Chapter 32Lower Airway Dysfunction: Nursing Management My Nursing Test Banks

Chapter 32Lower Airway Dysfunction: Nursing Management

MULTIPLE CHOICE

1.The nurse is reviewing clients for risk factors in the development of pneumonia. Which of the following clients would be at the highest risk for developing this disorder?

1.

A 48-year-old client experiencing menopause

2.

An 18-year-old client with abdominal pain

3.

A 23-year-old client diagnosed with sickle-cell anemia and a cough

4.

A 3-year-old client with fever

ANS: 3

High-risk groups for acquiring pneumonia are people with diabetes, infants 6- to 23-months old, and those with a chronic illness such as sickle-cell anemia. Menopause and abdominal pain are not symptoms associated with pneumonia. Fever in a 3-year-old client could be caused by many disorders and not necessarily pneumonia.

PTS:1DIF:Analyze

REF: Box 32-1 High-Risk Indicators for Acquiring Pneumonia

2.A client diagnosed with chronic obstructive pulmonary disease is experiencing pneumonia. The nurse applies oxygen at 2 L/min via nasal cannula. When the nurse leaves the room, a family member increases the oxygen to 5 L. Which complication may occur?

1.

Angina

2.

Apnea

3.

Metabolic acidosis

4.

Respiratory alkalosis

ANS: 2

The COPD clients drive to breathe is hypoxia. Increasing the oxygen removes this drive and leads to apnea. Angina occurs because of decreased oxygen to the myocardial tissues. Neither respiratory alkalosis nor metabolic acidosis would occur with the increased oxygen level.

PTS: 1 DIF: Analyze REF: Safety First: Oxygen Therapy

3.The nurse has a positive PPD during the last testing cycle for tuberculosis. Which of the following is indicated for this nurse?

1.

Nothing

2.

Chest x-rays every 2 months

3.

Pharmacological treatment

4.

Admission for inpatient treatment

ANS: 3

Latent tuberculosis infection occurs when a person exposed to the mycobacterium has a positive PPD test. This person is without an active clinical picture and has a 10% chance of developing TB if preventive pharmacological treatment is not initiated. The nurse needs pharmacological treatment. Doing nothing could result in active disease. The nurse does not need chest x-rays every 2 months or admission for inpatient treatment.

PTS: 1 DIF: Apply REF: Tuberculosis: Pathophysiology

4.A client undergoes a purified protein derivative (PPD) test. The test should be read:

1.

immediately after the test.

2.

24 to 48 hours after the test.

3.

48 to 72 hours after the test.

4.

anytime after 72 hours.

ANS: 3

A small amount of tuberculin is injected directly under the skin at the site and is read 48 to 72 hours after the test. The test should not be read immediately afterwards or within 24 to 48 hours. If the test is read after 72 hours, the test may need to be repeated.

PTS: 1 DIF: Apply REF: Tuberculosis: Diagnostic Tests

5.The nurse is instructing a client on ways to reduce the transmission of tuberculosis. Which of the following should be included in these instructions?

1.

The disease is transmitted by inhaling droplets exhaled by an infected person.

2.

The disease is transmitted by not fully cooking foods.

3.

The disease is transmitted by not washing hands.

4.

The disease is transmitted by sexual contact.

ANS: 1

Tuberculosis is transmitted by inhaling the bacillus present in the air. The bacillus is present in the air after an infected person has coughed, sneezed, or expectorated.Tuberculosis is not transmitted through poorly cooked foods, poor handwashing, or sexual contact.

PTS: 1 DIF: Apply REF: Tuberculosis: Patient and Family Teaching

6.A client receiving oral medications for the treatment of tuberculosis develops hepatitis. Which of the following medications would be indicated for the client at this time?

1.

Ethambutol

2.

Isoniazid

3.

Rifampin

4.

Streptomycin

ANS: 4

Streptomycin is a medication that can be used until the cause of hepatitis is identified or the liver tissue heals. It is also given for those who have a first-line drug intolerance. First-line drugs are isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA).

