chapter 30

Question 1

Following assessment of a client with pneumonia, the nurse identifies a nursing
diagnosis of ineffective airway clearance. Which of the following information 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%

Answer 1

A
The weak, nonproductive cough indicates that the client 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.

Question 2

The nurse is conducting a chest assessment on a client with pneumococcal pneumonia.
Which of the following findings should the nurse expect to assess?
a. Vesicular breath sounds
b. Increased tactile fremitus
c. Dry, nonproductive cough
d. Hyper-resonance to percussion

Answer 2

B
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.

Question 3

The nurse is caring for a client with bacterial pneumonia who has pleurisy. Which of the
following actions should the nurse implement to promote airway clearance?
a. Assist the client to splint the chest when coughing.
b. Educate the client about the need for fluid restrictions.
c. Encourage the client to wear the nasal oxygen cannula.
d. Instruct the client on the pursed lip breathing technique

Answer 3

A
Coughing is less painful and more likely to be effective when the client 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 clients with COPD, but will not improve airway
clearance.

Question 4

The nurse is providing teaching to a client with pneumonia. Which of the following
client statements indicate a good understanding of the discharge instructions given by
the nurse?
a. “I will call the doctor if I still feel tired after a week.”
b. “I will need to use home oxygen therapy for 3 months.”
c. “I will continue to do the deep-breathing and coughing exercises at home.”
d. “I will schedule two appointments for the pneumonia and influenza vaccines.”

Answer 4

C
Clients should continue to cough and deep breathe after discharge for up to 6–8 weeks.
Fatigue for several weeks is expected. Home oxygen therapy is not needed with
successful treatment of pneumonia. The pneumonia and influenza vaccines can be given
at the same time.

Question 5

Which of the following nursing actions is most effective in preventing aspiration
pneumonia in clients who are at risk?
a. Turn and reposition immobile clients at least every 2 hours.
b. Place clients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in clients who are immuno-suppressed.
d. Provide for continuous subglottic aspiration in clients receiving enteral feedings.

Answer 5

B
The risk for aspiration is decreased when clients with a decreased level of consciousness
are placed in a side-lying or upright position. Frequent turning prevents pooling of
secretions in immobilized clients but will not decrease the risk for aspiration in clients at
risk. Monitoring of parameters such as breath sounds and oxygen saturation will help
detect pneumonia in immuno-compromised clients, but it will not decrease the risk for
aspiration. Continuous subglottic suction is recommended for intubated clients but not
for all clients receiving enteral feedings.

Question 6

The nurse is caring for a client with right lower-lobe pneumonia who has been treated
with intravenous (IV) antibiotics for 2 days. Which of the following 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 client coughs up small amounts of green mucus.
c. The client’s white blood cell (WBC) count is 9 ´ 109
/L.
d. Increased tactile fremitus is palpable over the right chest.

Answer 6

C
The normal WBC count indicates that the antibiotics have been effective. All the other
data suggest that a change in treatment is needed.

Question 7

The health care provider writes a prescription for bacteriological testing for a client who
has a positive tuberculosis skin test. Which of the following actions should the nurse
take?
a. Repeat the tuberculin skin testing.
b. Teach about the reason for the blood tests.
c. Obtain consecutive sputum specimens from the client for 3 days.
d. Instruct the client to expectorate three specimens as soon as possible

Answer 7

C
Three consecutive sputum specimens are obtained on different days for bacteriological
testing for M. tuberculosis. The client should not provide all the specimens at once.
Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not
repeated.

Question 8

Which of the following information about a client who has a recent history of
tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
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.

Answer 8

D
Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and
the client 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 since it will not change
even with effective treatment.

Question 9

The nurse is providing teaching to a client with pulmonary tuberculosis (TB) regarding
the transmission of TB. Which of the following client actions indicate that the teaching
has been effective?
a. Demonstrates correct use of a nebulizer.
b. Washes dishes and personal items after use.
c. Covers the mouth and nose when coughing.
d. Reports daily to the public health department.

Answer 9

C
Covering the mouth and nose will help decrease airborne transmission of TB. The other
actions will not be effective in decreasing the spread of TB.

Question 10

Which of the following information should the nurse include in the teaching plan for a
client who is receiving rifampin for treatment of tuberculosis?
a. “Your urine, sweat, and tears will be orange coloured.”
b. “Read a newspaper daily to check for changes in vision.”
c. “Take vitamin B6 daily to prevent peripheral nerve damage.”
d. “Call the health care provider if you notice any hearing loss.”

Answer 10

A
Orange-coloured body secretions are an adverse effect of rifampin. The other adverse
effects are associated with other antituberculosis medications.

