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The health care provider performs a thoracentesis on a patient with a right pleural effusion. In preparing the patient for the procedure, the nurse positions the patient
The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have
Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Slow, shallow respirations, a low oxygen saturation rate, and a decrease in PVO2 would not be caused by acidosis.
A patient who has a 30-pack-year history of smoking asks the nurse, “How does smoking really harm my lungs?” The nurse’s response will be based on the effect of smoking on
Smoking decreases ciliary action and the ability of the mucociliary clearance system to trap particles and move them out of the lung. The cough/gag reflexes, reflex bronchoconstriction, and filtration of air by the nasal hairs are not affected by smoking.
An 80-year-old patient breathing room air has an ABG analysis. The nurse interprets which results as normal?
All the values in this answer are correct. The answer beginning “pH 7.32, PaO2 85 mm Hg” shows respiratory acidosis. The answer beginning “pH 7.48, PaO2 90 mm Hg” indicates respiratory alkalosis, and the answer beginning “pH 7.52, PaO2 91 mm Hg” shows metabolic alkalosis.
A patient with COPD is admitted to the hospital with dyspnea and a cough producing yellow sputum. When palpating the patient’s thorax, the nurse will expect to find that chest expansion is
Chronic lung hyperinflation, such as occurs in COPD, decreases expansion of the lungs with inspiration. Lung expansion is usually symmetrical with emphysema.
On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes. The nurse records this finding as
Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of the respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, “bubbling’ sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
A patient with COPD has a “barrel chest.” The nurse would expect the chest x-ray report to indicate that there is
A barrel chest results from lung hyperinflation and is a common finding in patients with COPD. Consolidation, fluid, and air in the pleural space all would indicate that intervention is needed.
When admitting a patient who has a pleural effusion, which technique will the nurse use to assess for tactile fremitus?
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as “99.” Percussion, palpation with the fingertips, and auscultation are also used during the respiratory assessment but will not assess for fremitus.
A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the bronchoscopy, the nurse should
Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Vital signs are monitored immediately after the procedure but should not need to be obtained every 15 minutes for 2 hours. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler’s position.
A patient who is restricted to bed rest asks the nurse the purpose of the deep breathing exercises. Which reply by the nurse is correct?
Taking deep breaths or sighs usually occurs every five to six breaths and (through alveolar stretching and improved surfactant production) decreases the risk for atelectasis. Ciliary activity, diaphragmatic strength, and the respiratory rate are not changed by deep breathing.
When auscultating a patient’s chest while the patient takes a deep breath, the nurse hears loud, high-pitched, “blowing” sounds at both lung bases. The nurse will document these as
The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base. Adventitious sounds are crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi.
In analyzing the results of a patient’s blood gas analysis, the nurse will be most concerned about an
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient’s oxygenation.
While assessing the role-relationship health pattern in a patient with respiratory problems, the nurse should specifically ask about
The role-relationship pattern includes information about the occupational exposure to fumes and allergens. History of cigarette smoking and the course of the illness are assessed in the health perception-health management pattern. Alterations in sexuality are assessed in the sexuality-reproductive pattern.
While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 94% to 85% when the patient ambulates in the hall. The nurse determines that
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. ABG measurements are unnecessary and would increase patient discomfort and expense. The patient will need to continue to ambulate to avoid the many complications of immobility.
In reviewing the results of a patient’s pulmonary function test, the nurse recognizes that a patient with COPD is likely to have an increased
Because elastic recoil of the lungs is decreased with COPD, the residual volume is increased. Tidal volume, forced vital capacity, and peak expiratory flow rate are likely to be decreased.
The nurse is observing a student who is auscultating a patient’s lungs. Which action by the student indicates that the nurse should intervene?
The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable.
When assessing the respiratory system of a 78-year-old patient, which of these data indicate that the nurse should take immediate action?
Crackles in the lower two thirds of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.
When performing an assessment of the patient’s respiratory system, the nurse uses the following illustrated technique to evaluate
When assessing chest expansion on the posterior chest, the nurse will place the hands at the level of the 10th rib, position the thumbs until they meet over the spine, and have the patient breathe deeply. Tactile fremitus is assessed by having the patient repeat a word or phrase such as “ninety-nine” while the nurse uses the palms of the hands to assess for vibration. Accessory muscle use and anterior-posterior diameter are assessed during inspection of the chest and do not require palpation.
