Medical Surgical Nursing - Ch 27
Terms
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A pt has chronic bronchitis. To prevent the development of an acute exacerbation of chronic bronchitis (AECB), the nurse teaches the pt to take provided antibiotics with the onset of:
a. rhinitis and headache
b. diffuse rhnonchi and wheezing - c. Acute bronchitis is the greatest threat to those who have chronic bronchitis, and they often are provided with antibiotics to take at the first symptoms, which include fever, increased productive cough, and exertional dyspnea. Diffuse rhonchi and wheezing may be heard on auscultation but would not usually be noted by the pt. Pleuritic pain may also occur, but the cough is productive.
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The classification of pneumonia as commuity-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) is clinically useful because:
a. atypical pneumonia syndrome is more likely to occur in HAP
b. diagnostic testing does not have to be used - c. Pneumonia that onsets in the community is usually caused by different microorganisms than pneumonia that develops during hospitalization, and tx can be empirical -- based on observations and experience w/o knowing the exact cause. In at least half the cases of pneumonia, a causative organism cannot be identified from cultures, and tx is based in experience.
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Identify the pathophysiologic stage of pneumococcal pneumonia:
Massive dilation of capillaries with alveolar filling with organisms, neutrophils, and fibrin - red hepatization
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Identify the pathophysiologic stage of pneumococcal pneumonia:
Exudate becomes lysed and processed by macrophages and normal lung tissue restored - resolution
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Identify the pathophysiologic stage of pneumococcal pneumonia:
Outpouring of fluid into alveoli that supports microorganism growth and spread - congestion
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Identify the pathophysiologic stage of pneumococcal pneumonia:
Blood flow decreases and leukocytes and fibrin consolidate in affected lung tissue - gray hepatization
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When obtaining a health hx from the pt with suspected CAP, the nurse expects the pt to report:
a. an insidious onset
b. a dry productive cough
c. a recent loss of consciousness
d. an abrupt onset of fever and chills - d. CAP usually has an acute onset with fever, chills, productive cough with purulent or bloody sputum, and pleuritic chest pain. A recent loss of consiousness or altered consciousness is common in those pneumonias associated with aspiration, such as anaerobic bacterial pneumonias.
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Initial antibiotic tx for pneumonia is usually based on:
a. the severity of symptoms
b. the presence of characteristic leukocytes
c. Gram's stains and cultures of sputum specimens
d. H&P exam and characteristic chest x-ray finding - d. Prompt tx of pneumonia with appropriate antibiotics is important in treating bacterial and mycoplasma pneumonia, and antibiotics are often administered on the basis of the hx, physical exam, and a chest x-ray showing a typical pattern characteristic of a particular organism, without further testing. Sputum and blood cultures take 24 to 72 hours for results, and microorganisms often cannot be identified with either Gram stains or cultures. Whether the pneumonia is community-acquired or hospital acquired is more significant than severity of symptoms.
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An example of a metastatic infection that occurs as a complication of pneumococcal pneumonia is:
a. pleurisy
b. empyema
c. meningitis
d. pleural effusion - c. Pneumococcal meningitis is a metastatic complication of pneumococcal pneumonia, as well as infectious pericarditis, arthritis, or endocarditis. Pleurisy, empyema, and pleural effusion may also result from pneumococcal pneumonia, but these conditions are caused by local spread rather than a hematogenous route.
- The class of antibiotics most commonly used to treat a Category 1 CAP is __________ __________ __________.
- advanced generation macrolides
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A pt with pneumonia has a nursing diagnosis of ineffective airway clearance r/t pain, fatigue, and thick secretions. An appropriate nursing intervention for this diagnosis is to:
a. encourage a fluid intake of at least 3 L/day
b. administer oxy - a. Secretions are liquified and more easily removed by coughing when fluid intake is at least 3L/day. Positioning and oxygen administration may help ineffective breathing patterns and impaired oxygen exchange but are not indicated for retained secretions. Deep breaths are necessary to move mucus from distal airways.
