Exam 2 - Resp

Question 1

Influenza—Clinical manifestations

Answer 1

• Fever and chills
• Malaise
• Muscle aching
• Headache
• Watery nasal discharge
• Nonproductive cough
• Sore throat
• Distinguishing feature of influenza: RAPID ONSET
• Secondary complications: sinusitis, otitis media, bronchitis, and bacterial pneumonia

Question 2

Pneumonia—Typical Age at Diagnosis

Answer 2

• The #1 age affected is the elderly (people over the age of 65). Being over 65, one has more of a risk for mortality than any of the other age groups.
• Another group affected is young children. Particularly noting children under the age of two.
• Although Pneumonia can affect all ages. If you are a person of targeted age groups, chronic disease, compromised immune systems, smoking, and ventilator use all increase the likelihood.

Question 3

Pneumonia—Prognosis

Answer 3

• The time it takes to recover is dependent on how closely one follows a treatment plan. They need to allow adequate rest, increase intake of fluids, and take medication if prescribed. Age and present chronic diseases play a role as well.
• A sought after prognosis is Pneumonia only lasting about a week.
• Some Pneumonia can take months to fully recover.

Question 4

Pulmonary edema—Clinical manifestations

Answer 4

• Coughing up blood or bloody froth
• Difficulty breathing when lying down (orthopnea) – you may notice the need to sleep with your head propped up or use extra pillows
• Feeling of “air hunger” or “drowning” (if this feeling wakes you from sleep and causes you to sit up and try to catch your breath, it’s called “paroxysmal nocturnal dyspnea”)
• Grunting, gurgling, or wheezing sounds with breathing
• Inability to speak in full sentences because of shortness of breath
Other sign/symptoms may include:
• Anxiety or restlessness
• Decrease in level of alertness (consciousness)
• Leg swelling
• Pale skin
• Sweating (excessive)

Question 5

“Acute” bronchitis—Nursing management

Answer 5

• Encourage hand washing
• Encourage an increase in fluid intake
• Cool mist humidifier
• Cough medication
• Avoid second hand smoke
• Smoking cessation
• Analgesics for fever and discomfort
• Lots of rest

Question 6

Cystic fibrosis—Clinical manifestations

Answer 6

• Very salty-tasting skin
• Persistent coughing, at times with phlegm
• Frequent lung infections
• Wheezing or shortness of breath
• Poor growth/weight gain in spite of a good appetite
• Frequent greasy, bulky stools or difficulty in bowel movements.
• Stomach pain and discomfort
• Dehydration
• Fatigue
• Weakness
• Decreased blood pressure
• Heat stroke
• Death (severe)

Question 7

Pulmonary embolism—Basic pathophysiology

Answer 7

• PE develops when a blood-borne substance lodges in a branch of the pulmonary artery and obstructs blood flow.
• The embolism may consist of a thrombus, air that has accidentally been injected during intravenous infusion, fat that has been mobilized from the bone marrow after a fracture or from a traumatized fat depot, or amniotic fluid that has entered the maternal circulation during childbirth.
• PE most often is a complication of a condition called deep vein thrombosis (DVT).
• In DVT, blood clots form in the deep veins of the body—most often in the legs. These clots can break free, travel through the bloodstream to the lungs, and block an artery. Deep vein clots are not like clots in veins close to the skin’s surface. Those clots remain in place and do not cause PE.

Question 8

Asthma/Reactive airway disorder—Clinical manifestations

Answer 8

Normal Mild/Moderate Symptoms:
•	Cough 
•	Shortness of Breath 
•	Intercostal Retractions 
•	Wheezing 
•	Anxiety 
•	Use of accessory muscles in breathing, orthopnea 
Occasional Symptoms: 
•	Chest Pain 
•	Tightness in Chest area 
•	Apnea 
Severe Symptoms: 
•	Cyanosis 
•	Dyspnea 
•	Diaphoresis 
•	Tachycardia 
•	Decreased Alertness

Question 9

Chronic obstructive pulmonary disorder (COPD)/Emphysema—Clinical manifestations

Answer 9

• Constant coughing, sometimes referred as “smokers cough”
• Wheezing
• Shortness of breath during every day activities
• Large production of mucus
• Feeling unable to take a deep breath
• Chest tightness
• Greater risk for colds and flu
• Fatigue
• If the symptoms are mild, they may not be noticed. If it is severe it can cause weight loss; swelling in the ankles, feet, or legs and lower muscle endurance. The severity of the symptoms depends on how much lung damage is present.

