true
B)false

A

477

PE usually occurs in patients identified to be at risk, such as those with prior thrombophlebitis; those who have recently had surgery, been pregnant, or given birth; women who are taking contraceptives on a long-term basis; and those with a history of congestive heart failure, obesity, or immobilization from fracture
A)true
B)false

A

478

Immobilization appears to be a key consideration. For PE
A)true
B)false

A

479

Venous stasis, venous wall injury, and increased coagulability of blood cause the formation of a venous thrombus.
A)true
B)false

A

480

The obstruction hinders oxygenation of the blood. Atelectasis develops, and pulmonary vascular resistance increases. Arterial hypoxia is the result.
A)true for pulmonary embolism
B)false

A

481

The classic signs and symptoms of dyspnea, hemoptysis, and chest pain occur in less than 20% of patients with a PE, making diagnosis difficult
A)true
B)false

A

482

The respiratory rate is rapid. In small areas of infarction, presenting signs and symptoms are a small amount of hemoptysis, pleuritic chest pain, elevated temperature, and increased white blood cell count. In large areas of infarction, symptoms include hypoxia, hemoptysis, hypotension, tachycardia, diaphoresis, and tachypnea.
A)a patient with PE
B)false

A

483

Regional bronchoconstriction, atelectasis, and pulmonary edema develop, along with decreased surfactant production. Lung sounds are diminished, and wheezes may be present.
A)true
B)false

A

484

Also assess breath sounds and vital signs, and be alert for tachycardia, hypotension, and tachypnea. Auscultation reveals crackles, decreased breath sotmds over the affected area, and a pleural friction rub. In assessing the patient's psychological response, document the presence and degree of anxiety, which is often associated with air hunger. Other objective data . may include hemoptysis, elevated temperature, increased white blood cell count, and diaphoresis.
A)objective data for PE
B)false

A

485

ABGs are sigrtificantly altered, indicating hypoxia. Of a patient with PE
A)true
B)false

A

486

Pulmonary angiogram is the gold standard for detecting PE because it provides a direct anatomical view of the pulmonary vessels to assess perfusion defects.
A)true
B)false

A

487

The normal range for o-dimer is 68 to 494 ng/ L. If the o-dimer levels are elevated, a venous ultrasound is indicated to look for a DVT. Positive results from venous ultrasound are helpful in diagnosing DVT.
A)true
B)false

A

488

When multiple PEs are present, an umbrella filter may be placed in the inferior vena cava to retain the emboli, preventing their migration to other parts of the body. y.
A)true
B)false

A

489

The physician prescribes anticoagulant therapy, for example, oral warfarin (Coumadin) or subcutaneous low-molecular-weight heparin (enoxaparin sodium [Lovenox]) or dalteparin (Fragmin), to prevent clot formation.
A)for a patient with PE
B)false

A

490

Heparin does not dissolve an existing thrombus; its role is to keep it from enlarging and to prevent more thrombi from forming while the body's natural fibrinolytic mechanism lyses (destroys red blood cells) the existing clot.
A)for patients with PE
B)false

A

491

nursing interventions include applying thromboembolic disease (TED) stockings and elevating the lower extremities. Check peripheral pulses and frequently measure bilateral calf circumference to monitor for occlusion caused by a dot.
A) patients with PE
B)false

A

492

Slightly elevate the head of the bed, and administer oxygen by mask or nasal cannula to facilitate optimal gas exchange. Promote lung expansion by encouraging the patient to cough and breathe deeply.
A)patient with PE
B)false

A

493

Related nursing interventions include assessing for signs of bleeding: epistaxis, hemoptysis, bleeding from gums or rectum, and ecchymosis.
A)patients with PE
B)false

A

494

Nursing diagnoses and interventions for the patient
with PE include but are not limited to the following:

