Chapter 27 Lower Respiratory Problems PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter27:LowerRespiratoryProblems TestBank MULTIPLECHOICE 1.Followingassessmentofapatientwithpneumonia,thenurseidentifiesanursingdiagnosisofineffective airwayclearance.Whichassessmentdatabestsupportsthisdiagnosis? a.

Weak,nonproductivecougheffort

b.

Largeamountsofgreenishsputum

c.

Respiratoryrateof28breaths/minute

d.

Restingpulseoximetry(SpO2)of85%

ANS:A 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. DIF:CognitiveLevel:Apply(application)REF:eNCP27-1 TOP:NursingProcess:DiagnosisMSC:NCLEX:PhysiologicalIntegrity 2.Thenurseassessesthechestofapatientwithpneumococcalpneumonia.Whichfindingwouldthenurse expect? a.

Increasedtactilefremitus

b.

Dry,nonproductivecough

c.

Hyperresonancetopercussion

d.

Agratingsoundonauscultation

ANS:A Increasedtactilefremitusovertheareaofpulmonaryconsolidationisexpectedwithbacterialpneumonias. Dullnesstopercussionwouldbeexpected.Pneumococcalpneumoniatypicallypresentswithaloose, productivecough.Adventitiousbreathsoundssuchascracklesandwheezesaretypical.Agratingsoundis morerepresentativeofapleuralfrictionrubratherthanpneumonia. DIF:CognitiveLevel:Apply(application)REF:505 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 3.Apatientwithbacterialpneumoniahasrhonchiandthicksputum.Whatisthenursesmostappropriate actiontopromoteairwayclearance?

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a.

Assistthepatienttosplintthechestwhencoughing.

b.

Teachthepatientabouttheneedforfluidrestrictions.

c.

Encouragethepatienttowearthenasaloxygencannula.

d.

Instructthepatientonthepursedlipbreathingtechnique.

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ANS:A 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,butwillnot improveairwayclearance.PursedlipbreathingisusedtoimprovegasexchangeinpatientswithCOPD,but willnotimproveairwayclearance. DIF:CognitiveLevel:Apply(application)REF:505 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 4.Thenurseprovidesdischargeinstructionstoapatientwhowashospitalizedforpneumonia.Which statement,ifmadebythepatient,indicatesagoodunderstandingoftheinstructions? a.

IwillcallthedoctorifIstillfeeltiredafteraweek.

b.

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

c.

Iwillscheduletwoappointmentsforthepneumoniaandinfluenzavaccines.

d.

Illcancelmychestx-rayappointmentifImfeelingbetterinacoupleweeks.

ANS:B Patientsshouldcontinuetocoughanddeepbreatheafterdischarge.Fatigueisexpectedforseveralweeks.The Pneumovaxandinfluenzavaccinescanbegivenatthesametimeindifferentarms.Explainthatafollow-up chestx-rayneedstobedonein6to8weekstoevaluateresolutionofpneumonia. DIF:CognitiveLevel:Apply(application)REF:506 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity 5.Thenursedevelopsaplanofcaretopreventaspirationinahigh-riskpatient.Whichnursingactionwillbe mosteffective? a.

Turnandrepositionimmobilepatientsatleastevery2hours.

b.

Placepatientswithalteredconsciousnessinside-lyingpositions.

c.

Monitorforrespiratorysymptomsinpatientswhoareimmunosuppressed.

d.

Insertnasogastrictubeforfeedingsforpatientswithswallowingproblems.

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ANS:B Theriskforaspirationisdecreasedwhenpatientswithadecreasedlevelofconsciousnessareplacedinasidelying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pneumoniainimmunocompromisedpatients,butitwillnotdecreasetheriskfor aspiration.Conditionsthatincreasetheriskofaspirationincludedecreasedlevelofconsciousness(e.g., seizure,anesthesia,headinjury,stroke,alcoholintake),difficultyswallowing,andnasogastricintubationwith orwithouttubefeeding.Withlossofconsciousness,thegagandcoughreflexesaredepressed,andaspirationi morelikelytooccur.Otherhigh-riskgroupsarethosewhoareseriouslyill,havepoordentition,orare receivingacid-reducingmedications. DIF:CognitiveLevel:Apply(application)REF:505 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 6.Apatientwithrightlower-lobepneumoniahasbeentreatedwithIVantibioticsfor3days.Which assessmentdataobtainedbythenurseindicatesthatthetreatmenthasbeeneffective? a.

