Chapter 27: Acute Lower Respiratory Disorders 1

50問 • 1年前

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While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?

Cover the insertion site with sterile gauze.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?

Encourage oral rinsing after fluticasone administration.

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?

Keep the client isolated from other clients with cystic fibrosis.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?

Administer pain medication and encourage the client to take deep breaths.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?

When the tube becomes disconnected from the drainage system

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations?

Increased pulmonary pressure creating a higher workload on the right side of the heart

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?

"Do you experience shortness of breath with basic activities?"

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond?

It is important to use this type of inhaler every day. Lets identify potential community services to help you.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?

A 52 year old in a tripod position using accessory muscles to breathe

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?

I plan to use cotton balls to cushion the oxygen tubing on my ears.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Keep padded clamps at the bedside for use if the drainage system is interrupted.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, What does this mean? How should the nurse respond?

"Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke."

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

"Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested."

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication?

Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system

A nurse auscultates a clients lung fields. Which pathophysiologic process should the nurse associate with this breath sound?

inflammation of the pleura

A nurse auscultates a clients lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.)

Assess for airway obstruction.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L Heart rate = 110 beats min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first?

Initiate oxygenation therapy to increase saturation to 92%.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)

Administer oxygen to keep saturations greater than 94%., Administer prescribed albuterol (Proventil) inhaler.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.)

Tracheal deviation, Sudden onset of shortness of breath, Drainage greater than 70 mL/hr, Disconnection at Y site

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.)

Avoid drinking fluids just before and during meals., Rest before meals if you have dyspnea., Have about six small meals a day

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.)

"Do you have any difficulty sleeping?", "How long does it take to perform your morning routine?", "Have you lost any weight lately?"

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)

Tracheal deviation, Sudden onset of shortness of breath

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

Ask the client to drink 2 liters of fluids daily., Use a vibrating positive expiratory pressure device., Add humidity to the prescribed oxygen.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the clients safety while on this medication? (Select all that apply.)

Keep an intravenous line dedicated strictly to the infusion., Ensure that there is always a backup drug cassette available., Use strict aseptic technique when using the drug delivery system.

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak cough effort

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

increased tactile fremitus

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?

Assist the patient to splint the chest when coughing.

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?

"I will continue to do deep breathing and coughing exercises at home."

Which action should the nurse plan to prevent aspiration in a high-risk patient?

Place a patient with altered consciousness in a side-lying position.

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?

The patient's white blood cell (WBC) count is 9000/μL.

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?

Teach the patient about providing specimens for 3 consecutive days.

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?

Sputum smears for acid-fast bacilli are negative.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

"My spouse will sleep in another room."

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?

Explain that orange discolored urine and tears are normal while taking this medication.

An older patient is receiving standard multi drug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

Yellow-tinged sclera

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

Arrange for a daily meal and drug administration at a community center.

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?

Ask the patient whether medications have been taken as directed.

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?

Use and side effects of isoniazid

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 surgical face mask is applied before visiting the patient.

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?

Require the use of protective equipment.

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?

"Tell me what you know about the treatments available."

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 should the nurse take?

Administer the prescribed morphine.

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?

"Can you tell me what it is that makes you think you will die so soon?"

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxical chest movement

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Chest tube connected to suction

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?

Continue to monitor the collection device.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care?

Frequent use of an incentive spirometer

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?

Observe for distended neck veins.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?

Patient reports a decrease in exertional dyspnea.

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