Question 11

The nurse is teaching a client who is receiving standard multidrug therapy for
tuberculosis (TB) about possible toxic effects of the antitubercular medications. Which
of the following findings should the nurse instruct the client to report to the health care
provider?
a. Yellow-tinged skin
b. Changes in hearing
c. Orange-coloured sputum
d. Thickening of the fingernails

Answer 11

A
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide,
and clients 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. Orange discoloration of body fluids is an expected adverse effect of
rifampin and not an indication to call the health care provider.

Question 12

The nurse is caring for clients with active tuberculosis (TB) who misuse alcohol and/or
are homeless. Which of the following interventions by the nurse will be most effective in
ensuring adherence with the treatment regimen?
a. Educating the client about the long-term impact of TB on health
b. Giving the client written instructions about how to take the medications
c. Teaching the client about the high risk for infecting others unless treatment is
followed
d. Arranging for a daily noontime meal at a community centre and giving the
medication then

Answer 12

D
Directly observed therapy is the most effective means for ensuring compliance with the
treatment regimen, and arranging a daily meal will help to ensure that the client is
available to receive the medication. The other nursing interventions may be appropriate
for some clients, but are not likely to be as helpful with this client.

Question 13

After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a
client continues to have positive sputum smears for acid-fast bacilli (AFB). Which of the
following actions should the nurse take next?
a. Ask the client whether medications have been taken as directed.
b. Discuss the need to use some different medications to treat the TB.
c. Schedule the client for directly observed therapy three times weekly.
d. Educate about using a 2-drug regimen for the last 4 months of treatment.

Answer 13

A
The first action should be to determine whether the client 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.
Depending on whether the client has been compliant or not, different medications or
directly observed therapy may be indicated. A two-drug regimen will be used only if the
sputum smears are negative for AFB.

Question 14

A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph
is negative, and the nurse has no symptoms of TB. Which of the following information
should the occupational health nurse provide to the staff nurse?
a. Use and adverse effects of isoniazid (INH)
b. Standard four-drug therapy for TB
c. Need for annual repeat TB skin testing
d. Bacille Calmette–Guérin (BCG) vaccine

Answer 14

A
The nurse is considered to have a latent TB infection and should be treated with INH
daily for 6–9 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 used to prevent TB and is rarely used in Canada; it would not be helpful
for this individual, who already has a TB infection.

Question 15

The nurse is caring for a client who is hospitalized with active tuberculosis (TB) and the
nurse observes a family member who is visiting the client. Which of the following
actions by the visitor should cause the nurse to intervene?
a. Washes hands before entering the client’s room
b. Hands the client a tissue from the box at the bedside
c. Puts on a surgical face mask before visiting the client
d. Brings food from a “fast-food” restaurant to the client

Answer 15

C
A high-efficiency particulate air (HEPA) mask, rather than a standard surgical mask,
should be used when entering the client’s room because the HEPA mask can filter out
100% of small airborne particles. Handwashing before visiting the client is not necessary,
but there is no reason for the nurse to stop the family member from doing this. Because
anorexia and weight loss are frequent problems in clients with TB, bringing food from
outside the hospital is appropriate. The family member should wash the hands after
handling a tissue that the client has used, but no precautions are necessary when giving
the client an unused tissue.

Question 16

Which of the following actions by the occupational health nurse at a manufacturing plant
where there is potential exposure to inhaled dust is most helpful in reducing incidence of
lung disease?
a. Teach about symptoms of lung disease.
b. Treat workers who inhale dust particles.
c. Monitor workers for shortness of breath.
d. Require the use of protective equipment.

Answer 16

D
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.

Question 17

The nurse is developing a teaching plan for a client with a 42 pack-year history of
cigarette smoking. Which of the following information should the nurse include in the
plan of care?
a. Computed tomography (CT) screening for lung cancer
b. Options for smoking cessation
c. Reasons for annual sputum cytology testing
d. Erlotinib therapy to prevent tumour risk

Answer 17

B
Because smoking is the major cause of lung cancer, the most important role for the nurse
is educating clients about the benefits of and means of smoking cessation. Early
screening of at-risk clients using sputum cytology, chest x-ray, or CT scanning has not
been effective in reducing mortality. Erlotinib may be used in clients who have lung
cancer but not to reduce risk for developing tumours.

Question 18

The nurse is caring for a client with stage I non–small cell lung cancer who is scheduled
for a lobectomy. The client tells the nurse, “I would rather have radiation than surgery.”
Which of the following responses by the nurse is best?
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.”