PTS: 1 DIF: Apply REF: Tuberculosis: Pharmacology

7.The spouse of a client diagnosed with tuberculosis is to begin isoniazid prophylactic therapy. Which of the following should the nurse instruct the spouse regarding length of time to take this medication? The medication should be taken for:

1.

10 to 24 days.

2.

1 to 3 months.

3.

4 to 7 months.

4.

6 to 12 months.

ANS: 4

Isoniazid therapy lasts 6 to 12 months. Taking the medication less than 6 months can be ineffective. The spouse should not be instructed to take the medication for 10 to 24 hours, 1 to 3 months, or 4 to 7 months.

PTS:1DIF:Apply

REF: Table 32-4 Treatment Regimens and Nursing Considerations for Tuberculosis

8.A client diagnosed with a lung abscess is being prescribed antibiotic therapy. Which of the following medications would be indicated if this client has a history of penicillin allergy?

1.

Metronidazole

2.

Clindamycin

3.

Ampicillin

4.

Steroid

ANS: 2

Clients allergic to penicillin are often given clindamycin since this medication is not part of the penicillin family. Metronidazole and ampicillin should not be administered to this client. Steroid is not an antibiotic.

PTS: 1 DIF: Analyze REF: Lung Abscess: Pharmacology

9.A client diagnosed with a hemothorax has had a chest tube inserted and attached to a portable water-seal drainage system. Which of the following interventions would be inappropriate for this client?

1.

Clamp the tubing when ambulating.

2.

Date and mark the amount of drainage in the collection chamber every shift.

3.

Monitor the suction chamber for continuous bubbling.

4.

Watch the water-seal chamber for fluctuation.

ANS: 1

The chest tube should not be clamped or raised above the chest when ambulating. All other options are appropriate.

PTS: 1 DIF: Apply REF: Pneumothorax: Planning and Implementation

10.A clients chest tube has been accidentally dislodged while the client was being transferred from the bed to a stretcher. Which of the following should the nurse do to help this client?

1.

Cover the site with occlusive petroleum jelly gauze and tape to four sides.

2.

Cover the site with occlusive petroleum jelly gauze and tape to three sides.

3.

Cover the site with occlusive petroleum jelly gauze and tape to two sides.

4.

Cover the site with occlusive petroleum jelly gauze and tape to one side.

ANS: 2

In the case of accidental dislodging of the chest tube, the site should be covered with occlusive petroleum jelly gauze and taped on three sides to prevent the development of a tension pneumothorax. If the gauze is taped on all four sides, the client can develop a tension pneumothorax. Taping the gauze on one or two sides will not be effective to support this client and should not be done.

PTS: 1 DIF: Apply REF: Red Flag: Ensuring Chest Tube Connections

11.A client is diagnosed with fractured ribs. Which of the following should the nurse instruct this client?

1.

Engage in routine activities of daily living after taking pain medication.

2.

Splint the rib cage when deep breathing and coughing.

3.

Restrict fluids.

4.

Stay on bed rest until the ribs heal.

ANS: 2

Nursing care for a client recovering from fractured ribs include splinting the rib cage when deep breathing and coughing. The client should be encouraged to avoid dangerous activities when taking pain medication. Fluids should not be restricted. Bed rest would not be necessary for fractured ribs.

PTS:1DIF:Apply

REF: Fractured Rib: Planning and Implementation; Patient and Family Teaching

12.A client is prescribed a diuretic for treatment of pulmonary hypertension. Which of the following should the nurse instruct the client regarding this medication?

1.

This medication expands the blood vessels.

2.

This medication causes smooth muscle relaxation to reduce pulmonary engorgement.

3.

This medication reduces the amount of water in the body.

4.

This medication keeps the blood from clotting.

ANS: 3

Diuretics in the treatment of pulmonary hypertension are used to reduce the amount of water in the body. Vasodilators expand the blood vessels. Sildenafil causes smooth muscle relaxation to reduce pulmonary engorgement. Anticoagulants keep the blood from clotting.