,

495

Impaired gas exchange, related to alteration in pulmonary vasculature, a nursing intervention would be?select all that apply
A)Assess sensorium and vital signs every 2 hours or as needed, noting any changes indicative of altered oxygenation or ventilation.
B)Elevate head of bed 30 degrees to improve ventilation.
C)Administer oxygen as ordered.
D)Monitor ABGs frequently, reporting any increase or decrease of Paco2 and Pao2 of more than 10 mm Hg

A B C D

496

Ineffective protection, related to risk of prolonged bleeding or hemorrhage secondary to anticoagulation therapy, a nursing intervention would be?select all that apply
A)Monitor vital signs for indicators of profuse bleeding or hemorrhage resulting from anticoagulant therapy: hypotension, tachycardia, and tachypnea.
B)At least once a shift, check stool, urine, sputum, and vomitus for occult blood using agency-approved method for testing
C)At least once a shift, inspect wounds, oral mucous membranes, any entry site of an invasive procedure, and nares for evidence of bleeding
D)To prevent hematoma formation, avoid giving intramuscular injection unless it is unavoidable.
E) Teach patient the necessity of using spongetipped applicators and mouthwash for oral care to minimize the risk of gum bleeding.
F)Instruct patient to shave with an electric rather than a bladed razor.

A B C D E F

497

Teach the patient techniques to reduce venous pooling (which could precipitate thrombophlebitis), such as changing positions and wearing nonrestrictive clothing.
A)true
B)false

A

498

Tell the patient to avoid crossing the legs while sitting or lying down and also to avoid standing in one place for a prolonged period, since these activities increase venous pooling.
A)true
B)false

A

499

Teach the rationale and application procedure for TED hose. Explain that the patient should put them on in the morning before getting out of bed.
A)true
B)false

A

500

Instruct the patient and the family on signs and symptoms of PE to report to the physician, such as chest pain; dyspnea; and blood-tinged sputum or blood in the urine, which could result from anticoagulant therapy.
A)true
B)false

A

501

ACUTE RESPIRATORY DISTRESS SYNDROME

,

502

Acute respiratory distress syndrome (ARDS) is not a disease but a complication that occurs as a result of other disease processes.
A)ACUTE RESPIRATORY DISTRESS SYNDROME
B)false

A

503

Possible causes include viral or bacterial pneumonia, chest trauma, pulmonary contusion, aspiration, inhalation injury, near drowning, fat emboli, sepsis, or any type of shock
A)ACUTE RESPIRATORY DISTRESS SYNDROME
B)false

A

504

ARDS is characterized by pulmonary artery hypertension, which results from vasoconstriction.
A)true
B)false

A

505

ARDS manifests 12 to 24 hours after injury, resulting in lung tissue damage or hypovolemic shock; 5 to 10 days after sepsis development, the patient experiences respiratory distress with altered breath sounds.
A)true
B)false

A

506

The medical plan focuses on supportive treatment by maintaining adequate oxygenation and treating the cause: drug overdose, infections, or inhaled toxins
A)true for patients with ARDS
B)flase

A

507

Medications commonly used to treat associated conditions include corticosteroids, antibiotics, vasodilators like nitroprusside, bronchodilators, mucolytics, and diuretics to treat pulmonary edema, aiding in restoring lung tissues to their normal structure and function
A)patient with ARDS
B)false

A

508

Morphine sulfate is commonly given to sedate restless patients and decrease respiratory rate.
A)patient with ARDS
B)false

A

509

Positive endexpiratory pressure is the most important ventilator treatment component for the patient with ARDS.
A)true
B)false

A

510

The goal of nursing interventions is to provide adequate oxygenation and ventilation and to treat the multisystem responses caused by ARDS.
A)true
B)false

A

511

To improve gas exchange, frequently reposition the patient from side to side, thus preventing one region of the lung from being in a dependent position for prolonged periods
A)patient with ARDS
B)false

A

512

Studies suggest some people with ARDS demonstrate a marked improvement in Pao2 when turned from the supine to prone position. Not all patients respond to prone positioning
A)true
B)false

A

513

Also, an accurate, ongoing assessment of cardiac function is important. Be alert for and document any rate or rhythm changes.
A)for patient with ARDS
B)false