Answer 18

D
More assessment of the client’s concerns about surgery is indicated. An open-ended
response will elicit the most information from the client. The answer beginning,
“Surgery is the treatment of choice” is accurate, but it discourages the client from
sharing concerns about surgery. The remaining two answers indicate that the nurse has
jumped to conclusions about the client’s reasons for not wanting surgery.

Question 19

The nurse is caring for a client who had a thoracotomy 1 hour ago and reports incisional
pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural
drainage system has 100 mL of bloody drainage and a large air leak. Which of the
following actions is best for the nurse to take next?
a. Administer the prescribed PRN morphine.
b. Assist the client to deep breathe and cough.
c. Milk the chest tube gently to remove any clots.
d. Tape the area around the insertion site of the chest tube.

Answer 19

A
The client 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

Question 20

A client with newly diagnosed lung cancer tells the nurse, “I think I am going to die
pretty soon.” Which of the following responses 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?”

Answer 20

B
The nurse’s initial response should be to collect more assessment data about the client’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 answer
beginning, “Are you afraid” implies that the client thinks that the cancer will be
immediately fatal, although the client’s statement may not be related to the cancer
diagnosis. The remaining two answers offer interventions that may be helpful to the
client, but more assessment is needed to determine whether these interventions are
appropriate.

Question 21

The health care provider inserts a chest tube in a client with a hemo-pneumothorax.
When monitoring the client after the chest tube placement, which of the following
findings is of greatest concern?
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

Answer 21

B
The large amount of blood may indicate that the client is in danger of developing
hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care
provider. A large air leak would be expected immediately after chest tube placement for
pneumothorax. 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 client with pneumothorax.

Question 22

The nurse is caring for a client who has a steering wheel injury as a result of an
automobile accident. Which of the following findings should be of most concern to the
nurse during the initial assessment?
a. Paradoxical chest movement
b. The complaint of chest wall pain
c. A heart rate of 110 beats/minute
d. A large bruised area on the chest

Answer 22

A
Paradoxical chest movement indicates that the client 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.

Question 23

The nurse is assessing a client who has just arrived after an automobile accident and the
nurse notes that the breath sounds are absent on the right side. Which of the following
actions should the nurse anticipate?
a. Emergency pericardiocentesis
b. Stabilization of the chest wall with tape
c. Administration of an inhaled bronchodilator
d. Insertion of a chest tube with a chest drainage system

Answer 23

D
The client’s history and absent breath sounds suggest a right-sided pneumothorax or
hemothorax, which will require treatment with a chest tube and drainage. The other
therapies would be appropriate for an acute asthma attack, flail chest, or cardiac
tamponade, but the client’s clinical manifestations are not consistent with these
problems.

Question 24

The nurse is caring for a client who has a right-sided chest tube following a thoracotomy
and has continuous bubbling in the suction-control chamber of the collection device.
Which of the following actions should the nurse implement?
a. Document the presence of a large air leak
b. Obtain and attach a new collection device
c. Notify the surgeon of a possible pneumothorax
d. Take no further action with the collection device

Answer 24

D
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. A new collection device is
needed when the collection chamber is filled.

Question 25

The nurse is providing preoperative instruction for a client who is scheduled for a left
pneumonectomy for cancer of the lung. Which of the following information should the
nurse include related to postoperative care?
a. Positioning on the right side
b. Bed rest for the first 24 hours
c. Frequent use of an incentive spirometer
d. Chest tubes to water-seal chest drainage

Answer 25

C
Frequent deep breathing and coughing are needed after chest surgery to prevent
atelectasis. To promote gas exchange, clients after pneumonectomy are positioned on the
surgical side. Chest tubes are not usually used after pneumonectomy because the
affected side is allowed to fill with fluid. Early mobilization decreases the risk for
postoperative complications such as pneumonia and deep vein thrombosis.

Question 26

To determine the effectiveness of prescribed therapies for a client with cor pulmonale
and right-sided heart failure, which of the following assessments should the nurse make?
a. Lung sounds
b. Heart sounds
c. Blood pressure
d. Peripheral edema

Answer 26

D
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical
manifestations of right ventricular failure such as peripheral edema, jugular vein
distension, and right upper-quadrant abdominal tenderness would be expected.
Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor
pulmonale

Question 27

The nurse is caring for a client with primary pulmonary hypertension (PPH) who is
receiving nifedipine. Which of the following findings indicate that the treatment is
effective?
a. BP is less than 140/90 mm Hg
b. Client reports decreased exertional dyspnea
c. Heart rate is between 60 and 100 beats/minute
d. Client’s chest x-ray indicates clear lung fields

Answer 27

B
Since a major symptom of PPH 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 effectiveness of therapy for a client
with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Question 28

The nurse is caring for a client with a pleural effusion who is scheduled for a
thoracentesis. Which of the following actions should the nurse implement prior to the
procedure?
a. Start a peripheral intravenous line to administer the necessary sedative drugs.
b. Position the client sitting upright on the edge of the bed and leaning forward.
c. Remove the water pitcher and remind the client not to eat or drink anything for 6
hours.
d. Instruct the client about the importance of incentive spirometer use after the
procedure.