- A pt is admitted to the hospital with fever, chills, productive cough with rusty sputum, and pleuritic chest pain. Pneumococcal pneumonia is suspected. An appropriate nursing diagnosis for the pt based on the systemic manifestations of pneumococcal pneum
- b. The pt with pneumococcal pneumonia is acutely ill with fever and the systemic manifestions of fever, such as chills, thirst, headache, and malaise. Interventions that monitor temp and aid in lowering body temp are appropriate. Diarrhea is not associated, nor is disorientation and confusion unless the pt is very hypoxemic. Pleuritic pain is a local manifestation of pneumococcal pneumonia, not a systemic manifestion.
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The nurse advises a 75 yr old man that to prevent pneumonia, he should:
a. obtain the pneumococcal vaccine q5-6yrs
b. obtain the pneumococcal vaccine and an annual influenza vaccine
c. seek medical care and antibiotic therapy for all URIs< - b. The pneumococcal vaccine is good for a lifetime except for immunosuppressed pts, who should receive the vaccine q5-6yrs. The influenze virus undergoes minor changes each year, and the vaccine should be taken by those at risk for influenze and lower respiratory infections annually in the fall before exposure to the flu virus occurs. Antibiotic therapy is not appropriate for all URIs unless secondary bacterial infections develop
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The resurgence in TB due to emergence of multidrug-resistant strains of M. tuberculosis is primarily the result of:
a. a lack of effective means to dx TB
b. poor compliance with drug therapy in pts with TB
c. the increased population of im - b. Drug-resistant strains of TB have developed becuase TB pts' compliance to drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of TB tx. Antituberculous drugs are almost exclusively used for TB infectious. TB can be effectively diagnosed with sputum cultures. The incidence of TB is at epidemic proportions in pts with HIV, but this does not account for drug-resistant strains of TB.
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One of the characteristic phathophysiologic responses to infection by the TB bacillus is:
a. metastases of osteocytes from the bone to the lung where they calcify lung tissue
b. necrotic abscesses formed from reactions of the TB bacilli with ly - d. The TB bacilli create a cellular immune response with development of an epithelioid granuloma that is surrounded by lymphocytes. The central portion of the granuloma undergoes necrosis characterized by a cheesy appearance and is named caseous necrosis and eventually heals with fibrosis and calcification.
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A pt diagnosed with Class 3 TB 1 week ago is admitted to the hospital with symptoms of chest pain and a possible MI. The nurse knows that:
a. the pt has a TB infection without clinical evidence of the disease
b. respiratory isolation may be req - b. A pt with class 3 TB has clinically active disease, and respiratory isolation is required for active disease until the pt has been on drug hterapy for at least 2 weeks or until smears are negative on 3 consecutive days. A TB infection without clinical evidence of TB is class 2, class 4 includes pts with a hx of TB but without current disease, and class 5 includes those suspected of having TB pending definite diagnosis.
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Usual initial clinical manifestations of TB include:
a. chest pain, hemoptysis, and weight loss
b. fatigue, low grade fever, and night sweats
c. cough with purulent mucus and fever with chills
d. pleuritic pain, nonproductive cough, a - b. TB usually develops insidiously with fatigue, malaise, low-grade fevers, and night sweats. Chest pain and a productive cough may also occur, but hemoptysis is a late symptom.
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Choose the appropriate word(s) from the choices in parentheses to complete the sentence r/t classification and tx protocols for TB.
A HCP who has cared for a pt with TB has a 7-mm reaction to PPD skin testing. This individual has been (exposed - infected with
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Choose the appropriate word(s) from the choices in parentheses to complete the sentence r/t classification and tx protocols for TB.
When a person who is taking corticosteroids for rheumatoid arthritis has a positive PPD skin test, tx would inc - latent
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Choose the appropriate word(s) from the choices in parentheses to complete the sentence r/t classification and tx protocols for TB.
A pt who has HIV and clinical TB should receive combination drug therapy for a minimum of (9 / 12) months and ( -
9 months (minimum)
6 months (beyond culture conversion) -
Choose the appropriate word(s) from the choices in parentheses to complete the sentence r/t classification and tx protocols for TB.