A patient with chronic hypoxemia (SaO2 levels of 89%-90%) caused by COPD has just been admitted with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching?
Hypoxemia interferes with the patient’s ability to learn and retain information, so having the patient’s spouse present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.
A patient is admitted to the emergency department complaining of sudden onset shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a
Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of malignancy
The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use?
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
A patient is scheduled for a spiral CT scan to rule out a pulmonary embolus. Which information obtained by the nurse is most important to communicate to the health care provider before the examination?
Because the contrast solution is iodine-based, the patient may need to have the CT scan without contrast or be premedicated before contrast injection. The irregular pulse, oxygen saturation, and tachypnea all need further assessment or intervention but are not unusual for a patient with a possible pulmonary embolus.
Chapter 27: Nursing Management: Upper Respiratory Problems
A patient has undergone a rhinoplasty to correct nasal deformities resulting from trauma during an automobile accident. The nursing intervention that is most appropriate postoperatively is to
Maintaining the head in an elevated position will decrease the amount of nasal swelling. Although acetaminophen may be appropriate, aspirin and the NSAIDs will increase the risk for postoperative bleeding. The nasal packing is usually removed the next day. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result.
When the nurse removes a nasogastric (NG) tube that has been in place for 7 days, the patient develops a nosebleed. To control the bleeding, the nurse should initially
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. The patient should be sitting and leaning forward. Ice compresses may be helpful in decreasing bleeding but is not the most appropriate initial action. If the bleeding persists, the nares may be packed with ribbon gauze by the health care provider.
When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that
The most important intervention is to assist the patient to identify and avoid potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.
After discussing care of upper respiratory infections (URI) and prevention of secondary infections with a patient who has a URI, the nurse determines that additional teaching is needed when the patient says
The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.
A patient who has sleep apnea and has been using CPAP for 2 weeks returns to the sleep clinic and tells the nurse, “My sleep has not improved at all.” Which response by the nurse is most appropriate?
Although CPAP is very effective in improving sleep quality in patients with sleep apnea, many patients are noncompliant with this therapy. The nurse should be sure that the patient is actually using the CPAP. When CPAP is used, the effects on sleep quality are immediate. Surgery may be an appropriate therapy for the patient, but suggesting surgery would not be an appropriate first action by the nurse in this situation. CPAP using higher pressures will make it more difficult for the patient to exhale and is likely to decrease compliance with therapy.
The nurse is reviewing the charts for these patients who are scheduled in October for their yearly physical examinations. The nurse will plan on administration of the influenza vaccine injection to the
It is recommended that patients who are immune compromised receive yearly influenza vaccinations. The corticosteroid use by the 30-year-old increases the risk for infection. The other three individuals are not at increased risk for influenza. Current guidelines suggest that healthy individuals between ages 5 and 49 receive intranasal immunization with live, attenuated influenza vaccine (FluMist).
The nurse notes all of these findings in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?
The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as OTC pain relievers and increased fluid intake.
A patient who has been diagnosed with sleep apnea has CPAP ordered. Which of these nursing actions in the plan of care can the RN delegate to a nursing assistant?
Reminding a patient about previously taught self-care activities is within the education level and scope of practice for a nursing assistant. Assessment and teaching are skills that require higher-level nursing education and scope of practice.
An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?
Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 2 minutes of preoxygenation, this would not be unsafe; 10 seconds of suction is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube.
When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient’s ability to swallow, it is important to
The patient’s mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.
A spontaneously breathing patient who has a cuffed tracheostomy tube in place has new orders for speech therapy and a soft diet. To evaluate whether the patient can safely have the cuff deflated to promote speaking and make swallowing easier, the nurse deflates the cuff and then
Assessing the ability of the patient to drink a colored fluid, such as grape juice, will provide evidence that the patient will not aspirate. Even if the patient is able to talk, aspiration may occur. Because the patient is already breathing spontaneously, deflating the cuff would not cause respiratory distress. Although aspiration may lead to complications such as pneumonia, the absence of lung crackles immediately after drinking a clear liquid is not a clear indicator that aspiration has not occurred.
A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. The nurse’s first action should be to
The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient’s airway. Assessing the patient’s oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler’s position, but the neck should remain in a neutral position.
A patient with a tracheostomy is to use a fenestrated tracheostomy tube to provide for speech. Which of the following interventions will be included in the plan of care?