Answer 28

B
When the client is sitting up, fluid accumulates in the pleural space at the lung bases and
can more easily be located and removed. The lung will expand after the effusion is
removed; incentive spirometry is not needed to assure alveolar expansion. The client
does not usually require sedation for the procedure, and there are no restrictions on oral
intake because the client is not sedated or unconscious.

Question 29

The nurse has completed discharge teaching for a client who has had a lung transplant.
Which of the following client statements indicate that the teaching was effective?
a. “I will make an appointment to see the doctor every year.”
b. “I will not turn the home oxygen up higher than 2 L/minute.”
c. “I will not worry if I feel a little short of breath with exercise.”
d. “I will call the health care provider right away if I develop a fever.”

Answer 29

D
Low-grade fever may indicate infection or acute rejection, so the client should notify the
health care provider immediately if the temperature is elevated. Clients require frequent
follow-up visits with the transplant team; annual health care provider visits would not be
sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of
breath should be reported.

Question 30

Which of the following prescriptions should the nurse implement first for a client who
has just been admitted with probable bacterial pneumonia and sepsis?
a. Administer Aspirin suppository.
b. Send to radiology for chest x-ray.
c. Give ciprofloxacin 400 mg IV.
d. Obtain blood cultures from two sites.

Answer 30

D
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be
obtained before antibiotic administration. The chest radiograph and Aspirin
administration can be done last.

Question 31

The nurse is caring for a client who has just had a thoracentesis. Which of the following
information is most important to communicate to the health care provider?
a. BP is 150/90 mm Hg.
b. Oxygen saturation is 89%.
c. Pain level is 5/10 with a deep breath.
d. Respiratory rate is 24 when lying flat.

Answer 31

B
Oxygen saturation would be expected to improve after a thoracentesis. A saturation of
89% 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.

Question 32

The nurse is caring for a client who has just been admitted with pneumococcal
pneumonia has a temperature of 38.7°C (101.7°F) with a frequent cough and symptoms
of severe pleuritic chest pain. Which of the following prescribed medications should the
nurse give first?
a. Guaifenesin
b. Acetaminophen
c. Azithromycin
d. Codeine phosphate

Answer 32

C
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The
other medications also are appropriate and should be given as soon as possible, but the
priority is to start antibiotic therapy.

Question 33

Which of the following information obtained by the nurse about a client who has human
immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to
communicate to the health care provider?
a. The Mantoux test had an induration of only 8 mm.
b. The chest x-ray showed infiltrates in the upper lobes.
c. The client is being treated with antiretrovirals for HIV infection.
d. The client has a cough that is productive of blood-tinged mucus.

Answer 33

C
Drug interactions can occur between the antiretrovirals used to treat HIV infection and
the medications used to treat tuberculosis. The other data are expected in a client with
HIV and TB disease.

Question 34

The nurse is caring for a client with pneumonia has a fever of 38.4°C (101.1°F), a
nonproductive cough, and an oxygen saturation of 89%. The client is very weak and
needs assistance to get out of bed. Which of the following nursing diagnoses is priority?
a. Hyperthermia related to increase in metabolic rate (illness)
b. Impaired transfer ability related to insufficient muscle strength
c. Ineffective airway clearance related to retained secretions
d. Ineffective breathing pattern related to respiratory muscle fatigue

Answer 34

D
All these nursing diagnoses are appropriate for the client, but the client’s oxygen
saturation indicates that all body tissues are at risk for hypoxia unless their breathing
pattern is improved.

Question 35

The nurse observes an unregulated care provider doing all the following activities when
caring for a client with a pulmonary embolism. Which of the following actions should
cause the nurse to intervene with the client’s care?
a. Lowers the head of the client’s bed to 10 degrees.
b. Splints the client’s chest during coughing.
c. Helps the client to ambulate to the bathroom.
d. Assists the client to a bedside chair for meals.

Answer 35

A
Positioning the client with the head of the bed lowered will decrease ventilation. The
patient should be kept on bed rest in a semi-Fowler’s position to facilitate breathing. The
other actions are appropriate for a client with a pulmonary embolism.

