Lower Respiratory Disease Part 1
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
a. Oxygen saturation is 88%.
b. Blood pressure is 145/90 mm Hg.
c. Respiratory rate is 22 breaths/minute when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS: a. Oxygen saturation is 88%.
Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?
a. Blood pressure (BP) is less than 140/90 mm Hg.
b. Patient reports decreased exertional dyspnea.
c. Heart rate is between 60 and 100 beats/minute.
d. Patient's chest x-ray indicates clear lung fields.
ANS: b. Patient reports decreased exertional dyspnea.
Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective
A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to
a. avoid all intranasal sprays and oral antihistamines
b. limit the usage of nasal decongestant spray to 10 days
c. use oral decongestants at bedtime to prevent symptoms during the night
d. keep a diary of when the allergic reaction occurs and what precipitates it
d. keep a diary of when the allergic reaction occurs and what precipitates it
Rationale: An important intervention involves identifying and avoiding triggers of allergic reactions. The nurse should instruct the patient to keep a diary of times when the allergic reaction occurs and of the activities that precipitate the reaction.
The major advantage of a Venturi mask is that it can
a. deliver up to 80% O2.
b. provide continuous 100% humidity.
c. deliver a precise concentration of O2.
d. be used while a patient eats and sleeps.
Correct answer: c. deliver a precise concentration of O2.
Rationale: The Venturi mask is a high-flow device that delivers fixed concentrations of O2 (e.g., 24% or 28%, independent of the patient's respiratory pattern).
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
a. Purpose of antibiotic therapy
b. Ways to limit oral fluid intake
c. Appropriate use of cough suppressants
d. Safety concerns with home oxygen therapy
ANS: c. Appropriate use of cough suppressants
Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative.
ANS: d. Three sputum smears for acid-fast bacilli are negative.
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
a. Yellow-tinged skin
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices
ANS: a. Yellow-tinged skin
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider
Which nursing action would be of highest priority when suctioning a patient with a tracheostomy?
a. Auscultating lung sounds after suctioning is complete
b. Providing a means of communication for the patient during the procedure
c. Assessing the patient's oxygenation saturation before, during, and after suctioning
d. Administering pain and/or antianxiety medication 30 minutes before suctioning
c. Assessing the patient's oxygenation saturation before, during, and after suctioning
Rationale: A patient with a tracheostomy is at risk for hypoxemia during and after suctioning. Patients should always be pre-oxygenated with 100% FIO2 prior to suctioning. In addition, it is imperative to monitor the patient's O2 status before, during, and after suctioning.
In evaluating an asthmatic patient's knowledge of self-care, the nurse recognizes that additional instruction is needed when the patient says,
a. "I use my corticosteroid inhaler when I feel short of breath."
b. "I get a flu shot every year and see my HCP if I have an upper respiratory tract infection."
c. "I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies."
d. "I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath."
Correct answer: a. "I use my corticosteroid inhaler when I feel short of breath."
Rationale: A rescue plan for patients with asthma includes taking two to four puffs of a short-acting bronchodilator every 20 minutes three times to obtain rapid control of symptoms. Corticosteroids cannot abort an acute asthma attack.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
a. "Is there any family history of TB?"
b. "How long have you lived in the United States?"
c. "Do you take any over-the-counter (OTC) medications?"
d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"
ANS: d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"
Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
a. Paradoxic chest movement
b. Complaint of chest wall pain
c. Heart rate of 110 beats/minute
d. Large bruised area on the chest
ANS: a. Paradoxic chest movement
Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
a. Standard four-drug therapy for TB
b. Need for annual repeat TB skin testing
c. Use and side effects of isoniazid (INH)
d. Bacille Calmette-Guérin (BCG) vaccine
ANS: c. Use and side effects of isoniazid (INH)
The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection
When planning health care teaching to prevent or detect early head and neck cancer, which people would be the priority to target (select all that apply)?
