Respiratory Function And Disorders Part 2

Respiratory Function and Disorders(Part 2) By: Reynel Dan L. Galicinao

29. The nurse caring for an elderly patient in the PACU after a bronchoscopy is monitoring for complications r/t the administration of lidocaine. The nurse recognizes the complications r/t the administration of large doses of lidocaine in the elderly as: Decreased urine output and hypertension Headache and vision changes Confusion and lethargy Jaundice and elevated liver enzymes

Bronchoscopyis the direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. Pre-procedure Consent NPO6hrs Remove dentures, oral prostheses lidocaine (Xylocaine) – topical anesthetic sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort Post-procedure NPO until the cough reflex returns Offer ice chips and eventually fluids For elderly, assesses for confusion and lethargy which may be due to the large doses of lidocaine given Monitor the patient’s respiratory status and observe for hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis, and dyspnea. Report any shortness of breath or bleeding immediately

#29. C. Confusion and lethargy Brunner, Unit 5, Chapter 21, pp 486-487

30. A patient admitted with a heart murmur is noted to have a depression in the lower portion of the sternum. This type of chest deformity is called: A barrel chest A funnel chest A pigeon chest kyphoscoliosis

CHEST CONFIGURATION Normally ratio of anteroposteriordiameter to the lateral diameter = 1:2 Barrel Chest occurs as a result of overinflationof the lungs increase in the anteroposterior diameter of the thorax Emphysema Funnel Chest (PectusExcavatum) occurs when there is a depression in the lower portion of the sternum this may compress the heart and great vessels, resulting in murmurs rickets or Marfan’ssyndrome Pigeon Chest (PectusCarinatum) occurs as a result of displacement of the sternum increase in the anteroposterior diameter rickets, Marfan’s syndrome, severe kyphoscoliosis Kyphoscoliosis characterized by elevation of the scapula and a corresponding S-shaped spine limits lung expansion within the thorax osteoporosis and other skeletal disorders that affect the thorax

#29. B. A funnel chest Brunner, Unit 5, Chapter 21, p. 476

31. The nurse instructs the patient to repeat the letter ‘E’, while assessing voice sounds. Upon auscultation, the nurse notes that the voice sounds are distorted and she hears the letter ‘A’ instead of the letter ‘E’. The nurse will document this voice sound as: Brochophony Egophony Whispered pectoriloquy Sonorous wheezes

Adventitious breath sounds Crackles Fine Coarse Wheezes Sibilant wheezes Sonorous wheezes (rhonchi) Friction rubs Pleural friction rub

VOICE SOUNDS V ocal resonance - the sound heard through the stethoscope as the patient speaks Voice sounds are usually assessed by having the patient repeat “ninety-nine” or “eee” while the nurse listens with the stethoscope in corresponding areas of the chest from the apices to the bases. Bronchophony vocal resonance that is more intense and clearer than normal Egophony voice sounds that are distorted It is best appreciated by having the patient repeat the letter E The distortion produced by consolidation transforms the sound into a clearly heard A rather than E Whispered pectoriloquy a very subtle finding, heard only in the presence of rather dense consolidation of the lungs Transmission of high-frequency components of sound is so enhanced by the consolidated tissue that even whispered words are heard, a circumstance not noted in normal physiology

#31. B. Egophony Brunner, Unit 5, Chapter 21, pp 481-482

32. Auscultation of the lung fields provides the nurse with information on the type of breath sound the patient is exhibiting. While listening over the manubrium, the nurse auscultates loud expiratory sounds that last longer than inspiratory sounds. The nurse will document her finding as: Vesicular breath sounds Bronchovesicular breath sounds Bronchial breath sounds Tracheal breath sounds

# 32. C. Bronchial breath sounds Brunner, Unit 5, Chapter 21, pp 480-481

33. A patient with pleural friction rub has presented to the emergency room. Upon initial assessment, the nurse is aware that a pleural friction rub is best heard: Over the lower lateral anterior surface of the thorax Over the upper medial posterior surface of the thorax Over the trachea Over the mediastinum

Pleural Friction Rub Sounds heard over areas where roughened visceral and parietal pleurae rub over each other during respiration. The cause of the roughening is usually a fibrinous or organizing exudate. The characteristic grating or creaking sound is usually loudest at the end of inspiration, but a rub may be heard during both phases of respiration. Pleural friction rubs vary greatly from breath to breath and may be heard only during a deep respiration. They are usually most evident over the lower lateral and anterior thorax, because this is the location of greatest chest wall motion. Very loud rubs may produce palpable vibrations.

# 33. A. Over the lower lateral anterior surface of the thorax Baum’s Textbook of Pulmonary Diseases p. 23

34. During cold season, what information should the nurse provide to the patient to best prevent transmission of microorganisms? Take prescribed antibiotics. Use warm salt-water gargles. Dress warmly. Wash the hands frequently.