A

514

Nursing diagnoses and interventions for the patient with ARDS include but are not limHed to the
following:

,

515

Impaired gas exchange, related to tachypnea, a nursing intervention would be?select all that apply
A)Monitor ABGs and report any changes.
B)Address any factors that would contribute to restlessness and anxiety, since they increase the body's oxygen demand and exacerbate the patient's already serious condition.
C)Administer oxygen as ordered, assessing and recording patient response.
D)Monitor electrocardiogram (ECG) changes.
E)Report any changes in vital signs and any change in patient's response, no matter how small or gradual.

A B C D E

516

Ineffective breathing pattern, related to respiratory distress, a nursing intervention would be?select all that apply
A)Assess respiratory rate, rhythm, and effort, being alert to signs of dyspnea.
B)Facilitate optimal ventilation by proper positioning
C)Maintain airway patency by encouraging frequent coughing and deep breathing, if able, or suctioning as needed

A. B C

517

Teach the patient effective breathing techniques, emphasizing the importance of frequent position changes, coughing, and deep breathing
A)for patient with ARDS
B)false

A

518

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

,

519

COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. It is a chronic respiratory condition . that obstructs the flow of air to or from the patient's bronchioles.
A)true
B)false

A

520

COPD includes emphysema, chronic bronchitis, asthma, and bronchiectasis. All these diseases are characterized by chronic airflow limitation.
A)true
B)false

A

521

EMPHYSEMA

,

522

emphysema is primarily an alveolar disease
A)EMPHYSEMA
B)false

A

523

Emphysema is an abnormal permanent enlargement of the alveoli distal to the terminal bronchioles, accompanied by destruction of their walls.
A)true
B)false

A

524

Cigarette smoking is by far the most common cause of emphysema and chronic bronchitis; 90% of COPD cases are caused by smoking, whereas as few as 25% of smokers develop the disorder.
A)true
B)false

A

525

COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation.
A)true
B)false

A

526

Cor pulmonale results in edema in the lower extremities and in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. Cor pulmonale is a late complication of emphysema.
A)true
B)false

A

527

The primary symptom of emphysema is dyspnea on exertion, which becomes progressively more severe. Eventually dyspnea occurs at rest.
A)true
B)false

A

528

The patient evenhtally appears barrel chested (an increased anteroposterior diameter caused by overinflation) and begins using accessory muscles for breathing
A)emphysema
B)false

A

529

Spontaneous pursed-lip breathing and chronic weight loss with emaciation ensue occurs with emphysema
A)true
B)false

A

530

Collection of objective data includes assessment of presenting signs, such as tachycardia, tachypnea, orthopnea, peripheral cyanosis, and clubbing of fingers. The most outstanding feature of clubbing is a lateral and longitudinal curvature of the nails accompanied by soft tissue enlargement, presenting a bulbous (bulb shaped), shiny appearance
A)patient with emphysema
B)false

A

531

therapeutic position for the patient with COPD is to lean forward with the head tilted and the arms resting on the patient's legs or a table.
A)tripod position true
B)false

A

532

Expiration is prolonged as the patient forces his or her breath out through obstructed airways
A)occurs with emphysema
B)false

A

533

ABGs are usually assessed in the severe stages and are monitored in hospitalized patients with acute exacerbations
A)patient with emphysema
B) false

A

534

The medical plan includes long-term management -with home oxygen therapy and chest physiotherapy as needed
A)patient with emphysema
B)false

A

535

Prescribed medications include bronchodilators such as beta-adrenergic agonists (e.g., short-acting albuterol and long-acting inhaled salmeterol [Serevent]) or the-ophyllines. Anticholinergics such as ipratropium (Atrovent) are also effective bronchodilators
A)true for emphysema
B)false

A

536

Bronchodilators enlarge the bronchioles for greater oxygenation and ease of secretion clearance, and corticosteroids decrease pulmonary inflammation and obstruction
A)true for emphysema
B)false

