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The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?
An uninsured man who is homeless
A woman newly immigrated from Korea
A man who is an inspector for the U.S. Postal Service
An older woman admitted from a long-term care facility
A man who is an inspector for the U.S. Postal Service
People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users.
The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse would place the client in which position for insertion?
Right side
Low-Fowler's position
High-Fowler's position
Supine, with the head flat
High-Fowler's position
Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply.
Notify the RN.
Notify the Rapid Response Team.
Finish the suctioning as quickly as possible.
Discontinue suctioning until the client is stabilized.
Contact the respiratory department to suction the client.
Notify the RN.
Discontinue suctioning until the client is stabilized.
When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.
The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?
Lateral position
Low-Fowler's position
Semi-Fowler's position
Head of the bed elevation at 40 degrees
Lateral position
Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated.
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding would be reported immediately to the primary health care provider (PHCP)?
Dry cough
Hematuria
Bronchospasm
Blood-tinged sputum
Bronchospasm
Rationale:
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?
Continue to monitor.
Empty the drainage.
Encourage the client to deep breathe.
Encourage the client to hold his or her breath periodically.
Continue to monitor.
The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her (client) breath.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Take Action
Level of Cognitive Ability: Analyzing
The client is diagnosed with pleurisy. The nurse would expect to see which signs and symptoms? Select all that apply.
Pleural friction rub
Sharp, knife-like pain
Cyanosis of lips and nailbeds
Pain that occurs on both sides of the chest
Pain that occurs most often during inspiration
Pleural friction rub
Sharp, knife-like pain
Cyanosis of lips and nailbeds
The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position would the nurse instruct the client to assume?
Side-lying in bed
Sitting in a recliner chair
Sitting up in bed at a 90 degree angle
Sitting on the side of the bed leaning on an overbed table
Sitting on the side of the bed leaning on an overbed table
Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. The positions in options 1, 2, and 3 will not enhance the effectiveness of breathing.
The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse would review the results of which diagnostic test to confirm this diagnosis?
Chest x-ray
Bronchoscopy
Sputum culture
Tuberculin skin test
Sputum culture
A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority?
Report the findings.
Document the finding in the client's record.
Call the employee health service department.
Call the radiology department for a chest x-ray.
Report the findings.
The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.
The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?
"I can't shop at the mall for the next 6 months.
""I need to continue medication therapy for 2 months.
""I can return to work if a sputum culture comes back negative.
""I should not be contagious after 2 to 3 weeks of medication therapy."
"I should not be contagious after 2 to 3 weeks of medication therapy."
The client continues medication therapy for 6 to 12 months depending on the situation. The client is generally considered to not be contagious after 2 to 3 weeks of medication. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative.
The nurse is assisting in planning care for a client with a chest tube. The nurse would suggest including which interventions in the plan? Select all that apply.
Pin the tubing to the bed linens.
Be sure all connections remain airtight.
Be sure all connections are taped and secure.
Monitor closely for tubing that is kinked or obstructed.
Empty the drainage from the drainage collection chamber daily.
Be sure all connections remain airtight.
Be sure all connections are taped and secure
Monitor closely for tubing that is kinked or obstructed.
The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. The connections should be airtight (no leaks), and all connections should be taped and secure. It is important that the tubes to the suction and the chest tube be patent (without kinks or obstructions). Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied, because a closed system must be maintained; if the system is opened, air pressure causes air to rush in, and lung collapse can occur.
The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse reinforce? Select all that apply.
Activities should be resumed gradually.
Avoid contact with other individuals except family members for at least 6 months.
A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
Respiratory isolation is not necessary because family members have already been exposed.
Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.
When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.
Activities should be resumed gradually.
A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
Respiratory isolation is not necessary because family members have already been exposed.
Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.
The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually. The client and family are informed that respiratory isolation is not necessary because family members have already been exposed. The client is instructed about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.
A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information would reassure the client that contaminating family members and others is not likely?
The family does not need therapy, and the client will not be contagious after 1 month of medication therapy.
The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy.
The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy.
The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis
A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply
"I will bleach my clothes and bedding after use.
""My family and I will practice good hand hygiene.
""I will discard disposable tissues into a plastic bag.
""I will cover my mouth when I cough, sneeze, or laugh.
""All the deep pile carpeting will be removed from my home."
"My family and I will practice good hand hygiene.
""I will discard disposable tissues into a plastic bag.
