Chapter 28: Nursing Management: Lower Respiratory Problems Flashcards
- Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
a.
Weak, nonproductive cough effort
b.
Large amounts of greenish sputum
c.
Respiratory rate of 28 breaths/minute
d.
Resting pulse oximetry (SpO2) of 85%
ANS: A
The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective 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 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 rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance?
a.
Assist the patient to splint the chest when coughing.
b.
Teach the patient about the need for fluid restrictions.
c.
Encourage the patient to wear the nasal oxygen cannula.
d.
Instruct the patient on the pursed lip breathing technique.
ANS: A
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 oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
- The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
a.
I will call the doctor if I still feel tired after a week.
b.
I will continue to do the deep breathing and coughing exercises at home.
c.
I will schedule two appointments for the pneumonia and influenza vaccines.
d.
Ill cancel my chest x-ray appointment if Im feeling better in a couple weeks.
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
- The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?
a.
Turn and reposition immobile patients at least every 2 hours.
b.
Place patients with altered consciousness in side-lying positions.
c.
Monitor for respiratory symptoms in patients who are immunosuppressed.
d.
Insert nasogastric tube for feedings for patients with swallowing problems.
ANS: B
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 oxygen 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. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.
- 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 has been effective?
a.
Bronchial breath sounds are heard at the right base.
b.
The patient coughs up small amounts of green mucus.
c.
The patients white blood cell (WBC) count is 9000/L.
d.
Increased tactile fremitus is palpable over the right chest.
ANS: C
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 about the need to get sputum specimens for 2 to 3 consecutive days.
d.
Instruct the patient to expectorate three specimens as soon as possible.
ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. 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 admitted with active tuberculosis (TB). The nurse should question a health care providers 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
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.
- 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 avoid being outdoors whenever possible.
b.
My husband will be sleeping in the guest bedroom.
c.
I will take the bus instead of driving to visit my friends.
d.
I will keep the windows closed at home to contain the germs.
ANS: B
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 is the best response by the nurse?
a.
Ask if the patient is experiencing shortness of breath, hives, or itching.
b.
Ask the patient about any visual abnormalities such as red-green color discrimination.
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.
A NS: C
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 occurs when taking ethambutol (Myambutol), which is a different TB medication.
- 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
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.
- An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a.
Arrange for a friend to administer the medication on schedule.
b.
Give the patient written instructions about how to take the medications.
c.
Teach the patient about the high risk for infecting others unless treatment is followed.
d.
Arrange for a daily noon meal at a community center where the drug will be administered.
ANS: D
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and 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.
- After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), 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 treatment for drug-resistant TB treatment.
b.
Ask the patient whether medications have been taken as directed.
c.
Schedule the patient for directly observed therapy three times weekly.
d.
Discuss with the health care provider the need for the patient to use an injectable antibiotic.
ANS: B
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. 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-Gurin (BCG) vaccine
ANS: C
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 caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. 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 patients room.
ANS: B
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patients room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patients 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, if recommended by the nurse, will be most helpful in reducing the incidence of 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
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.
- The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include?
a.
Options for smoking cessation
b.
Reasons for annual sputum cytology testing
c.
Erlotinib (Tarceva) therapy to prevent tumor risk
d.
Computed tomography (CT) screening for lung cancer
ANS: A
Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.
- A lobectomy is scheduled for a patient with stage I nonsmall 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.
Surgery is the treatment of choice for stage I lung cancer.
d.
Tell me what you know about the various treatments available.
ANS: D
More assessment of the patients 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 patients reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In nonsmall cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.
- 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
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 with newly diagnosed lung cancer tells the nurse, I dont think Im going to live to see my next birthday. Which response by the nurse is best?
a.
Would you like to talk to the hospital chaplain about your feelings?
b.
Can you tell me what it is that makes you think you will die so soon?
c.
Are you afraid that the treatment for your cancer will not be effective?
d.
Do you think that taking an antidepressant medication would be helpful?
ANS: B
The nurses initial response should be to collect more assessment data about the patients 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 answer beginning, Are you afraid implies that the patient thinks that the cancer will be immediately fatal, although the patients statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