A

537

Corticosteroids are usually prescribed only during an acute exacerbation because of the many side effects seen in long-term steroid therapy.
A)true
B)false

A

538

Diuretics assist with fluid removal.
A)patient with emphysema
B)false

A

539

Carefully monitor the patient with COPD because of the increased risk for respiratory failure from central nervous system depressants. Careful evaluation for hypoxemia is necessary before a central nervous system depressant is prescribed
A)true
B)false

A

540

Nursing interventions are directed toward decreasing the patient's anxiety and promoting optimal air exchange
A)emphysema
B)false

A

541

Such measures include elevating the head of the bed and administering low-flow (1 to 2 L by nasal cannula) oxygen as ordered. This is extremely important for COPD patients because a higher flow of oxygen delivery can be dangerous, since it diminishes the brain's respiratory (regulatory) center and can cause respiratory failure.(the brain pons regulate off of CO2 instead of oxygen due to emphysema)
A)true
B)false

A

542

Avoid use of respiratory depressants to ensure adequate alveolar ventilation.
A)true for patient with emphysema
B)false

A

543

Assist with chest physiotherapy, which includes percussion, vibration, and postural drainage. All three techniques help loosen secretions to be expectorated; sometimes it takes several hours after chest physiotherapy before the patient can expectorate loosened secretions.
A)true
B)false

A

544

Increasing oral intake of fluids liquefies secretions, thus aiding in their removal. Additionally, the use of a humidifier enhances this process. Allow sufficient rest periods and assist the patient in activities of daily living to prevent a decrease in oxygen saturation levels.
A)true for patient with emphysema
B)false

A

545

Assist the patient in maintaining nutritional intake by advising rest for 30 minutes before eating. This conserves energy and decreases dyspnea.
A)true for patient with emphysema
B)false

A

546

The patient with emphysema has a markedly increased need for protein and calories to maintain an adequate nutritional status. A high-protein, high-calorie diet should be divided into five or six small meals a day.
A)for patient with emphysema
B)false

A

547

Oral fluid intake should be 2 to 3 L/ day unless contraindicated (e.g., because of congestive heart failure). Instruct the .patient to drink fluids between meals, rather than with meals, to reduce gastric distention and pressure on the diaphragm.
A)true for patients with emphysema
B)false

A

548

The use of nicotine replacement therapy and the newer, nonnicotine medication bupropion (Zyban) may minimize the effects of nicotine withdrawal.
A)patient with emphysema who smoked
B)false

A

549

The patient with COPD should have a vaccination with influenza virus vaccine yearly and a pneumococcal revaccination every 5 years.
A)true for patient with emphysema because of the fluid lining the outside barrier of the lungs
B)false

W

550

Nursing diagnoses and interventions for the patient
with emphysema include but are not limited to the
following:

,

551

Ineffective airway clearance, related to narrowed bronchioles, a nursing intervention would be?select all that apply
A)Assess patient's ability to mobilize secretions, intervening as needed.
B)Encourage coughing and deep breathing, frequent position changes, and increased oral intake (up to 2 to 3 L/ day).
C)Elevate head of bed; suction as needed.
D)Assist with respiratory treatments.
E)Auscultate lungs, and report any changes in lung sounds.

A B C D E

552

Activity intolerance, related to imbalance between oxygen supply and demand, secondary to inefficient work of breathing, a nursing intervention would be? Select all that apply
A)Organize care so that periods of activity are interspersed with at least 90 minutes of undisturbed rest.
B)Assist patient with active range-of-motion exercises to build stamina and prevent complications of decreased mobility.
C)Monitor patient's respiratory response to activity. Activity intolerance is indicated by excessively increased respiratory rate (e.g., increased more than 10 breaths/ min above patient's baseline) and depth, dyspnea, and use of accessory muscles of respiration.

