Chapter 28- Lower Respiratory Problems Flashcards
After change-of-shift report, which patient should the nurse assess first?
a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C)
c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
ANS: D
The patient’s history and symptoms suggest possible tension pneumothorax,
a medical emergency. The other patients also require assessment as soon as
possible, but tension pneumothorax will require immediate treatment to
avoid death from inadequate cardiac output or hypoxemia
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale)
and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage
and a large air leak. Which action is best for the nurse to take next?
a. Milk the chest tube gently to remove any clots.
b. Clamp the chest tube momentarily to check for the origin of the air leak.
c. Assist the patient to deep breathe, cough, and use the incentive spirometer.
d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
ANS: D
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
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided
heart failure. Which assessment would best evaluate the effectiveness of the therapies?
a. Observe for distended neck veins.
b. Auscultate for crackles in the lungs.
c. Palpate for heaves or thrills over the heart.
d. Review hemoglobin and hematocrit values.
ANS: A
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right
ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness
would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale
include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second
heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and
increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be
elevated with cor pulmonale than decreased
The nurse cares for a patient who has just had a thoracentesis. Which assessment information
obtained by the nurse is a priority to communicate to the health care provider?
a. Oxygen saturation is 88%.
b. Blood pressure is 145/90 mm Hg.
c. Respiratory rate is 22 breaths/minute when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS: A
Oxygen saturation would be expected to improve after a thoracentesis. A
saturation of 88% 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
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which
nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Document the amount of drainage every eight hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.
ANS: A
UAP education includes documentation of intake and
output. The other actions are within the scope of
practice and education of licensed nursing personnel
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving
epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
a. The oxygen saturation is 94%.
b. The blood pressure is 98/56 mm Hg.
c. The patient’s central IV line is disconnected.
d. The international normalized ratio (INR) is prolonged
ANS: C
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
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse
is most concerned if which assessment finding is observed?
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
ANS: B
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock.
An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk
bubbling of air occurs in this chamber when a pneumothorax is evacuated. 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 patient with pneumothorax. A small amount of subcutaneous air is
harmless and will be reabsorbed
The nurse notes new onset confusion in an older patient who is normally alert and oriented.
In which order should the nurse take the following actions? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Obtain the oxygen saturation.
b. Check the patient’s pulse rate.
c. Document the change in status.
d. Notify the health care provider
ANS:
A, B, D, C
Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or
perfusion problems should be the first action by the nurse. Airway and oxygenation should be
assessed first, then circulation. After assessing the patient, the nurse should notify the health
care provider. Finally, documentation of the assessments and care should be done
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile
accident. Which statement, if made by the patient, would indicate that teaching has been effective?
a. “I am going to buy a rib binder to wear during the day.”
b. “I can take shallow breaths to prevent my chest from hurting.”
c. “I should plan on taking the pain pills only at bedtime so I can sleep.”
d. “I will use the incentive spirometer every hour or two during the day.”
ANS: D
Prevention of the complications of atelectasis and pneumonia is a
priority after rib fracture. This can be ensured by deep breathing and
coughing. Use of a rib binder, shallow breathing, and taking pain
medications only at night are likely to result in atelectasis
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat.
The emergency department nurse would be most concerned if which finding is observed during the initial
assessment?
a. Paradoxic chest movement
b. Complaint of chest wall pain
c. Heart rate of 110 beats/minute
d. Large bruised area on the chest
ANS: A
Paradoxic chest movement indicates that the patient 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
A patient is admitted to the emergency department with an open stab wound to the left
chest. What is the first action that the nurse should take?
a. Position the patient so that the left chest is dependent.
b. Tape a nonporous dressing on three sides over the chest wound.
c. Cover the sucking chest wound firmly with an occlusive dressing.
d. Keep the head of the patient’s bed at no more than 30 degrees elevation
ANS: B
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 left 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 to 45 degrees to facilitate breathing
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the
suction-control chamber of the collection device. Which action by the nurse is most appropriate?
a. Document the presence of a large air leak.
b. Notify the surgeon of a possible pneumothorax.
c. Take no further action with the collection device.
d. Adjust the dial on the wall regulator to decrease suction
ANS: C
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 waterseal
chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum
source will not adjust the suction pressure. The amount of suction applied is regulated by the
amount of water in this chamber and not by the amount of suction applied to the system
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which
assessment would best indicate to the nurse that the patient’s condition is improving?
a. Blood pressure (BP) is less than 140/90 mm Hg.
b. Patient reports decreased exertional dyspnea.
c. Heart rate is between 60 and 100 beats/minute.
d. Patient’s chest x-ray indicates clear lung fields.
ANS: B
Because a major symptom of IPAH 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 the effectiveness of therapy for a patient with IPAH. The chest x-ray
will show clear lung fields even if the therapy is not effective
When assessing a patient who has just arrived after an automobile accident, the emergency department
nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the
nurse prepare the patient?
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
ANS: D
The patient’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 patient’s clinical
manifestations are not consistent with these problems