Because the cuff is deflated when using a fenestrated tube, the patient’s risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient’s airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient’s vocal cords.
When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to
Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider’s order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.
A patient is discharged from the hospital with a tracheostomy tube for long-term airway management. The nurse determines that teaching related to care of the tracheostomy has been effective when the patient says,
It takes several months for the formation of a fully healed tract, so the patient is taught to leave the tracheostomy tube in place for several months. Clean (rather than sterile) gloves and catheters are used for suctioning at home to decrease expense. Semisoft foods, rather than liquids, are the easiest to swallow. Water should not be instilled into the tracheostomy; thick secretions may indicate the need for more fluid intake or humidification.
A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?
Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not effect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Use of lotions on skin being radiated is avoided.
The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask?
Prolonged alcohol use is associated with the development of laryngeal cancer, which the patient’s symptoms and history suggest. Use of chewing tobacco or snuff is associated with oral cancers rather than throat cancers. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but this is not the priority assessment to obtain at this time. Streptococcal throat infections may also cause these clinical manifestations, but patients will also complain of pain and fever.
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, “How will I talk after the surgery?” The best response by the nurse is,
Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.
The most important goals post-tracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the airway and breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding are also appropriate nursing actions but are not of as high a priority.
A nursing diagnosis of body image disturbance related to loss of control of personal care is identified for a patient with a total laryngectomy and radical neck dissection. The nurse evaluates that an expected outcome for the problem has been met when the patient
Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and the body image disturbance is at least partially resolved. Allowing the spouse to provide care, allowing family members to visit, and wearing clothing that masks the body changes are outcomes that do not directly address this nursing diagnosis.
After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says,
The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.
The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of these assessments will require the most immediate action by the nurse?
Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to assess further for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the fall in O2 saturation.
After teaching a patient with allergic rhinitis how to use a nasal inhaler, the nurse observes the patient self-administering a medication with the inhaler. Which patient action indicates that more teaching is needed?
The nurse needs to teach the patient to breathe out through the mouth after inhaler use to avoid exhaling some of the medication. The other patient actions indicate that the teaching has been effective.
The teaching plan for a patient with acute sinusitis will need to include which of the following interventions? (Select all that apply.)
Maintaining an upright posture decreases sinus pressure and the resulting pain. The steam and heat from a shower will help thin secretions and improve drainage. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Cool compresses will not improve drainage. Antihistamines are drying to the mucosa and tend to thicken secretions, making them more difficult to expel. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.
The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems?
The patient should first be placed in a semi-Fowler’s position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the Hemovac should be drained because the 200 ml of drainage will decrease the amount of suction in the Hemovac and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.
Chapter 28: Nursing Management: Lower Respiratory Problems
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
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.
A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first?
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion. Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric chest expansion is not typical with pneumonia.
To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
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 in patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia.
The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia?
The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria. The other patients do not meet the criteria for discharge.
A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is
All these nursing diagnoses are appropriate for the patient, but the patient’s oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next?
New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change in status.
Following discharge teaching, the nurse evaluates that the patient who was admitted with pneumonia understands measures to prevent a reoccurrence of the pneumonia when the patient states,
Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep breathing and coughing exercises or both for 6 to 8 weeks after discharge. Although caloric needs are increased during the acute infection, 3000 calories daily will lead to obesity and increase the risk for pneumonia. Patients with acute lower respiratory infections do not usually require home oxygen therapy. Upper respiratory infections require medical treatment only when they fail to resolve in 7 days.
To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to
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 pneumonias in immune compromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant
Positioning the patient with the left (or “good” lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia.
A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen?
Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no need to wait until the tuberculin skin test is administered.
A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the disease can be transmitted to others until
The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest x-rays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment. Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum smears are usually done to establish that treatment has been effective.
The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB
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.
A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan?
Peripheral neurotoxicity associated can be prevented by taking vitamin B6 when being treated with INH. Visual changes, hearing problems, and orange staining are adverse effects of other TB medications.
When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops
Noninfectious hepatitis is a toxic effect of 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 drug therapy. 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 TB. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
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 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 with this patient.
After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). The nurse discusses the treatment regimen with the patient with the knowledge that
After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. The nurse will need to initiate DOT if the patient has not been consistently taking the medications. Toxic reactions to the medications would not result in a positive sputum smear. Twice-weekly medication administration is not one of the options for therapy. INH and rifampin are used for the last 4 months of drug therapy only if the initial four-drug regimen has been effective as evidenced by negative sputum smears.