A B C

553

Instruct the patient and the family on
(1) the importance of not smoking and of reducing exposure to other inhaled irritants,
(2) effective breathing techniques (such as pursed-lip breathing), and
(3) relaxation exercises for anxiety control.
A)true for patient with emphysema
B)false

A

554

Emphysema is usually irreversible
A)true
B)false

A

555

Home Care Considerations Chronic Oxygen Therapy at Home

,

556

-The longer the continuous daily use of oxygen is maintained, the greater the improvement.

-Do not use electric razors, portable radios, open flames, wool blankets, or mineral oils in the area where oxygen is in use.

• Do not allow smoking in the home.

True

557

CHRONIC BRONCHITIS

,

558

Chronic bronchitis is characterized by a recurrent or chronic productive cough for a minimum of 3 months a year for at least 2 years. It is caused by physical or chemical irritants and recurrent lung infections.
A)true
B)false

A

559

Cigarette smoking is by far the most common cause of chronic bronchitis.
A)true
B)false

A

560

The underlying process is an impairment of cilia, so they can no longer move secretions.
A)chronic bronchitis
B) false

A

561

The lining of the bronchial tubes becomes inflamed and eventually scarred. The patient cannot clear tenacious mucus and it becomes a medium for bacteria and infection.
A) chronic bronchitis
B)false

A

562

This increased airway resistance leads to bronchospasm. The condition results in an altered oxygen-carbon dioxide exchange, hypoxia (an inadequate, reduced tension of cellular oxygen), and hypercapnia (greater than normal amounts of carbon dioxide in the blood).
A)chronic bronchitis
B) false

A

563

Primary signs include a productive cough, most pronounced in the mornings (this is often overlooked by cigarette smokers). The patient also has increased dyspnea and use of accessory muscles.
A)chronic bronchitis
B)false

A

564

A complication of chronic bronchitis is cor pulmonale, which is hypertrophy of the right side of the heart resulting from pulmonary hypertension
A)true
B)false

A

565

Cyanosis develops, often accompanied by right ventricular failure
A)chronic bronchitis
B)false

A

566

The patient with chronic bronchitis often has a characteristic reddish blue skin (resulting from chronic hypoxia, which stimulates erythropoiesis, thus resulting in polycythemia, cyanosis, and dependent edema).
A)true
B)false

A

567

Collection of objective data includes assessing the patient's productive cough, noting characteristics and amount of sputum. Assess the severity of dyspnea and . presence of wheezing, and note the patient's level of restlessness. Also, when checking vital signs, pay special attention to tachycardia, tachypnea, and elevated temperature.
A)chronic bronchitis
B)false

A

568

Chest radiographs taken early in the disease may not show abnormalties; later in the disease they will. An ECG may be normal or show signs indicative of right ventricular failure. An echocardiogram can be used to evaluate right and left ventricular function.
A)chronic bronchitis
B)false

A

569

To reverse bronchospasm, the health care provider may order beta-adrenergic agonists such as short-acting albuterol and long-acting salmeterol.
A)true for patient with chronic bronchitis
B)false

A

570

Corticosteroids are helpful in reducing airway inflammation. Long-term use of systemic steroids can lead to many adverse reactions, including osteoporosis.
A)true for patients whit chronic bronchitis
B)false

A

571

Inhaled steroids have fewer systemic effects and are preferred.
A)for chronic bronchitis
B)false

A

572

Antibiotic agents (erythromycin) are commonly ordered.
A)chronic bronchitis
B)false

A

573

Provide adequate hydration to liquefy secretions and aid in their removal. Suction the patient as needed, and provide low-flow oxygen to maintain Sao2 above 90%. Offer frequent oral hygiene and provide rest periods. The nutritional needs are similar to those of the patient with emphysema.( high protien and caloric intake)
A)true for chronic bronchitis
B)false
B)false

A

574

Nursing diagnoses and interventions for the patient with chronic bronchitis include but are not limited to the following:

,

575

lneffective breathing pattern, related to retained pulmonary secretions , a nursing intervention would be?select all that apply
A)Assess degree of dyspnea, noting nasal flaring, sternal retractions, and pursed-lip breathing.
B)Instruct on effective breathing techniques. C)Suction as needed

A B C

576

Fatigue, related to increased respiratory effort, a nursing intervention would be?select all that apply.
A)Assess degree of fatigue, and use problem-solving techniques with patient to explore ways to decrease fatigue.
B) Provide treatments in calm, unhurried manner.
C)Identify support systems and provide referrals if needed.
D)Encourage adequate periods of rest.

