Chapter 28: Nursing Management- Lower Respiratory Problems – Flashcards
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To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? a) Maintain adequate fluid intake. b) Splint the chest when coughing. c) Maintain a 30-degree elevation. d) Maintain a semi-Fowler's position. e) Instruct patient to cough at end of exhalation.*
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a, b, & e Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
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The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? a) Hyperthermia related to infectious illness b) Ineffective thermoregulation related to chilling c) Ineffective breathing pattern related to pneumonia d) Ineffective airway clearance related to thick secretions
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a) Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
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Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? a) Basilar crackles b) Respiratory rate of 28 c) Oxygen saturation of 85% d) Presence of greenish sputum
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a) Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.
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Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? a) Hyperresonance on percussion b) Vesicular breath sounds in all lobes c) Increased vocal fremitus on palpation d) Fine crackles in all lobes on auscultation
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c) Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
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What is the priority nursing intervention in helping a patient expectorate thick lung secretions? a) Humidify the oxygen as able. b) Administer cough suppressant q4hr. c) Teach patient to splint the affected area. d) Increase fluid intake to 3 L/day if tolerated.
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d) Increase fluid intake to 3 L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.
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During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? a) Pneumococcal b) Staphylococcus aureus c) Haemophilus influenzae d) Bacille-Calmette-Guérin (BCG)
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a) Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis (TB) is prevalent.
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The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? a) "I will seek immediate medical treatment for any upper respiratory infections." b) "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." c) "I will increase my food intake to 2400 calories a day to keep my immune system well." d) "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
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d) "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.
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After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? a) Orthostatic blood pressures b) Sputum culture and sensitivity c) Pulmonary function evaluation d) Serum laboratory studies ordered for AM
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b) Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.
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During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)? a) Asbestos exposure b) Exposure to uranium c) Chronic interstitial fibrosis d) History of cigarette smoking e) Geographic area in which he was born
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a, b, & d Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk, but not necessarily where the patient was born.
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What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? a) Positioning patient on right side b) Maintaining adequate fluid intake c) Positioning patient with "good lung" down d) Performing postural drainage every 4 hours
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c) Positioning patient with "good lung" down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
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A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient? a) Perform a comprehensive health history with the patient to review prior respiratory problems. b) Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c) Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d) Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
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d) Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.
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When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of a) cough reflex. b) mucociliary clearance. c) reflex bronchoconstriction. d) ability to filter particles from the air.
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b) mucociliary clearance. Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.
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While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? a) Continue with ambulation since this is a normal response to activity. b) Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. c) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. d) Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.
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c) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.
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When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)? a) Obesity b) Pneumonia c) Malignancy d) Cigarette smoking e) Prolonged air travel
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a, c, d, & e An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.
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The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? a) Notify the physician. b) Administer a nitroglycerin tablet sublingually. c) Conduct a thorough assessment of the chest pain. d) Sit the patient up in bed as tolerated and apply oxygen.
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d) Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.
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When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? a) Antibiotic b) Corticosteroid c) Bronchodilator d) Cough suppressant
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a) Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.
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The patient with HIV has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when she says, a) "I will be given amphotericin B to treat the fungus." b) "I got this fungus because I am immunocompromised." c) "I need to be isolated from my family and friends so they won't get it." d) "The effectiveness of my therapy can be monitored with fungal serology titers."
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c) "I need to be isolated from my family and friends so they won't get it." The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.
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The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a) The patient has lung cancer. b) The incision will be medial sternal or lateral. c) Chest tubes will not be needed postoperatively. d) Less discomfort and faster return to normal activity
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d) Less discomfort and faster return to normal activity The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.
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When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? a) Lobectomy surgery is usually needed to drain the abscess. b) IV antibiotic therapy will be used for a prolonged period of time. c) Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. d) No further culture and sensitivity tests are needed if the patient takes the medication as ordered.
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c) Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. IV antibiotics are used until the patient and x-ray show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.