A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
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 and would not be helpful for this individual, who already has a TB infection.
During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases the patient’s tolerance of the drug by
Administration of an antihistamine before giving the amphotericin B will reduce the incidence of hypersensitivity reactions. Cooling the solution and keeping the patient flat after infusion are not indicated. Amphotericin B does not need to be diluted in 500 ml of fluid, although the nurse should ensure adequate hydration in the patient receiving this drug.
The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask?
Patients who have received the BCG vaccine will have a positive Mantoux test; another method for screening (such as a chest x-ray) will be used in determining whether the patient has a TB infection. The other information may also be valuable but is not as pertinent to the decision about doing TB skin testing.
When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient 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 patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will monitor workers for
The nurse will monitor for the earliest signs of occupational lung disease, which are dyspnea and a cough. The other symptoms are also consistent with occupational lung disease but would occur much later, after significant lung involvement has occurred.
When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about
Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Tarceva may be used to in patients who have lung cancer, but not to reduce risk for developing tumors.
A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have radiation than surgery.” Which response by the nurse is most appropriate?
More assessment of the patient’s 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 patient’s reasons for not wanting surgery.
An hour after a left upper lobectomy, a patient complains of 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 action should the nurse take first?
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 think I am going to die pretty soon, maybe this week.” The best response by the nurse is
The nurse’s initial response should be to collect more assessment data about the patient’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 patient thinks that the cancer will be immediately fatal, although the patient’s 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.
A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should
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 patient 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 patient should receive oxygen, but this will have no effect on the development of tension pneumothorax.
The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe 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 patient with pneumothorax.
A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about
Paradoxic chest movement indicates that the patient may have flail chest, which will severely compromise gas exchange and can rapidly lead to hypoxemia. Severe pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if
Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest movement is associated with flail chest.
The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse’s first action should be to
A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to
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.
When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes
Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients 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.
A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis?
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. Lung crackles, a murmur, and numbness and tingling are not caused by cor pulmonale.
The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action?
The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.
A patient with primary pulmonary hypertension is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if
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 patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.
A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to
When the patient 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 patient does not usually require sedation for the procedure and there are no restrictions on oral intake, since the patient is not sedated or unconscious.
After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states
After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results. Patients 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 and patients would not usually have a central IV line.
A patient who was admitted the previous day with pneumonia complains of a sharp pain “whenever I take a deep breath.” Which action will the nurse take next?
The patient’s statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. The re is no indication that the oxygen saturation has decreased The patient 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.
A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give?
A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the patient has TB, the nurse should focus on the patient, rather than on the public health concerns.
All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to the health care provider?
The low BP may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin therapy. Subcutaneous heparin administration is given into the subcutaneous tissue of the abdomen and abdominal bruising is not unusual. An aPTT 2 times the baseline indicates a therapeutic heparin level. The patient should be monitored for gastrointestinal bleeding, which would be indicated by black or red stools.
In developing a teaching plan for a patient who is being discharged with a warfarin (Coumadin) prescription after having a pulmonary embolus, the nurse will include information about
The patient who is taking Coumadin should have a consistent vitamin K intake, since vitamin K interferes with the effect of the medication. INR testing, rather than aPTT testing, is used to monitor for a therapeutic level of Coumadin. Aside from vitamin K, there are no other dietary requirements associated with Coumadin use. Aspirin should be avoided when taking anticoagulant medications because of the effect on platelet function.
Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider?
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.
All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first?
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.
The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first?
Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate evaluation by the nurse. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse’s first action should be to
The patient 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).
Chapter 29: Nursing Management: Obstructive Pulmonary Diseases
A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the health care provider immediately about
Decreased breath sounds and wheezing would indicate that the patient was experiencing an asthma attack, and immediate bronchodilator treatment would be indicated. The other data indicate that the patient needs ongoing monitoring and assessment but do not indicate a need for immediate treatment.
The nurse recognizes that intubation and mechanical ventilation are indicated for a patient in status asthmaticus when
Although all of the assessment data indicate the need for rapid intervention, the fatigue and hypoxia indicate that the patient is no longer able to maintain an adequate respiratory effort and needs mechanical ventilation. The initial treatment for the other clinical manifestations would initially be administration of rapidly acting bronchodilators and oxygen.