A B C D

577

Stress the importance of increasing fluid intake, unless contraindicated
A)true for chronic bronchitis
B)false

A

578

ASTHMA

,

579

Asthma is a broad clinical syndrome and an airway pathologic condition. It involves episodic increased tracheal and bronchial responsiveness to various stimuli, resulting in widespread narrowing of the airways.
A)true
B)false

A

580

Asthma usually improves either spontaneously or with treatment. It is classified as extrinsic or intrinsic.
A)true
B)false

A

581

Extrinsic means it is caused by external factors, such as environmental allergens (pollen, dust, feathers, animal dander, foods, etc.);
A)true
B)false

A

582

intrinsic asthma is from internal causes, not fully understood but often triggered by respiratory tract infection
A)true
B)false

A

583

Asthma can result from an altered immune response or increased airway resistance and altered air exchange. Gastroesophageal reflux disease (GERD) can trigger an asthma attack
A)true
B)false

A

584

Mild asthma is manifested by dyspnea on exertion and wheezing. Symptoms are usuaLly controlled by medications.
A)true
B)false

A

585

An acute asthma attack usually occurs at night and includes tachypnea, tachycardia, diaphoresis, chest tightness, cough, expiratory wheezing, use of accessory muscles, and nasal flaring
A)true
B)false

A

586

The wheezing sound characteristic of asthma is caused by air forcing its way through the narrowed bronchioles and by vibrating mucus
A)true
B)false

A

587

The patients also has increased anxiety; diaphoresis; and a productive cough of copious, thick mucus. Asthma can be triggered by external factors (e.g., dust, mold, or lint) or precipitated intrinsically by a respiratory tract infection or exercise.
A)true
B)false

A

588

Status asthmaticus is a severe, unrelenting, lifethreatening attack that fails to respond to usual treatment and places the patient at risk for respiratory failure. Symptoms of an acute attack are present, and the trapped air leads to exhaustion and respiratory failure. An axiom describes status asthmaticus: "The longer it lasts, the worse it gets, and the worse it gets, the longer it lasts"
A) true
B)false

A

589

Subjective data include complaints of anxiety, fear of suffocation, breathlessness, chest tightness, and cough, particularly at night and in the early morning
A)asthma
B)false

A

590

Collection of objective data includes assessing for signs of hypoxia, which may include restlessness, inappropriate behavior, increased pulse and blood pressure, and tachypnea. The patient may assume a "hunched forward" position in an attempt to get more air. Auscultate the lungs for inspiratory and expiratory wheezing. Coughing produces thick, stringy mucus
A)asthma
B)false

A

591

To diagnose asthma, the physician orders ABGs and PFTs. The chest radiographic examination reveals lung hyperinflation related to air trapping, and a flat diaphragm related to increased intrathoracic volume.
A)true
B)false

A

592

Medication management of asthma can be placed in two categories: maintenance therapy and acute (or rescue) therapy.
A)true
B)false

A

593

Maintenance therapy prevents and minimizes symptoms; the medications are taken on a regular basis. These include the long acting betaTagonist salmeterol and formoterol (Foradil), which are used prophylactically only; inhaled corticosteroids, such as fluticasone; cromolyn; and theophylline. A combination of fluticasone and salmeterol (Advair Diskus) is also sometimes prescribed.
A) asthma
B)false

A

594

Leukotrienes are chemicals present in the body that are powerful bronchoconstrictors and vasodilators; some also cause airway edema and inflammation, thus contributing to the symptoms of asthma
A)true
B) false