Latent TB infection is treated with (INH / combination) therapy. - INH
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Choose the appropriate word(s) from the choices in parentheses to complete the sentence r/t classification and tx protocols for TB.
The minimum tx period for a pt with an active TB infection is (6 / 9) months. - 6 months
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Choose the appropriate word(s) from the choices in parentheses to complete the sentence r/t classification and tx protocols for TB.
A diagnosis of TB is established with (chest x-ray / positive smear and culture). - positive smear and culture
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A pt with active TB does not have negative sputum cultures after 6 months of tx because she says she cannot remember to take the meds all the time. The best action by the nurse is to:
a. schedule the pt to come to the clinic every day to take - d. The nurse should notify the public health department if drug compliance is questionable so that follow-up of pts can be made by directly observed tx (DOT) by a public health nurse or a responsible family member. A pt who cannot remember to take the meds usually will not remember to come to the clinic daily or will find it too inconvenient. Additional teaching, or support from others, is not usually effective for this type of pt.
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A pt receiving chemo for breast cancer develops cryptococcoses and is treated with IV amphotericin B. The nurse monitors the pt for side effects of the amphotericin B with the knowledge that this pt is at risk for increased:
a. renal impairment
- c. Apmhotericin B is a toxic drug with many side effects, including hypersensitivity reactions, fever, chills, malaise, nausea and vomiting, and abnormal renal function, but it does not commonly cause immunosuppression. The side effect that would most commonly intesify when a pt also receives chemotherapeutic agents would be the nausea and vomiting.
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The nursing assessment of a pt with bronchiectasis is most likely to reveal a hx of:
a. chest trauma
b. childhood asthma
c. smoking or oral tobacco use
d. recurrent lower respiratory tract infections - d. Almost all forms of bronchiectasis are associated with bacterial infections that damage the bronchial walls. The incidence of bronchiectasis has decreased with use of measles and pertussis vaccines and better tx of lower respiratory tract infections.
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In planning care for the pt with bronchiectasis, the nurse includes measures that will:
a. relieve or reduce pain
b. prevent paroxysmal coughing
c. prevent spread of the dx to others
d. promote drainage and removal of mucus - d. Mucus production is increased in bronchiectasis and collects in the dilated, pouched bronchi. A major goal of tx is to promote drainage and removal of the mucus, primarily through deep breathing, coughing, and postural drainage.
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The nurse uses protective measures with pts at risk for lung abscesses based on the knowledge that lung abscesses occur most frequently in pts with:
a. lung tumors
b. altered consciousness
c. altered immune response
d. pulmonary infar - b. The most common cause of lung abscesses is aspiration of oropharyngeal materials into the lung, especially when oral and dental hygiene are poor. Positioning to protect the airway and prevent aspiration in pts with altered consciousnes is an important measure.
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The most important precaution in reducing the risk of most occupational lung diseases is:
a. maintaining smoke-free work environments for all employees
b. using masks and effective ventilation systems to reduce exposure to irritants
c. ins - b. Although all of the precautions identified in this question are appropriate in decreasing the risk of occupational lung diseases, using masks and effective ventilation systems to reduce exposure is the most efficient and affects the greatest number of employees.
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During a health-promotion program, the nurse teaches the participants that the best way to prevent lung cancer is to:
a. stop smoking and avoid secondhand smoke
b. have an annual chest x-ray after the age of 50
c. wear masks when exposed t - a. Smoking is responsible for approximately 80%-90% of cases of lung cancer, and enough cannot be said about its contribution to lung cancer as well as many other diseases. To prevent lung cancer, avoid exposure to cigarette smoke. Chest x-rays and evaluation of cough are diagnostic means once cancer has already developed.
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A pt is diagnosed with cancer of the lung after seeking medical tx for symptoms of SIADH. The nurse recognizes that the lung malignancy most commonly r/t this symptom:
a. can be successfully treated with radiation
b. metastasizes early and has - b. SIADH is one manifestation of paraneoplastic endocrine disturbance associated with small cell lung cancer. Small cell lung cancer is associated with cigarette smoking and has the poorest prognosis because of high malignancy and early spread. Surgical resection of squamous cell lung cancer and adenocarcinoma is possible if localized, and large cell tumors are somewhat radiosensitive. Adenocarcinoma is associated with lung scarring and chronic interstitial fibrosis.