a. 65-year-old man who has used chewing tobacco most of his life
b. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle
c. 21-year-old college student who drinks beer on weekends with his fraternity brothers
d. 78-year-old woman who has been drinking hard liquor since her husband died 15 years ago
e. 22-year-old woman who has been diagnosed with human papilloma virus (HPV) of the cervix
a. 65-year-old man who has used chewing tobacco most of his life
b. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle
d. 78-year-old woman who has been drinking hard liquor since her husband died 15 years ago
e. 22-year-old woman who has been diagnosed with human papilloma virus (HPV) of the cervix
Rationale: Eighty five percent of head and neck cancers are caused by tobacco use. Excessive alcohol consumption is also a major risk factor. Head and neck cancers in people younger than 50 years of age have been associated with human papillomavirus (HPV) infection. Sun exposure is also a risk factor
A patient with asthma has the following arterial blood gas (ABG) results early in an acute asthma attack: pH 7.48,
PaCO2 30 mm Hg, PaO2 78 mm Hg. What is the most appropriate action by the nurse?
a. Prepare the patient for mechanical ventilation.
b. Have the patient breathe in a paper bag to raise the PaCO2
c. Document the findings and monitor the ABGs for a trend toward alkalosis.
d. Reduce the patient's oxygen flow rate to keep the PaO2
at the current level.
c. Document the findings and monitor the ABGs for a trend toward alkalosis.
Early in an asthma attack, an increased respiratory rate and hyperventilation create a respiratory alkalosis with increased pH and decreased PaCO2, accompanied by hypoxemia. As the attack progresses, pH shifts to normal,
then decreases, with arterial blood gases (ABGs) that reflect respiratory acidosis with hypoxemia. During the attack, high-flow oxygen should be provided. Breathing in a paper bag, although used to treat some types of hyperventilation, would increase the hypoxemia.
What is the pathophysiologic mechanism of cystic fibrosis leading to obstructive lung disease?
a. Fibrosis of mucous glands and destruction of bronchial walls
b. Destruction of lung parenchyma from inflammation and scarring
c. Production of secretions low in sodium chloride and therefore thickened mucus
d. Increased serum levels of pancreatic enzymes that are deposited in the bronchial mucosa
c. Production of secretions low in sodium chloride and therefore thickened mucus
Cystic fibrosis (CF) is an autosomal recessive, multi-system disease involving altered transport of sodium and chloride ions in and out of epithelial cells, which affects the lungs, pancreas, and sweat glands. Abnormally thick, abundant secretions from mucous glands lead to a chronic, diffuse, obstructive pulmonary disorder in almost all patients, whereas exocrine pancreatic insufficiency
occurs in about 85% to 90% of patients with CF.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
ANS: b. 400 mL of blood in the collection chamber
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?
a. Milk the chest tube gently to remove any clots.
b. Clamp the chest tube momentarily to check for the origin of the air leak.
c. Assist the patient to deep breathe, cough, and use the incentive spirometer.
d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
ANS: d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy
A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply)
a. antiviral agents to treat influenza
b. treatment with antibiotics starting ASAP
c. a throat culture or rapid strep antigen test
d. supportive care, including cool, bland liquids
e. comprehensive history to determine possible etiology
c. a throat culture or rapid strep antigen test
d. supportive care, including cool, bland liquids
e. comprehensive history to determine possible etiology
Rationale: The goals of nursing management are infection control, symptom relief, and prevention of secondary complications. Drugs are not prescribed until the etiology is known. Unnecessary use of antibiotics leads to the development of antibiotic-resistant organisms. A thorough history and a throat culture help identify the cause. The nurse should encourage the patient with pharyngitis to increase fluid intake. Cool, bland liquids and gelatin do not irritate the pharynx; citrus juices are often irritating.
Priority Decision: Which medication should the nurse anticipate being used first in the emergency department for
relief of severe respiratory distress related to asthma?
a. Prednisone orally
b. Tiotropium inhaler
c. Fluticasone inhaler
d. Albuterol nebulizer
d. Albuterol nebulizer
The albuterol nebulizer will rapidly cause bronchodilation and be easier to use in an emergency situation than an inhaler. It will be used every 20 minutes to 4 hours as needed. The ipratropium inhaler could be used if the patient does not tolerate the short-acting β2-adrenergic
agonists (SABA) but its onset is slower than albuterol. Inhaled or oral corticosteroids will be used to decrease the inflammation and provide better symptom control after the emergency situation is over.