A

595

The two types of leukotriene modifiers are leukotriene receptor antagonists (zafirlukast, montelukast) and leukotriene synthesis inhibitors (zileuton [Zyflo]). These drugs interfere with the synthesis or block the action of leukotrienes.
A) true
B)false

A

596

Acute (or rescue) therapy works immediately to relieve symptoms of an asthma attack. The drugs involved include short-acting inhaled beta-2 agonist albuterol, metaproterenol (Alupent, Metaprel), and pirbuterol (Maxair) taken by a metered dose inhaler using spacer devices or by a nebulizer; oral or IV corticosteroids; and epinephrine.
A)true
B) false

A

597

Epinephrine, given subcutaneously or intramuscularly, may be considered in an emergency when symptoms have not been relieved by the use of a betaragonist.
A)asthma patients
B)false

A

598

Severe, persistent asthma is characterized by a peak flow of less than 60% of the value predicted.
A) true
B)false

A

599

A severe, life-threatening exacerbation of asthma is characterized by a peak flow of less than 50% of the patient's predicted value
A)true
B)false

A

600

Normal peak flow is 80% to 100% of the value predicted for the patient based on height, weight, age, and sex. A device that measures normal peak flow on expiration of a patients
A)true
B)false

A

601

To accomplish these goals, incorporate rest periods into activities and interventions; elevate the head of the bed; teach effective breathing techniques, such as pursed-lip breathing and correct use of the peak flowmeter; and provide oxygen therapy as ordered. Morutor vital signs and electrolytes. Kind and . empathic emotional support is vital.
A)asthma intervention
B)false

A

602

Nursing diagnoses and interventions for the patient with asthma include but are not limHed to the following:

,

603

Ineffective breathing pattern, related to narrowed airway, a nursing intervention would be? Select all that apply
A)Assess ventilation, and be alert for signs of increasing dyspnea, such as using accessory muscles, nasal flaring, dyspnea, pursed-lip breathing, or prolonged expiration.
B)Maintain position to facilitate ventilation.
C)Administer prescribed medications
D)Assist with administration of respiratory treatments.
E)Provide care in calm, unhurried manner. F)Attempt to minimize exposure to dust and other irritants by maintaining clean environment and use of humidifier.
G)Maintain adequate hydration.

A B C D E F G

604

Ineffective health maintenance, related to possible allergens in the home, a nursing intervention would be?select all that apply
A)Implement mutual problem solving to explore with patient and family what stimulants may be in home environment, such as allergens.
B)Facilitate allergy testing if needed.
C)Teach the patient and the family importance of avoiding exposure to known irritants.

A B C

605

BRONCHIECTASIS

M

606

Bronchiectasis is a disease characterized by abnormal permanent dilation of one or more large bronchi This dilation eventually destroys muscular elements and bronchial elastic that support the bronchial wall
A)true
B)false

A

607

This condition is usually secondary to failure of normal lung tissue defenses (as caused by cystic fibrosis, foreign body, or tumor). It occurs as a complication of recurrent inflammation and infection process that gradually alters the pulmonary structures.
A)Bronchiectasis
B)asthma

A

608

Signs and symptoms occur after a respiratory tract infection. The late signs and symptoms usually seen are dyspnea, cyanosis, and clubbing of fingers. The patient has paroxysms of coughing on arising in the morning and when lying down. This severe coughing . produces copious amounts of foul-smelling sputum. -Fatigue, weakness, and a loss of appetite are also noted.
A)Bronchiectasis
B)asthma

A

609

Subjective data include the patient's report of difficulty breathing, weight loss, and fever.
A)Bronchiectasis
B)asthma

A

610

Objective data include fine crackles and wheezes in the lower lobes on auscultation. The patient exhibits a prolonged expiratory phase and increased dyspnea. Hemoptysis is seen in 50% of the patients.
A)Bronchiectasis
B)asthma

A

611

Diagnostic Tests Chest radiographic examination
A)Bronchiectasis
B)false

A

612

Medical management of bronchiectasis involves treatment of exacerbations with antibiotics
A)Bronchiectasis
B)false