An asthmatic patient who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that
Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid; they work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not used during an acute attack because the medications do not work rapidly.
The health care provider has prescribed triamcinolone (Azmacort) metered-dose inhaler (MDI) two puffs every 8 hours and pirbuterol (Maxair) MDI 2 puffs four times a day for a patient with asthma. In teaching the patient about the use of the inhalers, the best instruction by the nurse is
More medication reaches the bronchioles when a spacer is used along with an MDI. There is no evidence that using a bronchodilator before a corticosteroid inhaler is helpful. The medications can be used at the same time. The patient should inhale slowly when using an MDI.
When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to
Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should also be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.
The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. A common etiologic factor for this nursing diagnosis in patients with asthma is
The activity intolerance patients with asthma experience is related to the increased effort needed to breathe when airways are inflamed and narrowed and interventions are focused on decreasing inflammation and bronchoconstriction. The other listed etiologies are not as appropriate for this diagnosis but would be appropriate for diagnoses seen in patients with asthma, such as social isolation, knowledge deficit, and anxiety
Which finding would be the best indication to the nurse that the patient having an acute asthma attack was responding to the prescribed bronchodilator therapy?
Louder wheezes indicate that more air is moving through the airways and that the bronchodilator therapy is working. An oxygen saturation level less than 90% indicates continued hypoxemia. Vesicular breath sounds are normal. A decreased respiratory effort may indicate that the patient is becoming too fatigued to breathe effectively and needs mechanical ventilation.
A patient who has mild persistent asthma uses an albuterol (Proventil) inhaler for chest tightness and wheezing has a new prescription for cromolyn (Intal). To increase the patient’s management and control of the asthma, the nurse should teach the patient to
Cromolyn is prescribed to reduce airway inflammation. It takes several weeks for maximal effect and is not used to treat acute asthma symptoms Albuterol is used as a rescue medication in mild persistent asthma and will not decrease inflammation.
During assessment of a patient with a history of asthma, the nurse notes wheezing and dyspnea. The nurse will anticipate giving medications to reduce
The symptoms of asthma are caused by inflammation and spasm of the bronchioles, leading to airway narrowing. Treatment for laryngospasm or pulmonary edema would not be appropriate. There are no medications used to treat alveolar distention.
A patient with an acute attack of asthma comes to the emergency department, where ABGs are drawn. The nurse determines the patient is in the early phase of the attack, based on the ABG results of
The initial response to hypoxemia caused by airway narrowing in a patient having an acute asthma attack is an increase in respiratory rate, which causes a drop in PaCO2. The other PaCO2 levels are normal or elevated, which would indicate that the attack was progressing and that the patient is decompensating.
While teaching a patient with asthma the appropriate use of a peak flow meter, the nurse instructs the patient to
It is recommended that patients check peak flows when asthma symptoms or attacks occur to compare the peak flow with the baseline. Increased doses of rapidly acting β2-agonists are indicated for peak flows in the red zone. Peak flows should be checked every morning before using medications. Peak flows are assessed during rapid exhalation
A 32-year-old patient is seen in the clinic for dyspnea associated with the diagnosis of emphysema. The patient denies any history of smoking. The nurse will anticipate teaching the patient about
When emphysema occurs in young patients, especially without a smoking history, a congenital deficiency in α1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with emphysema.
When teaching a patient with chronic obstructive pulmonary disease (COPD) about reasons to quit smoking, the nurse will explain that long-term exposure to tobacco smoke leads to a
Tobacco smoke leads to an increase in proteolytic enzymes, which break down alveolar walls and lead to less alveolar surface area for gas exchange. Bronchial smooth muscle is not weakened by chronic smoking. Polycythemia is a common compensatory mechanism for patients with COPD. The quantity of respiratory secretions increases as a result of smoking.
Which of these is the best goal for the patient admitted with chronic bronchitis who has a nursing diagnosis of ineffective airway clearance?
The goal for the nursing diagnosis of ineffective airway clearance is to maintain a clear airway by coughing effectively. The other goals may be appropriate for the patient with COPD, but they do not address the problem of ineffective airway clearance.
A patient with an acute exacerbation of COPD has the following ABG analysis: pH 7.32, PaO2 58 mm Hg, PaCO2 55 mm Hg, and SaO2 86%. The nurse recognizes these values as evidence of
The elevated PaCO2 and low pH indicate respiratory acidosis. The patient is hypoxemic and hypercapnic, but the pH indicates acidosis, not a normal acid-base balance.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements for a patient with COPD. An appropriate intervention for this problem is to
Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.
