Chapter 27 Flashcards
- Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?
a. Weak cough effort
b. Profuse green sputum
c. Respiratory rate of 28 breaths/min
d. Resting pulse oximetry (SpO2) of 85%
ANS: A : Weak cough effort
The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathing pattern.
- The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
a. Increased tactile fremitus
b. Dry, nonproductive cough
c. Hyperresonance to percussion
d. A grating sound on auscultation
ANS: A : Increased tactile fremitus
Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
- A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
a. Restrict oral fluids during the day.
b. Encourage pursed-lip breathing technique.
c. Help the patient to splint the chest when coughing.
d. Encourage the patient to wear the nasal O2 cannula.
ANS: C : Help the patient to splint the chest when coughing.
Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.
- The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions?
a. “I will call my health care provider if I still feel tired after a week.”
b. “I will continue to do deep breathing and coughing exercises at home.”
c. “I will schedule two appointments for the pneumonia and influenza vaccines.”
d. “I will cancel my follow-up chest x-ray appointment if I feel better next week.”
ANS: B : “I will continue to do deep breathing and coughing exercises at home.”
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
- Which action should the nurse plan to prevent aspiration in a high-risk patient?
a. Turn and reposition an immobile patient at least every 2 hours.
b. Place a patient with altered consciousness in a side-lying position.
c. Insert a nasogastric tube for feeding a patient with high-calorie needs.
d. Monitor respiratory symptoms in a patient who is immunosuppressed.
ANS: B : Place a patient with altered consciousness in a side-lying position.
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
- A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient coughs up small amounts of green mucus.
c. The patient’s white blood cell (WBC) count is 6000/µL.
d. Increased tactile fremitus is palpable over the right chest.
ANS: C : The patient’s white blood cell (WBC) count is 6000/µL.
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
- The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach the patient about providing specimens for 3 consecutive days.
d. Instruct the patient to collect several separate sputum specimens today.
ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used to test for tuberculosis. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
- A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued?
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. Sputum smears for acid-fast bacilli are negative.
ANS: D : Sputum smears for acid-fast bacilli are negative.
Repeated negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.
- The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
a. “I will take the bus instead of driving.”
b. “I will stay indoors whenever possible.”
c. “My spouse will sleep in another room.”
d. “I will keep the windows closed at home.”
ANS: C : My spouse will sleep in another room.”
Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation
- A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?
a. Ask the patient about any visual changes in red-green color discrimination.
b. Question the patient about experiencing shortness of breath, hives, or itching.
c. Explain that orange discolored urine and tears are normal while taking this medication.
d. Advise the patient to stop the drug and report the symptoms to the health care provider.
ANS: C : Explain that orange discolored urine and tears are normal while taking this medication.
Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occur when taking ethambutol, which is a different tuberculosis medication.
- An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider?
a. Yellow-tinged sclera
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices
ANS: A : Yellow-tinged sclera
Noninfectious hepatitis is a toxic effect of isoniazid, 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.
- A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Repeat warnings about the high risk for infecting others several times.
b. Give the patient written instructions about how to take the medications.
c. Arrange for a daily meal and drug administration at a community center.
d. Arrange for the patient’s friend to administer the medication on schedule.
ANS: C : Arrange for a daily meal and drug administration at a community center.
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen. Arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient’s situation.
- After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
a. Teach about drug-resistant TB.
b. Schedule directly observed therapy.
c. Ask the patient whether medications have been taken as directed.
d. Discuss the need for an injectable antibiotic with the health care provider.
ANS: C : Ask the patient whether medications have been taken as directed.
The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
- 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 and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse?
a. Use and side effects of isoniazid
b. Standard four-drug therapy for TB
c. Need for annual repeat TB skin testing
d. Bacille Calmette-Guérin (BCG) vaccine
ANS: A : Use and side effects of isoniazid
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 those who have already had a positive skin test result. 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.
- The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?
a. The patient is offered a tissue from the box at the bedside.
b. A surgical face mask is applied before visiting the patient.
c. A snack is brought to the patient from the unit refrigerator.
d. Hand washing is performed before entering the patient’s room.
ANS: B : A surgical face mask is applied before visiting the patient.
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient’s room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
- An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?
a. Treat workers with pulmonary fibrosis.
b. Teach about symptoms of lung disease.
c. Require the use of protective equipment.
d. Monitor workers for coughing and wheezing.
ANS: C : Require the use of protective equipment.
Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
- After change-of-shift report, which patient should the nurse assess first?
a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain
b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion
d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)
ANS: C : A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion
The patient’s history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.
- A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, “I would rather have chemotherapy than surgery.” Which response by the nurse is most appropriate?
a. “Are you afraid that the surgery will be very painful?”
b. “Did you have bad experiences with previous surgeries?”
c. “Tell me what you know about the treatments available.”
d. “Surgery is the treatment of choice for stage I lung cancer.”
ANS: C : “Tell me what you know about the treatments available.”
More assessment of the patient’s concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, “Surgery is the treatment of choice” is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient’s reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery
- An hour after a left thoracotomy, a patient reports 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 should the nurse take?
a. Clamp the chest tube in two places.
b. Administer the prescribed morphine.
c. Milk the chest tube to remove any clots.
d. Assist the patient with incentive spirometry.
ANS: B : Administer the prescribed morphine.
Treat the pain. 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. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.
- A patient with newly diagnosed lung cancer tells the nurse, “I don’t think I’m going to live to see my next birthday.” Which is the best initial response by the nurse?
a. “Are you ready to talk with family members about dying?”
b. “Can you tell me what makes you think you will die so soon?”
c. “Do you think that an antidepressant medication would be helpful?”
d. “Would you like to talk to the hospital chaplain about your feelings?”
ANS: B : Can you tell me what makes you think you will die so soon?”
The nurse’s initial response should be to collect more assessment data about the patient’s statement. The answer beginning “Can you tell me what it is” is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