Question 36

The nurse is caring for a client with a possible pulmonary embolism who has symptoms
of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60
mm Hg, and respirations of 42 breaths/minute. Which of the following actions should
the nurse implement first?
a. Elevate the head of the bed to 45–60 degrees.
b. Administer the ordered pain medication.
c. Notify the client’s health care provider.
d. Offer emotional support and reassurance.

Answer 36

A
The client has symptoms consistent with a pulmonary embolism. Elevating the head of
the bed will improve ventilation and gas exchange. The other actions can be
accomplished after the head is elevated (and oxygen is started).

Question 37

After the nurse has received change-of-shift report about the following four clients,
which client should be assessed first?
a. A 77-year-old client with tuberculosis (TB) who has four antitubercular
medications due in 15 minutes
b. A 23-year-old client with cystic fibrosis who has pulmonary function testing
scheduled
c. A 46-year-old client who has a deep vein thrombosis and is complaining of sudden
onset shortness of breath.
d. A 35-year-old client who was admitted the previous day with pneumonia and has a
temperature of 37.9°C (100.2°F)

Answer 37

C
Sudden onset shortness of breath in a client with a deep vein thrombosis suggests a
pulmonary embolism and requires immediate assessment and actions such as oxygen
administration. The other clients also should be assessed as soon as possible, but there is
no indication that they may need immediate action to prevent clinical deterioration.

Question 38

The nurse is performing tuberculosis (TB) screening in a clinic that has many clients
who have immigrated to Canada. Before doing a TB skin test on a client, which of the
following questions is most important for the nurse to ask?
a. “Is there any family history of TB?”
b. “Have you received the bacille Calmette–Guérin (BCG) vaccine for TB?”
c. “How long have you lived in the Canada?”
d. “Do you take any over-the-counter (OTC) medications?”

Answer 38

B
Clients 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 client has a TB infection. The other information also may be valuable but is not as
pertinent to the decision about doing TB skin testing.

Question 39

The nurse is caring for a client in the emergency department who has an open stab
wound to the right chest. Which of the following actions should the nurse implement
first?
a. Position the client so that the right chest is dependent.
b. Keep the head of the client’s bed at no more than 30 degrees elevation.
c. Tape a nonporous dressing on three sides over the chest wound.
d. Cover the sucking chest wound firmly with an occlusive dressing.

Answer 39

C
The dressing taped on three sides will allow air to escape when intrapleural pressure
increases during expiration, but it will prevent air from moving into the pleural space
during inspiration. Placing the client on the right side or covering the chest wound with
an occlusive dressing will allow trapped air in the pleural space and cause tension
pneumothorax. The head of the bed should be elevated to 30–45 degrees to facilitate
breathing.

Question 40

The nurse is caring for a client who has incisional pain, a poor cough effort, and
scattered rhonchi after a thoracotomy. Which of the following actions should the nurse
take first?
a. Assist the client to sit up at the bedside.
b. Splint the client’s chest during coughing.
c. Medicate the client with the prescribed morphine.
d. Have the client use the prescribed incentive spirometer.

Answer 40

C
A major reason for atelectasis and poor airway clearance in clients after chest surgery is
incisional pain (which increases with deep breathing and coughing). The first action by
the nurse should be to medicate the client to minimize incisional pain. The other actions
are all appropriate ways to improve airway clearance but should be done after the
morphine is given.

Question 41

The nurse is caring for a client with primary pulmonary hypertension (PPH) who has
been taking a calcium channel blocker with no effect. Which of the following
medications should the nurse expect that the client will receive next?
a. Nifedipine
b. Diltiazem
c. Iloprost
d. Bosentan

Answer 41

C
Iloprost has revolutionized care for PPH. It is now the treatment of choice for select
clients unresponsive to calcium channel blockers. It is a long-acting chemically stable
prostacyclin analogue, which is administered in an aerosolized form (100–150 mcg/day).
Bosentan is an oral form of prostacyclin used to treat PPH. Nifedipine and diltiazem are
calcium channels.

Question 42

The nurse is caring for a client with pneumonia who has symptoms of a sharp pain
“whenever I take a deep breath.” Which of the following actions should the nurse take
next?
a. Listen to the client’s lungs.
b. Administer the PRN morphine.
c. Have the client cough forcefully.
d. Notify the client’s health care provider.

Answer 42

A
The client’s statement indicates that pleurisy or a pleural effusion may have developed
and the nurse will need to listen for a pleural friction rub or decreased breath sounds.
Assessment should occur before administration of pain medications. The client is
unlikely to be able to cough forcefully until pain medication has been administered. The
nurse will want to obtain more assessment data before calling the health care provider.