A patient is seen in the clinic with COPD. Which information given by the patient would help most in confirming a diagnosis of chronic bronchitis?
A diagnosis of chronic bronchitis is based on a history of having a productive cough for several months for at least 2 consecutive years. There is no familial tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.
The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by
Pursed-lip breathing increases the airway pressure during the expiratory phase and prevents collapse of the airways, allowing for more complete exhalation. Although loosening of secretions, improving inhalation, and decreasing anxiety are desirable outcomes for the patient with COPD, pursed-lip breathing does not directly impact these.
The nurse makes a diagnosis of impaired gas exchange for a patient with COPD in acute respiratory distress, based on the assessment finding of
The best data to support the diagnosis of impaired gas exchange are abnormalities in the ABGs or pulse oximetry. The other data would support a diagnosis of risk for impaired gas exchange.
When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for
Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular vein distension. The other clinical manifestations may occur in the patient with other complications of COPD but are not indicators of cor pulmonale.
When a patient with COPD is receiving oxygen, the best action by the nurse is to
The best way to determine the appropriate oxygen flow rate is by monitoring the patient’s oxygenation either by ABGs or pulse oximetry; an oxygen saturation of 90% indicates adequate blood oxygen level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an oxygen flow rate of 2 L/min may not be adequate. Because oxygen use improves survival rate in patients with COPD, there is not a concern about oxygen dependency. The patient’s perceived dyspnea level may be affected by other factors (such as anxiety) besides blood oxygen level.
A patient with COPD asks the home health nurse about home oxygen use. The nurse should teach the patient that long-term home O2 therapy
Research supports the use of home oxygen to improve quality of life and prognosis. Oxygen dependency is not an issue for patients with COPD. Although most patients using home oxygen have SpO2 levels less than 89% on room air, it would not be appropriate to tell the patient that he or she was at the end stage of the disease. Oxygen use at night can improve sleep quality and is frequently recommended.
A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse
The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or non-rebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation.
Postural drainage with percussion and vibration is ordered bid for a patient with chronic bronchitis. The nurse will plan to
Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 to 15 minutes. Percussion and vibration are done after the postural drainage. Bronchodilators are administered before chest physiotherapy.
When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe COPD, the nurse should teach the patient that an appropriate exercise goal is to
The goal for exercise programs for patients with COPD is to increase exercise time gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient’s exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).
A patient with severe COPD tells the nurse, “I wish I were dead! I cannot do anything for myself anymore.” Based on this information, the nurse identifies the nursing diagnosis of
The patient’s statement about not being able to do anything for himself or herself supports this diagnosis. Although hopelessness, anticipatory grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the patient does not mention long-term stress, death, or an unknown outcome as being concerns.
A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange?
Patients with COPD improve the mechanics of breathing by sitting up in the “tripod” position. Resting in bed with the head elevated would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg’s position or sitting upright in bed with the knees flexed would decrease the patient’s ability to ventilate well.
A patient with COPD tells the nurse, “At home, I only have to use an albuterol (Proventil) inhaler. Why did the doctor add an ipratropium (Atrovent) inhaler while I’m in the hospital? The appropriate response by the nurse is
Combining bronchodilators improves effectiveness. Atrovent does not have to be used before Proventil, it does not decrease airway inflammation, and it does not require hospitalization.
The nurse has completed teaching a patient about MDI use. Which patient statement indicates that further patient teaching is needed?
This method is no longer recommended as a means of determining whether the medication needs replacement. The other patient statements are accurate and indicate the patient understands how to use the MDI.
A 23-year-old with cystic fibrosis (CF) is admitted to the hospital. Which intervention will be included in the plan of care?
Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.
A 26-year-old patient has had CF since birth and has severe lung changes and cor pulmonale as a result of the disease. An appropriate expected outcome is that the patient will
The patient’s severe lung disease and cor pulmonale are late complications of CF, and a realistic attitude about what outcome can be expected from treatment is an appropriate outcome. Exercising without dyspnea and weaning from home oxygen therapy are not realistic outcomes for this patient with end-stage disease. The patient already has multiple CF-related complications and is likely to continue to develop complications.