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A pt with a lung mass found on chest x-ray is undergoing further testing. A definitive diagnosis of cancer of the lung may be made with:
a. CT scans
b. lung tomograms
c. pulmonary angiography
d. identification of malignant cells in sp - d. Although chest x-rays, lung tomograms, CT scans, MRI, and PET can identify tumors and masses, exact diagnosis of a lung malignancy requires identification of malignant cells either in sputum specimens or biopsies. It is important to note that a negative sputum cytology does not rule out the possibility fo cancer, but positive findings can confirm it.
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In assisting a pt to stop smoking, the nurse advises the pt that the most successful programs for smoking cessation include:
a. hypnosis and acupuncture
b. self-help programs with group therapy
c. aversion therapy and individual psychother - d. The most successful programs for smoking cessation combine behavioral approaches to alter habits with pharmacologic intervention to decrease the physical addiction to nicotine. Other methods may work for some individuals and include hypnosis, education, environmental control, and social support.
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A pt with advanced lung cancer refuses pain meds, saying "I deserve everything this cancer can give me." The nurse's best response to the pt is:
a. "Would you like to talk to a counselor?"
b. "Can you tell me what the p - b. Before making any judgments about the pt's statement, it is important to explore what meaning he finds in the pain. It may be that he feels it is deserved punishment for smoking, but further information needs to be obtained from the pt. Immediate referral to a counselor negates the nurse's responsibility in helping the pt, and there is no indication that he is not dealing effectively with his feelings.
- Collapse of the lung due to accumulation of air in the intrapleural space caused by a sucking chest wound is a _____ _____.
- open pneumothorax
- Multiple fractured ribs causing paradoxic chest movement is known as _____ _____.
- flail chest
- Collapse of the lung due to accumulation of blood in the intrapleural space is a _____.
- hemothorax
- Collapse of the lung due to accumulation of air in the intrapleural space caused by an injury to the lungs from closed rib fractures is known as _____ _____.
- closed pneumothorax
- When air in the intrapleural space progressively increases intrathoracic pressure because it cannot escape during expiration, a _____ _____ occurs.
- tension pneumothorax
- Accumulation of lymphatic fluid in the pleural space due to a leak in the thoracic duct is known as _____.
- chylothorax
- The usual treatment for a large pneumothorax or hemothorax of any cause is a _____ _____ connected to _____-_____ _____.
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chest tube
water-seal drainage -
S/s that indicate to the nurse that a tension pneumothorax is developing in a pt with chest trauma include:
a. dull percussion sounds on the injured side
b. severe respiratory distress and tracheal deviation
c. muffled and distant heart so - b. A tension pneumothorax causes many of the same symptoms as a pneumothorax, but severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures and trachea to the unaffected side are present in a tension pneumothorax. Percussion dullness on the injured site indicates the presence of blood or fluid, and decreased movement and diminished breath sounds are characteristic of a pneumothorax. Muffled and distant heart sounds indicate a cardiac tamponade.
- What is the function of the FIRST CHAMBER in a three-chamber water-seal pleural drainage system?
- Collection of air and fluid from chest cavity with air vented to second chamber
- What is the function of the SECOND CHAMBER in a three-chamber water-seal pleural drainage system?
- Water-seal chamber allowing escape of air but preventing its reentry to collection chamber
- What is the function of the THIRD CHAMBER in a three-chamber water-seal pleural drainage system?
- Suction-control chamber to which water is added to control the amount of suction
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The nurse should check for leaks in the chest tube and water-seal system when:
a. there is constant bubbling of water in the suction-control chamber
b. there is continuous bubbling from the tube in the water-seal chamber
c. the water level - b. The water-seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing pt, and continuous bubbling indicates a leak. The water in the suction-control chamber will bubble continuously, and the fluid in the tubing in the water-seal chamber fluctuates with the pt's breathing. Water in the suction-control chamber, and perhaps in the water-seal chamber, evaporates and may need to be replaced periodically.