Bronchialbreathsoundsareheardattherightbase.

b.

Thepatientcoughsupsmallamountsofgreenmucus.

c.

Thepatientswhitebloodcell(WBC)countis9000/L.

d.

Increasedtactilefremitusispalpableovertherightchest.

ANS:C ThenormalWBCcountindicatesthattheantibioticshavebeeneffective.Alltheotherdatasuggestthata changeintreatmentisneeded. DIF:CognitiveLevel:Apply(application)REF:502 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity 7.Thehealthcareproviderwritesanorderforbacteriologictestingforapatientwhohasapositive tuberculosisskintest.Whichactionshouldthenursetake? a.

Teachaboutthereasonforthebloodtests.

b.

Scheduleanappointmentforachestx-ray.

c.

Teachabouttheneedtogetsputumspecimensfor2to3consecutivedays.

d.

Instructthepatienttoexpectoratethreespecimensassoonaspossible.

ANS:C Sputumspecimensareobtainedon2to3consecutivedaysforbacteriologictestingforM.tuberculosis.The

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patientshouldnotprovideallthespecimensatonce.Bloodculturesarenotusedfortuberculosistesting.A chestx-rayisnotbacteriologictesting.Althoughthefindingsonchestx-rayexaminationareimportant,itis notpossibletomakeadiagnosisofTBsolelybasedonchestx-rayfindingsbecauseotherdiseasescanmimic theappearanceofTB. DIF:CognitiveLevel:Apply(application)REF:508 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 8.Apatientisadmittedwithactivetuberculosis(TB).Thenurseshouldquestionahealthcareprovidersorder todiscontinueairborneprecautionsunlesswhichassessmentfindingisdocumented? a.

Chestx-rayshowsnoupperlobeinfiltrates.

b.

TBmedicationshavebeentakenfor6months.

c.

Mantouxtestingshowsanindurationof10mm.

d.

Threesputumsmearsforacid-fastbacilliarenegative.

ANS:D NegativesputumsmearsindicatethatMycobacteriumtuberculosisisnotpresentinthesputum,andthepatient cannottransmitthebacteriabytheairborneroute.Chestx-raysarenotusedtodeterminewhethertreatment hasbeensuccessful.Takingmedicationsfor6monthsisnecessary,butthemultidrug-resistantformsofthe diseasemightnotbeeradicatedafter6monthsoftherapy.RepeatMantouxtestingwouldnotbedonebecause theresultwillnotchangeevenwitheffectivetreatment. DIF:CognitiveLevel:Apply(application)REF:511 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 9.Thenurseteachesapatientaboutthetransmissionofpulmonarytuberculosis(TB).Whichstatement,if madebythepatient,indicatesthatteachingwaseffective? a.

Iwillavoidbeingoutdoorswheneverpossible.

b.

Myhusbandwillbesleepingintheguestbedroom.

c.

Iwilltakethebusinsteadofdrivingtovisitmyfriends.

d.

Iwillkeepthewindowsclosedathometocontainthegerms.

ANS:B Teachthepatienthowtominimizeexposuretoclosecontactsandhouseholdmembers.Homesshouldbewell ventilated,especiallytheareaswheretheinfectedpersonspendsalotoftime.Whilestillinfectious,thepatient shouldsleepalone,spendasmuchtimeaspossibleoutdoors,andminimizetimeincongregatesettingsoron publictransportation. DIF:CognitiveLevel:Apply(application)REF:511

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TOP:NursingProcess:EvaluationMSC:NCLEX:HealthPromotionandMaintenance 10.Apatientwhoistakingrifampin(Rifadin)fortuberculosiscallstheclinicandreportshavingorange discoloredurineandtears.Whichisthebestresponsebythenurse? a.