Question 10

Tb Mantoux Test—Physical findings in a positive test (inspection & palpation)

Answer 10

• There are 2 types of tests to check for TB in a person: the TB skin test, and TB blood test. The most common test, the skin test, is performed by injecting tuberculin into the arm (intradermal). The injected person then returns to the clinic within 72 hours to check for a reaction.
• The blood test works by measuring how the immune system reacts to the TB bacteria. The test measures a person’s immune response to TB by using the blood culture in a laboratory.
• The skin test reaction should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will need to be rescheduled for another skin test.
• The reaction should be measured in millimeters of the induration (palpable, raised, hardened area or swelling). The reader should not measure erythema (redness). The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis).
• > 5 mm HIV+ or recent contact to TB, organ transplants; >10 mm high risk groups, >15 mm persons of all health

Question 11

Atelectasis—Physical assessment findings (auscultation)

Answer 11

• Tachypnea, tachycardia, dyspnea, cyanosis, signs of hypoxemia, diminished chest expansion, absence of breath sounds, and intercostals retractions
• Both chest expansion and breath sounds are decreased on the affected side
• May be intercostals retraction (pulling in of the intercostals spaces) over the involved area during inspiration
• Signs of respiratory distress are proportional to extent of lung collapse

Question 12

Non-Small Cell Lung Cancer (NSCLC)—Population at risk & in class information on 10-08-2013

Answer 12

• Non smoking females 80%
• Non smoking male 60%
• Female smokers 40%
• Male smokers 30%
• Common among Asian population
• Also people 45 years of age and under

Question 13

Pleural effusion—What is it & where does it occur?

Answer 13

• Excess fluid formation from the interstitium of the lung, parietal pleura, peritoneal cavity
• Most common cause is congestive heart failure
• Occurs when rate of fluid formation exceeds the rate of its removal

Question 14

On the first postoperative day after a right lower lobe (RLL) lobectomy, the client deep-breathes and coughs but has difficulty raising mucus. What nursing observation would indicate the client is not adequately clearing secretions?

1. Chest x-ray film showing right-sided pleural fluid
2. A few scattered crackles on RLL on auscultation
3. Increase in PaCO2 from 35 to 45 mm Hg
4. Decrease in forced vital capacity

Answer 14

3
Retained secretions may cause hypoventilation; this results in an increase in the PaCO2. The other options do not effectively reflect a problem with clearing mucus. Pleural fluid is not removed via coughing; the fluid is in the pleural space, not in the lung. Although PaCO2 is within normal limits, there is still an increase noted, which is due to hypoventilation. The nurse cannot easily measure the forced vital capacity at bedside.

(Illustrated, p 337)

Question 15

The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?

1. Because of his need for oxygen, the client will have to limit activity at home.
2. The use of oxygen will eliminate the client’s shortness of breath.
3. Precautions are necessary because oxygen can spontaneously ignite and explode.
4. Use oxygen during activity to relieve the strain on the client’s heart.

Answer 15

4
The primary purpose of oxygen therapy is to decrease the workload of the heart in clients with chronic pulmonary diseases and to assist in preventing right-sided heart failure. Use of oxygen may help to relieve shortness of breath but will not eliminate it. Oxygen supports combustion but is not explosive; supplemental oxygen will allow more activity for the client, not less.

(Illustrated, p 337)

Question 16

The nurse is caring for a client who is experiencing an acute asthma attack. He is dyspneic and experiencing orthopnea; his pulse rate is 120 beats/min. In what order will the nurse provide care to this client? Number the following options in the order in which they will be performed, with 1 being the first action and 4 being the last action.

1. ____ Administer humidied oxygen.
2. ____ Place in semi-Fowler’s position.
3. ____ Provide nebulizer treatment with bronchodilator.
4. ____ Discuss factors that precipitate attack.

Answer 16

2, 1, 3, 4
1 __2__ Because oxygen is a priority, begin administration of oxygen.
2 __1__ The first action is to place the client in semi-Fowler’s position. Oxygen or inhalation therapy cannot be effective with severe orthopnea if the client is not in a sitting or upright position.
3 __3__ Then administer the nebulizer treatment, which would include bronchodilators.
4 __4__ Physiologic needs must be addressed before teaching or psychosocial needs are considered.

(Illustrated, p 337)

Question 17

The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information?

1. “You should avoid emotional situations that increase his shortness of breath.”
2. “Help your husband arrange activities so that he does as little walking as possible.”
3. “Arrange a schedule so your husband does all the necessary activities before noon; then he can rest during the afternoon and evening.”
4. “Your husband will be more short of breath when he walks, but that will not hurt him.”

Answer 17

4
Physical conditioning is important for clients with COPD. Activity needs to be paced so that undue fatigue does not occur. Some increase in shortness of breath with exercise is to be expected but will not damage the lungs. If the client stops exercising before an increase in shortness of breath, he will not experience a training effect.

(Illustrated, p 337)

Question 18

On auscultation, the nurse hears wheezing in a client with asthma. Considering the pathophysiology of asthma, what would the nurse identify as the primary cause of this type of lung sound?