During an acute exacerbation of mild COPD, the patient is severely short of breath and the nurse
identifies a nursing diagnosis of ineffective breathing pattern related to alveolar hypoventilation and anxiety. What is the best action by the nurse?
a. Prepare and administer routine bronchodilator medications.
b. Perform chest physiotherapy to promote removal of secretions.
c. Administer oxygen at 5 L/min until the shortness of breath is relieved.
d. Position the patient upright with the elbows resting on the over-the-bed table.
d. Position the patient upright with the elbows resting on the over-the-bed table.
The tripod position with an elevated backrest and supported upper extremities to fix the shoulder girdle maximizes respiratory excursion and an effective breathing pattern. Staying with the patient and encouraging pursed lip breathing also helps. Bronchodilators may help but can also
increase nervousness and anxiety; rescue inhalers would be used before routine bronchodilators. Postural drainage is not tolerated by a patient in acute respiratory distress and oxygen is titrated to an effective rate based on ABGs because of the possibility of carbon dioxide narcosis
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?
a. Document the presence of a large air leak.
b. Notify the surgeon of a possible pneumothorax.
c. Take no further action with the collection device.
d. Adjust the dial on the wall regulator to decrease suction.
ANS: c. Take no further action with the collection device.
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?
a. Observe for distended neck veins.
b. Auscultate for crackles in the lungs.
c. Palpate for heaves or thrills over the heart.
d. Review hemoglobin and hematocrit values.
ANS: a. Observe for distended neck veins.
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be elevated with cor pulmonale than decreased
Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (select all that apply)
a. encouraging regular exercise such as swimming
b. washing around the stoma daily with a moist washcloth
c. encouraging participation in postlaryngectomy support group
d. providing pictures and "hands-on" instruction for tracheostomy care
e. teaching how to hold breath and trying to gag to promote swallowing reflex
b. washing around the stoma daily with a moist washcloth
c. encouraging participation in postlaryngectomy support group
d. providing pictures and "hands-on" instruction for tracheostomy care
Rationale: Although regular exercise is important, such as walking and shoulder and arm exercises, swimming is contraindicated. The nurse would instruct the patient NOT to swim, as water entering the laryngeal stoma would risk choking and aspiration. All of the other activities identified (including cleaning around the stoma daily with a damp, moist washcloth, providing pictures and "hands-on" time to practice for tracheostomy care, and encouraging the patient to join a support group with other laryngectomees) are appropriate.
The patient has had COPD for years and his ABGs usually show hypoxia (PaO2 <60 mm Hg or SaO2 <88%) and hypercapnia (PaCO2 >45 mm Hg). Which ABG results show movement toward respiratory acidosis and further hypoxia indicating respiratory failure?
a. pH 7.35, PaO2 62 mm Hg, PaCO2 45 mm Hg
b. pH 7.34, PaO2 45 mm Hg, PaCO2 65 mm Hg
c. pH 7.42, PaO2 90 mm Hg, PaCO2 43 mm Hg
d. pH 7.46, PaO2 92 mm Hg, PaCO2 32 mm Hg
b. pH 7.34, PaO2 45 mm Hg, PaCO2 65 mm Hg
These results show worsening respiratory function and failure. The results in option a show potential normal results for the patient described. The results in option c show normal ABGs. The results in option d show alkalosis, probably
respiratory, but the HCO3- results are needed to be sure.
A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply.)?
A. Obtain antibiotic therapy promptly.
B. Drink noncaffeinated fluids daily.
C. Obtain an influenza vaccination.
D. Cover the nose when coughing.
E. Stay at home when symptomatic.
C. Obtain an influenza vaccination.
D. Cover the nose when coughing.
E. Stay at home when symptomatic.
Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.