""I will cover my mouth when I cough, sneeze, or laugh."
TB is spread by droplet nuclei or by the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand-washing technique. It is unnecessary to remove carpeting from the home. The client should protect others by covering the mouth when coughing, laughing, or sneezing. The client and family should wash hands often. Disposable tissues should be used and discarded in a plastic bag.
The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?
Hypothermia
Respiratory distress
Hematoma in the left groin
Discomfort in the left groin
Respiratory distress
Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. Discomfort is expected.
The nurse is caring for a client with emphysema receiving oxygen. The nurse would consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?
1 L/min
2 L/min
6 L/min
10 L/min
2 L/min
Between 1 L/min and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 mm Hg to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min unless specifically prescribed. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system.
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A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points would be included in the instructions? Select all that apply.
The client leans over a bedside table.
The client should sit on the edge of the bed.
The procedure involves obtaining a biopsy.
A time-out is performed before the procedure.
The procedure is performed during a bronchoscopy.
A local anesthetic is administered before the procedure.
The client leans over a bedside table.
The client should sit on the edge of the bed.
A time-out is performed before the procedure.
A local anesthetic is administered before the procedure.
A thoracentesis is a procedure in which fluid is removed from the pleural space. The procedure involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle. Before the thoracentesis, the nurse needs to check for allergies because a local anesthetic is administered. A time-out is performed in which the client identification, coagulation studies, and area of the pleural effusion are verified. A chest x-ray is performed after the procedure. A potential complication is a pneumothorax. The client sits on the bedside and leans over a bedside table, which exposes the area between the ribs. A lung biopsy is often done during a bronchoscopy.
The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus?
Auscultating the posterior breath sounds
Asking the client about pain upon inspiration
Placing the hands over the rib area and observing expansion
Palpating the skin around the chest and neck for a crackling sensation
Palpating the skin around the chest and neck for a crackling sensation
Air caught under the skin in the subcutaneous tissues is known as crepitus or subcutaneous emphysema. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It is monitored by palpating, and it feels like bubble wrap when palpated. Auscultation of posterior breath sounds gives data about adequate depth of respirations. Pain upon inspiration can occur with pleurisy (inflammation of the pleurae) or pericarditis. Placing the hands over the rib area is a method of determining equal chest expansion on each side.
The nurse is helping perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of data collection? Select all that apply.
Listening to lung sounds
Obtaining the client's temperature
Checking the strength of peripheral pulses
Obtaining information about the client's respirations
Performing a musculoskeletal and neurological examination
Asking the client about a family history of any illness or disease
Listening to lung sounds
Obtaining the client's temperature
Obtaining information about the client's respirations
A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.
Client Needs: Health Promotion and Maintenance
Clinical Judgment/Cognitive Skills: Analyze Cues
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Respiratory
Health Problem: Adult Health: Respiratory: Infections of the Upper Airway
Integrated Process: Nursing Process/Data Collection
The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.
Excessive bubbling in the water-seal chamber
Vigorous bubbling in the suction-control chamber
50 mL of drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
50 mL of drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. The chest tube is placed during the surgery to remove fluid and air so the remaining lung can reinflate. The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 mL/hour to 100 mL/hour is considered excessive and requires RN and surgeon notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. Excessive and/or vigorous bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding.
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client?
Stridor and cyanotic lips
Diminished breath sounds and fever
Wheezes and use of accessory muscles
Pleural friction rub and inspirational chest pain
Wheezes and use of accessory muscles
Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a life-threatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Analyze Cues, Recognize Cues
The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures would the nurse include in the plan? Select all that apply.
To avoid activities that require bending over
To contact the surgeon if eye scratchiness occurs
To take acetaminophen for minor eye discomfort
To place an eye shield on the surgical eye at bedtime
That episodes of sudden severe pain in the eye are expected
To contact the surgeon if a decrease in visual acuity occurs
To avoid activities that require bending over
To take acetaminophen for minor eye discomfort
To place an eye shield on the surgical eye at bedtime
To contact the surgeon if a decrease in visual acuity occurs
After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye, and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note in this client? Select all that apply.
Hypocapnia
Dyspnea during exertion
Presence of a productive cough
Difficulty breathing while talking
Increased oxygen saturation with exercise
A shortened expiratory phase of respiration
Dyspnea during exertion
Presence of a productive cough
Difficulty breathing while talking