Handwashing rubbing together of all surfaces and crevices of the hands using a soap or chemical and water a component of all types of isolation precautions the most basic and effective infection control measure that prevents and controls the transmission of infectious agents The CDC (2000) recommends vigorous scrubbing with warm, soapy water for at least 15 seconds to prevent the transfer of germs. Three essential elements of handwashing: Soap or chemical Water Friction

# 34. D. Wash the hands frequently Fundamentals of Nursing: Standards and Practice 2nd ed. By: Sue C. DeLaune, MN, RN, C and Patricia K. Ladner, MS, MN, RN (2002) Pp 807-808

35. A patient visits the clinic and is diagnosed with acute sinusitis. To promote sinus drainage, the nurse instructs the patient to: Apply a cold pack to the affected area Apply a mustard poultice to the forehead Perform postural drainage Increase fluid intake

ACUTE SINUSITIS an infection of the paranasal sinuses. Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities Management Methods To Promote Drainage Inhaling steam (steam bath, hot shower, and facial sauna) Increasing fluid intake, Applying local heat (hot wet packs) Nasal sprays Antibiotic regimen Teach about S/e of nasal spray Preventive measures Early signs of a sinus infection (fever, severe headache, nuchal rigidity)

#35. D. Increase Fluid intake Brunner, pp. 495-497

36. The nurse is instructing the patient on the administration of nasal spray. What information is most important to include in this teaching plan? Finish the bottle of nasal spray to clear the infection effectively. Nasal spray can be shared between family members only. Administer the nasal spray in a prone position only. Overuse of nasal spray may cause rebound congestion.

The nurse also informs the patient about the side effects of nasal sprays and about rebound congestion. In the case of rebound congestion, the body’s receptors, which have become dependent on the decongestant sprays to keep the nasal passages open, close and congestion results after the spray is discontinued.

#36. D. Overuse of nasal spray may cause rebound congestion. Brunner p 497

37. The patient has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. The patient informs the nurse that she is feeling better and is stopping the medication because she has taken it for 4 days. What information should the nurse provide to this patient? Keep the remaining tablets for an infection at a later time. Discontinue the medications if the fever is gone. Dispose of the remainder of the medication in a biohazard receptacle. Antibiotics must be completed to eliminate organism.

Tonsillitis generally results from infection with beta-hemolytic streptococci but can also result from other bacteria or viruses. Management of acute tonsillitis stresses symptom relief and requires rest, adequate fluid intake, aspirin or acetaminophen and, for bacterial infection, an antibiotic. For group A beta-hemolytic streptococcus, penicillin is the drug of choice. (Erythromycin or another broad-spectrum antibiotic may be given if the patient is allergic to penicillin.) To prevent complications, antibiotic therapy should continue for 10 days.

# 37. D. Antibiotics must be completed to eliminate organism. Brunner p 499 Diseases: A Nursing Process Approach to Excellent Care 4th ed. By McCann et al. p.1235

38. Which of the following patients is at greater risk for developing chronic pharyngitis? Habitual use of alcohol and tabacco Caffeine use Diet of spicy foods Type A personality

Chronic pharyngitis is a persistent inflammation of the pharynx. It is common in adults who: work or live in dusty surroundings use their voice to excess suffer from chronic cough habitually use alcohol and tobacco.

#38. A. Habitual use of alcohol and tabacco Brunner p.499

39. Following tonsillectomy surgery, the nurse will assess the patient for: Difficulty ambulating Frequent swallowing Decrease in temperature Bradycardia

Continuous nursing observation is required in the immediate postoperative and recovery period because of the significant risk of hemorrhage. In the immediate postoperative period, the most comfortable position is prone with the head turned to the side to allow drainage from the mouth and pharynx. The nurse must not remove the oral airway until the patient’s gag and swallowing reflexes have returned. The nurse applies an ice collar to the neck, and a basin and tissues are provided for the expectoration of blood and mucus. Bleeding may be bright red if the patient expectorates blood before swallowing it. Often, however, the patient swallows the blood, which immediately becomes brown because of the action of the acidic gastric juice.

#39. B. Frequent swallowing Brunner P 499-500

40. Which of the following would be the best diet choice for a patient 3 days after a tonsillectomy? Tacos Pork chops Chili Macaroni and cheese

A liquid or semiliquid diet is given for several days. Sherbet and gelatin are acceptable foods. The patient should avoid spicy, hot, acidic, or rough foods. Milk and milk products (ice cream and yogurt) may be restricted because they may make removal of mucus more difficult. Taco- a crisp fried corn tortilla usually filled with meat, lettuce or cabbage, tomatoes, cheese, and hot sauce

#40. D. Macaroni and cheese Brunner P 500

41. A 45-year-old obese man who arrives in a clinic with complaints of daytime sleepiness, headache, and sore throat in the morning is exhibiting manifestations of which of the following? Angina Diabetes Obstructive sleep apnea Depression

Obstructive sleep apnea is defined as frequent and loud snoring and breathing cessation for 10 seconds or more for five episodes per hour or more, followed by awakening abruptly with a loud snort as the blood oxygen level drops. Patients with sleep apnea may experience anywhere from five apneic episodes per hour to several hundred per night. Other symptoms include excessive daytime sleepiness morning headache sore throat Intellectual deterioration personality changes behavioral disorders Enuresis Impotence Obesity complaints by the partner that the patient snores loudly or is unusually restless during sleep

#41. C. Obstructive sleep apnea Brunner p. 503

42. A patient visits the clinic and is diagnosed with acute laryngitis. The nurse should instruct the patient to: Place warm cloths on the throat. Inhale warm steam. Limit speech. Decrease fluid intake.

