Lewis Chapter 30: Lower Respiratory Conditions Flashcards
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 38.6°C (101.5°F), a productive cough with yellow sputum, and a respiratory rate of 20 breaths/minute. Which of the following nursing diagnoses 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
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 the patient’s 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.
Which of the following physical assessment findings 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
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.
Which of the following clinical manifestations should the nurse expect to find during an assessment of a patient who has been admitted with pneumococcal pneumonia?
A. Hyper-resonance on percussion
B. Vesicular breath sounds in all lobes
C. Increased tactile fremitus on palpation
D. Fine crackles in all lobes on auscultation
C. Increased tactile fremitus on palpation
A typical physical examination finding for a patient with pneumonia is increased tactile fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following 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
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, but does not liquefy the secretions so that they can be removed.
The nurse is providing discharge teaching to an older person with chronic obstructive pulmonary disease (COPD) and pneumonia. Which of the following vaccines should the nurse recommend that this patient receive?
A. Staphylococcus aureus
B. Haemophilus influenzae
C. Pneumococcal
D. Bacille Calmette–Guérin (BCG)
C. 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.
The nurse is providing discharge teaching to a patient that was hospitalized with pneumonia. Which of the following patient statements about measures to prevent a relapse indicates that the teaching has been effective?
A. “I will seek immediate medical treatment for any upper respiratory infections.”
B. “I will increase my food intake to 2 400 calories a day to keep my immune system well.”
C. “I should continue to do deep-breathing exercises for at least 6 weeks.”
D. “I must use home oxygen therapy for three months and then will have a chest X-ray to re-evaluate.”
C. “I should continue to do deep-breathing exercises for at least 6 weeks.”
It is important for the patient to continue with deep-breathing exercises for 6–8 weeks until all of the infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions. Home oxygen is not a requirement unless the patient’s oxygenation saturation is below normal.
The nurse is admitting a patient to the medical unit with a diagnosis of pneumonia. Which of the following orders should the nurse verify the completion of before administering a dose of trimethoprim-sulfamethoxazole to the patient?
A. Orthostatic blood pressures
B. Sputum culture and sensitivity
C. Pulmonary function evaluation
D. Serum laboratory studies ordered for the morning
B. Sputum culture and sensitivity
The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering trimethoprim-sulfamethoxazole. It is important that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; 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, all of the other options will not be affected by the administration of antibiotics.
Which of the following nursing interventions 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
C. Positioning patient with “good lung down”
Therapeutic positioning identifies the best position for the patient 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.
The nurse is admitting a patient with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions 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.
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 complete a focused assessment—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.
The nurse is planning care for a patient with metastatic lung cancer who has a 60-pack-per-year history of cigarette smoking. Which of the following respiratory defences is impaired related to tobacco use?
A. Cough reflex
B. Mucociliary clearance
C. Reflex bronchoconstriction
D. Ability to filter particles from the air
B. Mucociliary clearance
Smoking affects the bronchial epithelium, which ultimately decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
The nurse is assisting a patient with metastatic lung cancer to ambulate when the nurse observes a decrease in oxygen saturation from 93% to 86%. Which of the following nursing interventions is best for the nurse to implement?
A. Continue with ambulation since this is a normal response to activity.
B. Obtain a prescription for arterial blood gas determinations to verify the oxygen saturation.
C. Obtain a prescription 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.
C. Obtain a prescription 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 nurse is caring for a patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient has symptoms of shortness of breath, slight chest pain, and reports that “something is wrong.” Upon assessment, the nurse notes the patient’s temperature is 36.9°C (98.4°F), blood pressure 130/88 mm Hg, respirations 36 breaths/minute, and oxygen saturation 91% in room air. Which of the following etiologies should the nurse first suspect related to these findings?
A. New onset of angina pectoris
B. Septic embolus from the knee joint
C. Pulmonary embolus from deep vein thrombosis
D. Pleural effusion related to positioning in the operating room
C. Pulmonary embolus from deep vein thrombosis
The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
The nurse is caring for a patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient has symptoms of shortness of breath, slight chest pain, and reports that “something is wrong.” Upon assessment, the nurse notes that the patient’s temperature is 36.9°C (98.4°F), blood pressure 130/88 mm Hg, respirations 36 breaths/minute, and oxygen saturation 91% in room air. Which of the following actions should the nurse take first?
A. Notify the health care provider.
B. Administer nitroglycerine sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen.
D. Sit the patient up in bed as tolerated and apply oxygen.
The patient’s clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.
What clinical manifestations should the nurse expect when assessing a client with pneumococcal pneumonia?
a. Fever, chills, and a productive cough with purulent sputum
b. Nonproductive cough and night sweats that are usually self-limiting
c. Gradual onset of nasal stuffiness, sore throat, and purulent productive cough
d. Abrupt onset of fever, nonproductive cough, and formation of lung abscesses
A.
A client with pneumonia has the nursing diagnosis of inadequate airway clearance from an excessive amount of mucus and retained secretions. What would be an appropriate nursing intervention?
a. Promote fluid hydration, as appropriate, to help liquefy secretions.
b. Provide analgesics as ordered to promote client comfort.
c. Administer oxygen as prescribed to maintain optimal oxygen levels.
d. Teach the client how to cough effectively to bring secretions to the mouth.
A.
A client with tuberculosis (TB) has a history of nonadherence to the medication regimen. What is the most common cause of this behaviour in clients with TB?
a. Fatigue and lack of energy to manage self-care
b. Lack of knowledge about how the disease is transmitted
c. Lack of social support systems for the client and family
d. Feelings of shame and the response to the social stigma associated with TB
D.