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One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? a) Water-seal chamber has 5 cm of water. b) No new drainage in collection chamber c) Chest tube with a loose-fitting dressing d) Small pneumothorax at CT insertion site
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c) Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
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The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient? a) Pulmonary infarction b) Pulmonary hypertension c) Cytomegalovirus (CMV) d) Bronchiolitis obliterans (BOS)
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d) Bronchiolitis obliterans (BOS) Bronchiolitis obliterans (BOS) is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.
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When caring for a patient with acute bronchitis, the nurse will prioritize: a. auscultating lung sounds b. encouraging fluid restriction c. administering antibiotic therapy d. teaching the patient to avoid cough suppressants
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a. auscultating lung sounds
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For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)? a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding
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a, b, & e
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An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to: a. perform postural drainage every hour b. provide analgesics as ordered to promote patient comfort c. administer O2 as prescribed to maintain optimal oxygen levels d. teach the patient how to cough effectively to bring secretions to the mouth.
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d. teach the patient how to cough effectively to bring secretions to the mouth.
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A patient with TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the patient be taught (select all that apply)? a. Expect routine TST to evaluate infection. b. Visitors will not be allowed while in airborne isolation. c. Take all medication for full length of time to prevent multi drug-resistant TB. d. Wear a standard isolation mask if leaving the airborne infection isolation room. e. Maintain precautions in airborne infection isolation room by coughing into a paper tissue.
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c, d, & e
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A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to: a. candidiasis b. aspergillosis c. histoplasmosis d. coccidioidomycosis
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a. candidiasis
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When caring for a patient with a lung abscess, what is the nurse's priority intervention? a. Postural drainage b. Antibiotic administration c. Obtaining a sputum specimen d. Patient teaching regarding home care
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b. Antibiotic administration
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The emergency department nurse is caring for patients exposed to a chlorine leak from a local factory. The nurse would closely monitor these patients for: a. pulmonary edema b. anaphylactic shock c. respiratory alkalosis d. acute tubular necrosis
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a. pulmonary edema
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The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will: a. call the healthcare provider to question the order. b. administer both vaccines at the same time in different arms c. administer the flu shot and tell the patient to come back d. week later to receive the pneumococcal vaccine and suggest FluMist (nasal vaccine) instead of the influenza injection.
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b. administer both vaccines at the same time in different arms
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The nurse identifies a flail chest in a trauma patient when: a. multiple rib fractures are determined by x-ray b. a tracheal deviation to the unaffected side is present c. paradoxic chest movement occurs during respiration d. there is decreased movement of the involved chest wall
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c. paradoxic chest movement occurs during respiration
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The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should: a. continue to monitor the patient b. check all connections for a leak in the system c. lower the drainage collector further from the chest d. clamp the tubing at progressively distal points away from the patient until the tidaling stops
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a. continue to monitor the patient
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An appropriate nursing intervention for a patient postpneumonectomy is: a. monitoring chest tube drainage and functioning b. positioning the patient on the unaffected side or back c. doing range-of-motion exercises on the affected upper limb d. auscultating frequently for lung sounds on the affected side
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c. doing range-of-motion exercises on the affected upper limb
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A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is: a. administering ordered analgesia b. monitoring chest tube drainage c. sending pleural fluid for laboratory analysis d. monitoring the patient's level of consciousness
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a. administering ordered analgesia
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When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes: a. maintaining the patient on bed rest b. using sequential compression devices c. encouraging the patient to cough and deep breathe d. teaching the patient how to use the incentive spirometer
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b. using sequential compression devices
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Which statement(s) describe(s) the management of a patient following lung transplantation (select all that apply)? a. The lung is biopsied using a transtracheal method b. High doses of oxygen are administered around the clock c. The use of a home spirometer will help to monitor lung function d. Immunosuppressant therapy usually involves a three-drug regimen e. Most patients experience an acute rejection episode in the first 3 days.
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a, c, & d