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When caring for the pt with a chest tube, the nurse questions the practice of:
a. looping the drainage tubing on the bed
b. clamping the chest tube momentarily to check for leaks
c. having the pt cough and deep breathe q2h
d. strippin - d. Although stripping or milking chest tubes to promote drainage is somewhat controversial, there is no indication to milk the tubes when there is no bloody drainage, as in a pneumothorax. Tubing should be looped in the bed without any dependent loops to promote drainage, and pts should cough and deep breathe at least q2h to aid in lung reexpansion. Clamping of chest tubes may cause a tension pneumothorax, but tubes may be clamped momentarily to check for leaks in the system.
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Following a thoracotomy, the pt has a nursing diagnosis of ineffective airway clearance r/t inability to cough secondary to pain and positioning. The best nursing intervention for this pt is to:
a. have the pt drink 16 oz of water before attempting - d. A thoracotomy incision is large and involves cutting into bone, muscle, and cartilage, resulting in significant postop pain. The pt has difficulty deep breathing and coughing because of the pain, and the analgesics should be provided before attempting these activities. Water intake is important to liquefy secretions, but it is not indicated in this case, nor should a pt with chest trauma or surgery be place in Trendelenburg's position because it increases intrathoracic pressure.
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What is the mechanism of pulmonary hypertension for the following condition:
Chronic Obstructive Pulmonary Disease (COPD)
a. stiffening of pulmonary vasculature
b. obstruction of pulmonary blood flow
c. pulmonary capillary - c. pulmonary capillary/alveolar damage
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What is the mechanism of pulmonary hypertension for the following condition:
Pulmonary fibrosis
a. stiffening of pulmonary vasculature
b. obstruction of pulmonary blood flow
c. pulmonary capillary/alveolar damage
d. l - a. stiffening of pulmonary vasculature
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What is the mechanism of pulmonary hypertension for the following condition:
Pulmonary embolism
a. stiffening of pulmonary vasculature
b. obstruction of pulmonary blood flow
c. pulmonary capillary/alveolar damage
d. l - b. obstruction of pulmonary blood flow
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What is the mechanism of pulmonary hypertension for the following condition:
Neuromuscular disorders
a. stiffening of pulmonary vasculature
b. obstruction of pulmonary blood flow
c. pulmonary capillary/alveolar damage
- d. local vasoconstriction and shunting
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While caring for a pt with primary pulmonary htn, the nurse observes that the pt has exertional dyspnea and chest pain, in addition to fatigue. The nurse knows that these symptoms are r/t:
a. decreased L ventricular output
b. R ventricular hype - b. High pressure in the pulmonary arteries increases the workload of the R ventricle and eventually causes R ventricular hypertrophy and dilation, known as cor pulmonale. Eventually decreased L ventricular output may occur because of decreased return to the L atrium, but it is not the primary effect of pulmonary htn. Alveolar interstitial edema is pulmonary edema associated with L ventricular failure. Pulmonary htn does not cause systemic htn.
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The primary tx for cor pulmonale is directed toward:
a. controlling arrhythmias
b. dilating the pulmonary arteries
c. strengthening the cardiac muscle
d. treating the underlying pulmonary condition - d. If possible, the primary management of cor pulmonale is treatment of the underlying pulmonary problem that caused the heart problem. Low-flow oxygen therapy will help prevent hypoxemia and hypercapnia that causes pulmonary vasoconstriction.
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Six days after a heart-lung transplant, the pt develops a low-grade fever and a decreased SpO2 with exercise. The nurse recognizes that this indicates:
a. a normal response to extensive surgery
b. a frequently fatal cytomegalovirus infection - c. Acute rejection may occur as early as 5-7 days after surgery and is manifested by low-grade fever, fatigue, and oxygen desaturation with exertion. Complete remission of symptoms can be accomplished with bolus corticosteroids. CMV and other infections can be fatal but usually occur weeks after surgery and manifest with symptoms of pneumonia. Obliterative bronchiolitis is a late complication of lung transplantation, reflecting chronic rejection.