A 19-year-old male patient with CF and his wife are considering having a child. Which statement by the patient indicates that the nurse’s teaching has been effective?
Children of patients with CF are either CF carriers or have the disease. Most men with CF are sterile, but erectile dysfunction is not associated with CF. The life expectancy for CF is getting longer, with a mean age of 35. Despite appropriate therapy, the couple is likely to experience problems becoming pregnant.
The nurse caring for a patient with CF recognizes that the manifestations of the disease are caused by the pathophysiologic processes of
CF is characterized by abnormal secretions of exocrine glands, mainly of the lungs, pancreas, and sweat glands. Damage to lung tissue develops late in the disease. The goblet cells continue to produce mucus.
All of these orders are received for a patient having an acute asthma attack. Which one will the nurse administer first?
Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.
Which statement by the COPD patient indicates that the nurse’s teaching about nutrition has been effective?
High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.
When teaching the patient with COPD about exercise, which information should the nurse include?
Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.
The nurse has received a change-of-shift report about these patients with COPD. Which patient should the nurse assess first?
A respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic patient.
Which information given by an asthmatic patient during the admission assessment will be of most concern to the nurse?
Long-acting β2-agonists should be used only in patients who are also using another medication for long-term control (typically an inhaled corticosteroid). Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.
When taking an admission history of a patient with possible asthma who has new-onset wheezing and shortness of breath, the nurse will be most concerned about which information?
β-blockers such as propranolol can cause bronchospasm in some patients. The other information will be documented in the health history but does not indicate a need for a change in therapy.
A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse’s first action should be to
Assessment of the patient’s breath sounds will help to determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient’s status at present. Most patients having an acute attack will be unable to cooperate with a FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.
After teaching the patient with asthma about home care, the nurse will evaluate that the teaching has been successful if the patient states,
Peak flows of 80% or greater indicate that the asthma is well controlled. Corticosteroids are long-acting, prophylactic therapy for asthma and are not used to treat acute dyspnea. Because asthma is an acute and intermittent process, home oxygen is not used. The patient who has effective treatment should sleep throughout the night without waking up with dyspnea.
Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome
It will be most important for the nurse to check pulse oximetry for which of these patients?
: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause problems with hypercapnia because of ventilatory failure.
The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has
Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema, and ARDS are more commonly associated with hypoxemia.
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of
: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker, which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid pulmonary blood flow is another cause of shunt but does not describe the pathology of pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and perfusion are matched in pulmonary fibrosis; the problem is with diffusion.
A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include?
A pulmonary embolus limits blood flow but does not affect ventilation, leading to a ventilation-perfusion mismatch. The response beginning, “Oxygen transfer into your blood is slow because of thick membranes” describes a diffusion problem. The remaining two responses describe ventilation-perfusion mismatch with adequate blood flow but poor ventilation.
A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care?
The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure.
When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?
The nurse needs to collect additional clinical data to share with the health care provider and to start interventions quickly if appropriate (e.g., increased oxygen flow if hypoxic). The change in the patient’s neurologic status may indicate deterioration in respiratory function, and the health care provider should be notified immediately but only after some additional information is obtained. Monitoring the patient and attempting to calm the patient are appropriate actions, but they will not prevent further deterioration of the patient’s clinical status and may delay care.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern?
A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest; therefore, the nurse will need to take immediate action. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.
To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with
ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both.
A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will
Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.
A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate?
The patient’s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient’s respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient’s respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
A patient in acute respiratory failure as a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to
The patient’s assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange.
When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned
The patient should be positioned with the “good” lung in the dependent position to improve the match between ventilation and perfusion. The obese patient’s abdomen will limit respiratory excursion when sitting in the high-Fowler’s or tripod positions.
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?
Increasing somnolence will decrease the patient’s respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.
The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?
The patient’s dropping SpO2 despite having an increase in FIO2 indicates the possibility of acute respiratory distress syndrome (ARDS). The patient’s blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.
When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient’s family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate?
The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever.
All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration?
Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.
After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with
Pulmonary artery wedge pressure will remain at normal levels in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.
Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring?
Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP.
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct?
By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.
When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?
The purpose of prone positioning is to improve the patient’s oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.
A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient’s family members are anxious about the patient’s condition and are continuously present at the hospital. In addressing the family’s concerns, it is important for the nurse to
The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process.
The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?
The patient’s increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient.
Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit?
Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.
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