Askifthepatientisexperiencingshortnessofbreath,hives,oritching.

b.

Askthepatientaboutanyvisualabnormalitiessuchasred-greencolordiscrimination.

c.

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

d.

Advisethepatienttostopthedrugandreportthesymptomstothehealthcareprovider.

ANS:C Orange-coloredbodysecretionsareasideeffectofrifampin.Thepatientdoesnothavetostoptakingthe medication.Thefindingsarenotindicativeofanallergicreaction.Alterationsinred-greencolordiscrimination commonlyoccurswhentakingethambutol(Myambutol),whichisadifferentTBmedication. DIF:CognitiveLevel:Apply(application)REF:509 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 11.Anolderpatientisreceivingstandardmultidrugtherapyfortuberculosis(TB).Thenurseshouldnotifythe healthcareproviderifthepatientexhibitswhichfinding? a.

Yellow-tingedskin

b.

Orange-coloredsputum

c.

Thickeningofthefingernails

d.

Difficultyhearinghigh-pitchedvoices

ANS:A Noninfectioushepatitisisatoxiceffectofisoniazid(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TBdrugtherapy.Presbycusisisanexpectedfindinginthe olderadultpatient.Orangediscolorationofbodyfluidsisanexpectedsideeffectofrifampinandnotan indicationtocallthehealthcareprovider. DIF:CognitiveLevel:Apply(application)REF:509 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 12.Analcoholicandhomelesspatientisdiagnosedwithactivetuberculosis(TB).Whichinterventionbythe nursewillbemosteffectiveinensuringadherencewiththetreatmentregimen? a.

Arrangeforafriendtoadministerthemedicationonschedule.

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b.

Givethepatientwritteninstructionsabouthowtotakethemedications.

c.

Teachthepatientaboutthehighriskforinfectingothersunlesstreatmentisfollowed.

d.

Arrangeforadailynoonmealatacommunitycenterwherethedrugwillbeadministered.

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ANS:D Directlyobservedtherapyisthemosteffectivemeansforensuringcompliancewiththetreatmentregimen,and arrangingadailymealwillhelp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forthispatient. DIF:CognitiveLevel:Apply(application)REF:509 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 13.After2monthsoftuberculosis(TB)treatmentwithisoniazid(INH),rifampin(Rifadin),pyrazinamide (PZA),andethambutol,apatientcontinuestohavepositivesputumsmearsforacid-fastbacilli(AFB).Which actionshouldthenursetakenext? a.

Teachabouttreatmentfordrug-resistantTBtreatment.

b.

Askthepatientwhethermedicationshavebeentakenasdirected.

c.

Schedulethepatientfordirectlyobservedtherapythreetimesweekly.

d.

Discusswiththehealthcareprovidertheneedforthepatienttouseaninjectableantibiotic.

ANS:B Thefirstactionshouldbetodeterminewhetherthepatienthasbeencompliantwithdrugtherapybecause negativesputumsmearswouldbeexpectediftheTBbacillusissusceptibletothemedicationsandifthe medicationshavebeentakencorrectly.Assessmentisthefirststepinthenursingprocess.Dependingon whetherthepatienthasbeencompliantornot,differentmedicationsordirectlyobservedtherapymaybe indicated.Theotheroptionsareinterventionsbasedonassumptionsuntilanassessmenthasbeencompleted. DIF:CognitiveLevel:Apply(application)REF:509 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 14.Employeehealthtestresultsrevealatuberculosis(TB)skintestof16-mmindurationandanegativechest x-rayforastaffnurseworkingonthepulmonaryunit.ThenursehasnosymptomsofTB.Whichinformation shouldtheoccupationalhealthnurseplantoteachthestaffnurse? a.

Standardfour-drugtherapyforTB

b.

NeedforannualrepeatTBskintesting

c.

Useandsideeffectsofisoniazid(INH)

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d.