PTS: 1 DIF: Apply REF: Pulmonary Arterial Hypertension: Pharmacology

13.The nurse is assessing a client experiencing manifestations of cor pulmonale. Which of the following will the nurse most likely assess in this client?

1.

Low blood pressure

2.

Low heart rate

3.

Hoarseness

4.

Lumbar pain

ANS: 3

Manifestations of cor pulmonale include hoarseness, chest pain, distended neck veins, liver enlargement, peripheral edema, abnormal heart sounds. Low blood pressure, low heart rate, and lumbar pain are not manifestations of cor pulmonale.

PTS:1DIF:Apply

REF:Cor Pulmonale: Assessment with Clinical Manifestations

MULTIPLE RESPONSE

1.The nurse is caring for a client diagnosed with pneumonia. Which of the following signs and symptoms would the nurse most likely assess in this client? (Select all that apply.)

1.

Abdominal pain

2.

Anorexia

3.

Cough

4.

Dyspnea

5.

Fever

6.

Frequent wiping of the nose

ANS: 1, 2, 3, 4, 5

Specific symptoms suggestive of pneumonia include fever, chills or rigor, sweats, new cough (with or without sputum), pleuritic chest pain, and dyspnea. Nonspecific symptoms include malaise, fatigue, abdominal pain, headaches, anorexia, and worsening of an underlying illness. Frequent wiping of the nose is a sign of allergic rhinitis.

PTS:1DIF:Apply

REF: Pneumonia: Assessment with Clinical Manifestations

2.The nurse is planning to administer the pneumococcus vaccination to a client. Which of the following would indicate that a client is a candidate for this vaccination? (Select all that apply.)

1.

Age 70

2.

Age 55

3.

Diagnosis of heart failure

4.

Recovering from knee replacement surgery

5.

Diagnosis of asthma

6.

Recovering from an appendectomy

ANS: 1, 3, 5

Criteria for the pneumococcus vaccination include high-risk groups such as people over age 65, diagnosed with chronic heart disease, and diagnosed with asthma. Age 55, recovering from knee replacement surgery; and recovering from an appendectomy are not criteria for the pneumococcus vaccination.

PTS: 1 DIF: Analyze REF: Pneumonia: Pharmacology

3.The nurse is planning care for a client diagnosed with bronchiolectasis. Which of the following would be goals for this clients care? (Select all that apply.)

1.

Treat the infection.

2.

Reduce the heart rate.

3.

Minimize further damage.

4.

Improve urine output.

5.

Promote breathing.

6.

Remove secretions.

ANS: 1, 3, 5, 6

Treatment goals for the client diagnosed with bronchiolectasis include treat the infection, minimize further damage, promote effective airway breathing, and remove secretions. Treatment goals do not include reducing heart rate and improving urine output.

PTS: 1 DIF: Apply REF: Bronchiolectasis: Planning and Implementation

4.The nurse, planning care for a client diagnosed with a pneumothorax, identifies which types of pneumothorax? (Select all that apply.)

1.

Spontaneous

2.

Radical

3.

Traumatic

4.

Incomplete

5.

Iatrogenic

6.

Tension

ANS: 1, 3, 5, 6

The four types of pneumothorax are spontaneous, traumatic, iatrogenic, and tension. Radical and incomplete are not types of pneumothorax.

PTS: 1 DIF: Analyze REF: Pneumothorax: Etiology

5.Which of these instructions are for a client diagnosed with a pneumothorax? (Select all that apply.)

1.

Remove air from the pleural space.

2.

Correct acid-base imbalances.

3.

Treat infection.

4.

Minimize damage.

5.

Reexpand the lung.

6.

Improve fluid balance.

ANS: 1, 2, 4, 5

Treatment goals for pneumothorax include removing the air and fluid from the pleural space, correcting acid-base imbalance, minimizing further damage, and reexpanding the lung. Treating infection and improving fluid balance are not treatment goals for a pneumothorax.

PTS: 1 DIF: Apply REF: Pneumothorax: Planning and Implementation

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