A

613

Oxygen may be ordered at low-flow volume. The patient may require surgery if he or she does not respond to more conservative measures, such as medications, chest physiotherapy, and adequate hydration. If surgery is needed, the affected area is removed (lobectomy). Medications also include mucolytic agents (acetylcysteine) and bronchodilators.
A)Bronchiectasis
B)false

A

614

General nursing interventions include using a cool mist vaporizer to provide humidity and increasing oral intake of fluids to aid in secretion removal. Assess vital signs and lung sounds every 2 to 4 hours. Suction the patient as needed and provide assistance in turning, coughing, and deep breathing every 2 hours. Assist with chest physiotherapy.
A)Bronchiectasis
B)false

A

615

Nursing diagnoses and interventions for the patient with bronchiectasis include but are not limited to the following:

,

616

Ineffective airway clearance, related to retained pulmonary secretions, a nursing intervention would be?select all that apply
A)Assess patient's ability to mobilize secretions, assisting as needed.
B)Encourage postural drainage and coughing; suction if needed.
C)Encourage frequent position changes to facilitate secretion mobility and removal
D)Maintain adequate hydration.
E)Administer mucolytic agents as ordered, and note patient response.

A B C D E

617

Impaired physical mobility, related to decreased exercise tolerance, a nursing intervention would be? Select all that apply
A)Assess patient's activity tolerance, and promote adaptive techniques, such as incorporating rest periods into activities. B)Promote a gradual increase of activity, noting patient tolerance.
C)Problem solve with patient and family to identify methods of energy conservation and ways to integrate them into lifestyle

A B C

618

Nursing Diagnosis

,

619

• Ineffective airway clearance
• Ineffective breathing pattern
• Impaired gas exchange
• Anxiety
• Activity intolerance
• Imbalanced nutrition: less than body requirements

True

620

The overall goals are that the patient with a respiratory disorder will have
(1) effective breathing patterns,
(2) adequate airway clearance,
(3) adequate oxygenation of tissues, and
(4) a realistic attitude toward compliance to treatment.

True

621

Extra Information

,

622

The most important structure of the respiratory system is the alveolus, where actual air exchange occurs.
A)true
B)false

A

623

Activity tolerance is frequently altered as a result of decreased oxygenation-ventilation.
A)true
B)false

A

624

Anxiety can exacerbate pulmonary disorders, increasing the body's need for oxygen.
A)true
B)false

A

625

Nursing interventions after thoracic surgery that assist in preventing complications by promoting effective airway clearance are
(1) frequent repositioning,
(2) coughing, and
(3) deep breathing.

True

626

Studies have revealed that hypoxia worsens when patients are placed on their backs or sides with the affected (sick) lung down.
A)true
B)false

A

627

Low-flow oxygen therapy is required for patients with COPD because higher oxygen concentrations depress the body's own respiratory regulatory centers.
A)true
B)false

A

628

Because PE impairs gas exchange, its hallmark is acute, unexplained dyspnea with abrupt, constant, nonradiating pain that worsens with inspiration.
A)true
B)false

A

629

COPD includes emphysema, chronic bronchitis, asthma, and bronchiectasis
A)true
B)false

A

630

Transmission of TB is primarily by inhalation of minute droplet nuclei (each containing a single tubercle bacillus) coughed or sneezed by a person whose sputum contains tubercle bacilli
A)true
B)false

A

631

Areas of the body that are involved in gas exchange are brain, lungs, mouth and heart
A)true
B)false

A

632

List five causes of pulmonary edema listed in the text
1)severe left ventricular failure
2)left sided heart failure
3)hypoalbuminmia, hepatic disease
4)rapid administration of IV FLUIDS
5)inhaled toxics and severe hypoxia

True

633

The primary manifestation of nasal septal deviations and polyps include _________ respirations, dyspena and possible postnasal drip.
A)stertorous
B)crackling

A

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