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BacilleCalmette-Gurin(BCG)vaccine

ANS:C 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forTBand wouldnotbehelpfulforthisindividual,whoalreadyhasaTBinfection. DIF:CognitiveLevel:Apply(application)REF:510 TOP:NursingProcess:PlanningMSC:NCLEX:HealthPromotionandMaintenance 15.Whencaringforapatientwhoishospitalizedwithactivetuberculosis(TB),thenurseobservesastudent nursewhoisassignedtotakecareofapatient.Whichaction,ifperformedbythestudentnurse,wouldrequire aninterventionbythenurse? a.

Thepatientisofferedatissuefromtheboxatthebedside.

b.

Asurgicalfacemaskisappliedbeforevisitingthepatient.

c.

Asnackisbroughttothepatientfromtheunitrefrigerator.

d.

Handwashingisperformedbeforeenteringthepatientsroom.

ANS:B Ahigh-efficiencyparticulate-absorbing(HEPA)mask,ratherthanastandardsurgicalmask,shouldbeused whenenteringthepatientsroombecausetheHEPAmaskcanfilterout100%ofsmallairborneparticles.Hand washingbeforeenteringthepatientsroomisappropriate.Becauseanorexiaandweightlossarefrequent problemsinpatientswithTB,bringingfoodtothepatientisappropriate.Thestudentnurseshouldperform handwashingafterhandlingatissuethatthepatienthasused,butnoprecautionsarenecessarywhengiving thepatientanunusedtissue. DIF:CognitiveLevel:Apply(application)REF:511 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 16.Anoccupationalhealthnurseworksatamanufacturingplantwherethereispotentialexposuretoinhaled dust.Whichaction,ifrecommendedbythenurse,willbemosthelpfulinreducingtheincidenceoflung disease? a.

Treatworkerswithpulmonaryfibrosis.

b.

Teachaboutsymptomsoflungdisease.

c.

Requiretheuseofprotectiveequipment.

d.

Monitorworkersforcoughingandwheezing.

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ANS:C Preventionoflungdiseaserequirestheuseofappropriateprotectiveequipmentsuchasmasks.Theother actionswillhelpinrecognitionorearlytreatmentoflungdiseasebutwillnotbeeffectiveinpreventionoflung damage.Repeatedexposureeventuallyresultsindiffusepulmonaryfibrosis.Fibrosisistheresultoftissue repairafterinflammation. DIF:CognitiveLevel:Apply(application)REF:513 TOP:NursingProcess:ImplementationMSC:NCLEX:HealthPromotionandMaintenance 17.Theclinicnurseteachesapatientwitha42pack-yearhistoryofcigarettesmokingaboutlungdisease. Whichinformationwillbemostimportantforthenursetoinclude? a.

Optionsforsmokingcessation

b.

Reasonsforannualsputumcytologytesting

c.

Erlotinib(Tarceva)therapytopreventtumorrisk

d.

Computedtomography(CT)screeningforlungcancer

ANS:A Becausesmokingisthemajorcauseoflungcancer,themostimportantroleforthenurseisteachingpatients aboutthebenefitsofandmeansofsmokingcessation.CTscanningiscurrentlybeinginvestigatedasa screeningtestforhigh-riskpatients.However,ifthereisapositivefinding,thepersonalreadyhaslungcancer. Erlotinibmaybeusedinpatientswhohavelungcancer,butitisnotusedtoreducetheriskofdeveloping cancer. DIF:CognitiveLevel:Apply(application)REF:518 TOP:NursingProcess:PlanningMSC:NCLEX:HealthPromotionandMaintenance 18.AlobectomyisscheduledforapatientwithstageInonsmallcelllungcancer.Thepatienttellsthenurse,I wouldratherhavechemotherapythansurgery.Whichresponsebythenurseismostappropriate? a.

Areyouafraidthatthesurgerywillbeverypainful?

b.

Didyouhavebadexperienceswithprevioussurgeries?

c.

SurgeryisthetreatmentofchoiceforstageIlungcancer.

d.

Tellmewhatyouknowaboutthevarioustreatmentsavailable.

ANS:D Moreassessmentofthepatients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patientsreasonsfornotwantingsurgery.Chemotherapyisthe primarytreatmentforsmallcelllungcancer.Innonsmallcelllungcancer,chemotherapymaybeusedinthe

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treatmentofnonresectabletumorsorasadjuvanttherapyt...