1. Increased respiratory pressure in the upper airways.
2. Dilation of the respiratory bronchioles and increased mucus.
3. Movement of air through narrowed airways.
4. Increased pulmonary compliance.

Answer 18

3
The wheezing is due to narrowing of the airway caused by bronchospasm. Increased mucous production hinders the airway as well; this also results in trapping of air in the alveoli. Increased pulmonary compliance indicates the lungs have good recoil expansion.

(Illustrated, p 338)

Question 19

What finding on the nursing assessment would be associated with a diagnosis of pneumonia in the older adult?

1. Acute confusion
2. Hypertension
3. Hematemesis in the morning
4. Dry hacking cough at night

Answer 19

1
Confusion in the older adult is related to hypoxemia, which occurs with pneumonia. Vasodilation and dehydration cause hypotension and orthostatic changes. Crackles are typically heard when fluid is in the alveolar area. The cough is generally productive. The breathing is rapid and shallow without the use of accessory muscles. Hemoptysis may occur, but not hematemesis (blood from the GI tract).

(Illustrated, p 338)

Question 20

The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client’s condition?

1. Respiratory rate of 18 breaths/min
2. Pulse oximetry of 88%
3. Pulse rate of 110 beats/min
4. Productive cough with rapid breathing

Answer 20

1
The respiratory rate is within normal limits at 18 breaths/min. The option for pulse oximetry is too low. The pulse rate is too high to indicate improvement, and the productive cough with rapid breathing is not as significant as the decrease in respiratory rate.

(Illustrated, p 338)

Question 21

Clients with COPD usually receive low-dose oxygen via nasal cannula. The nurse understands that which problem may occur if the client receives too much oxygen?

1. Hyperventilation
2. Tachypnea
3. Hypoventilation or apnea
4. Increased snoring

Answer 21

3
In clients with chronic high PCO2 levels (COPD), the administration of oxygen at a flow rate that increases the PaO2 may cause apnea and require the use of a bag valve mask resuscitator to ventilate the client. When the PaO2 increases significantly, it can decrease the client’s stimulus to breath and may cause carbon dioxide narcosis.

(Illustrated, p 338)

Question 22

For a client with COPD, what is the main risk factor for pulmonary infection?

1. Fluid imbalance with pitting edema
2. Pooling of respiratory secretions
3. Decreased fluid intake and loss of body weight
4. Decreased anterior-posterior diameter of the chest

Answer 22

2
The ineffective clearing of secretions with resultant pooling can lead to an increased risk for infection. The client’s appetite is usually decreased. The client has an increased anteroposterior diameter of the chest.

(Illustrated, p 338)

Question 23

A client has a history of atherosclerotic blood heart disease with a sustained increase in his blood pressure. What is important to discuss with this client before he uses an over-the-counter decongestant?

1. Urinary frequency and diuresis
2. Bradycardia and diarrhea
3. Vasoconstriction and increased arterial pressure
4. Headache and dysrhythmias

Answer 23

3
Decongestants should be avoided by clients with hypertension because these medications often contain pseudoephedrine and phenylephrine, which cause central nervous system stimulation with vasoconstriction and increased blood pressure. They also precipitate anxiety and insomnia. Decongestants do not cause urinary frequency, diuresis, or dysrhythmias.

(Illustrated, p 338)

Question 24

Croup/epiglottis – Clinical manifestations— What are the respirations like?

Answer 24

• Inspiratory stridor
• Hoarseness
• Barking cough
• Epiglottis can have edema –> asphyxiation

Question 25

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

1. Hypocapnia
2. A hyperinflated chest noted on the chest x-ray
3. Increased oxygen saturation with exercise
4. A widened diaphragm noted on the chest x-ray

Answer 25

2
Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

(Yellow book, p 755)

Question 26

A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:

1. Promote oxygen intake
2. Strengthen the diaphragm
3. Strengthen the intercostal muscles
4. Promote carbon dioxide elimination

Answer 26

4
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not purposes for this type of breathing.

(Yellow book, p 755)

Question 27

A nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?

1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate

Answer 27

4
The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

(Yellow book, p 756)

Question 28

A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported?

1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken

Answer 28

3
The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

(Yellow book, p 756)

Question 29

A client who is human immunodeficiency virus-positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as:

1. Positive
2. Negative
3. Inconclusive
4. Indicating the need for repeat testing

Answer 29

1
The client with human immunodeficiency virus (HIV) infection is considered to have positive results on Mantoux skin testing with an area larger than 5 mm of induration. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

(Yellow book, p 756)

Question 30

A nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis?

1. Chest x-ray
2. Bronchoscopy
3. Sputum culture
4. Tuberculin skin test

Answer 30

3
Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

(Yellow book, p 757)