Question 1

To determine the effectiveness of prescribed therapies for a client with cor pulmonale and right-sided heart failure, which of the following assessments should the nurse make?
A)Lung sounds
B)Heart sounds
C)Blood pressure
D)Peripheral edema

Accepted Answer

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

Question 2

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

Accepted Answer

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

Question 3

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

Accepted Answer

Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a client with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

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

Question 6

The health care provider inserts a chest tube in a client with a hemo-pneumothorax. When monitoring the client after the chest tube placement, which of the following findings is of greatest concern?
A)A large air leak in the water-seal chamber
B)400 mL of blood in the collection chamber
C)Complaint of pain with each deep inspiration
D)Subcutaneous emphysema at the insertion site

Accepted Answer

The large amount of blood may indicate that the client is in danger of developing hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care provider. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a client with pneumothorax.

Question 7

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

Accepted Answer

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

Question 8

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

Accepted Answer

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

Question 9

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

Accepted Answer

Clients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the client has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

Question 10

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

Accepted Answer

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

Question 11

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

Accepted Answer

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

Question 12

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

Accepted Answer

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

Question 13

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

Accepted Answer

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

Question 14

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

Accepted Answer

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

Question 15

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

Accepted Answer

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

Question 16

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

Accepted Answer

Paradoxical chest movement indicates that the client may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Question 17

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

Accepted Answer

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

Question 18

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

Accepted Answer

Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.

Question 19

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

Accepted Answer

Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

Question 20

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

Accepted Answer

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

Quiz 30: Nursing Management Lower Respiratory Problems

To determine the effectiveness of prescribed therapies for a client with cor pulmonale and right-sided heart failure, which of the following assessments should the nurse make?

The nurse is assessing a client who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate?

The nurse is caring for a client with primary pulmonary hypertension (PPH) who is receiving nifedipine. Which of the following findings indicate that the treatment is effective?

The nurse is caring for a client with a pleural effusion who is scheduled for a thoracentesis. Which of the following actions should the nurse implement prior to the procedure?

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

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

The nurse is caring for a client with pneumonia has a fever of 38.4°C (101.1°F) , a nonproductive cough, and an oxygen saturation of 89%. The client is very weak and needs assistance to get out of bed. Which of the following nursing diagnoses is priority?

After the nurse has received change-of-shift report about the following four clients, which client should be assessed first?

The nurse is performing tuberculosis (TB) screening in a clinic that has many clients who have immigrated to Canada. Before doing a TB skin test on a client, which of the following questions is most important for the nurse to ask?

The nurse has completed discharge teaching for a client who has had a lung transplant. Which of the following client statements indicate that the teaching was effective?

The nurse is caring for a client who has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which of the following actions should the nurse take first?

The nurse observes an unregulated care provider doing all the following activities when caring for a client with a pulmonary embolism. Which of the following actions should cause the nurse to intervene with the client's care?

The nurse is caring for a client in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first?

Which of the following information obtained by the nurse about a client who has human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider?

The nurse is providing preoperative instruction for a client who is scheduled for a left pneumonectomy for cancer of the lung. Which of the following information should the nurse include related to postoperative care?

The nurse is caring for a client who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?

Which of the following prescriptions should the nurse implement first for a client who has just been admitted with probable bacterial pneumonia and sepsis?

The nurse is caring for a client who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?

The nurse is caring for a client who has just had a thoracentesis. Which of the following information is most important to communicate to the health care provider?

The nurse is caring for a client with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. Which of the following actions shouldthe nurse implement first?