Laryngitis - an inflammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection. Signs of acute laryngitis include hoarseness or aphonia(complete loss of voice) and severe cough. Management Resting the voice Avoiding smoking Resting inhaling cool steam or an aerosol The nurse instructs the patient to rest the voice and to maintain a well-humidified environment If laryngeal secretions are present during acute episodes, expectorant agents are suggested, along with a daily fluid intake of 3 L to thin secretions.

# 42. C. Limit speech. Brunner, p 501

43. A patient is admitted with epistaxis. Pressure has been applied to the patient’s midline septum for 10 minutes. The attempt to stop the bleeding is unsuccessful. What treatment may be used to control the bleeding? Nasal plugs Suction Nasal spray Silver nitrate applicators

Most nosebleeds originate from the anterior portion of the nose Initial treatment may include: applying direct pressure. patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood pt is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously. If this measure is unsuccessful, additional treatment is indicated. the area may be treated with a silver nitrate applicator and Gelfoam, or by electrocautery. Topical vasoconstrictors, such as adrenaline (11,000), cocaine (0.5%), and phenylephrine

#43. D. Silver nitrate applicator Brunner, P. 504

44. A patient has been treated in the emergency room for epistaxis. What information should the patient include in the patient discharge teaching to prevent epistaxis? Keep nasal passages clear. Use a dehumidifier. Avoid picking the nose. Use a tissue when blowing the nose.

TEACHING PATIENTS SELF-CARE Discharge teaching includes reviewing ways to prevent epistaxis: avoiding forceful nose blowing, straining, high altitudes, and nasal trauma (including nose picking). Adequate humidification may prevent drying of the nasal passages. The nurse instructs the patient how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in the case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the patient is instructed to seek additional medical attention.

#44. C. Avoid picking the nose. Brunner, p 504-505

45. A nurse is caring for a postoperative patient following lung surgery who is reluctant to cough and has a shallow, monotonous respiratory pattern. The patient may be at increased risk for which of the following? Increased oxygen saturation Atelectasis Aspiration Malnutrition

Acute atelectasis occurs frequently in the postoperative setting or in people who are immobilized and have a shallow, monotonous breathing pattern. Breathing techniques, such as diaphragmatic and pursed-lip breathing, that were taught before surgery should be performed by the patient every 2 hours to expand the alveoli and prevent atelectasis. Deep breathing and coughing help to raise the intrapleural pressure, which promotes drainage of accumulated fluid in the pleural space Deep breathing and coughing also promote removal of secretions from the tracheobronchial tree, which in turn promotes lung expansion and prevents atelectasis (alveolar collapse).

#45. B. Atelectasis Brunner p. 517, 631, 633

46. A nurse is caring for a 68-year-old patient diagnosed with mycoplasmal pneumonia observes that the patient has difficulty breathing due to copious tracheobronchial secretions. The patient should be encouraged to do which of the following? Increase oral fluids unless contraindicated. Call the nurse for deep suctioning. Lie in a low-Fowler’s position. Increase activity.

Gerontologic considerations The nurse encourages hydration (2 to 3 L/day) because adequate hydration thins and loosens pulmonary secretions. Supportive treatment includes: hydration (with caution and frequent assessment because of the risk of fluid overload in the elderly) supplemental oxygen therapy assistance with deep breathing, coughing frequent position changes early ambulation

#46. A. Increase oral fluids unless contraindicated, Brunner P 529-530

47. A patient is receiving oxygen therapy for pneumonia. What should the nurse assess for to determine if the patient is hypoxic? Restlessness Cold hands Confusion Noncompliance

Hypoxia: inadequate supply of oxygen to the cell Signs and symptoms of hypoxia: Restlessness Apprehension Confusion Tachycardia Tachypnea Labored breathing Pallor progressing to cyanosis Diaphoresis Transient hypertension Decreased urine output

#47. A. Restlessness Brunner, p. 463, 622

48. A patient has been ordered a Mantoux test. How should the nurse administer the test? Intradermal injection into the inner forearm Intramuscular injection into the vastuslateralis Subcutaneous injection into the umbilical area At a 45-degree angle into the deltoid

TUBERCULIN SKIN TEST The Mantoux test is used to determine if a person has been infected with the TB bacillus The Mantoux test is a standardized procedure and should be performed only by those trained in its administration and reading Tubercle bacillus extract (tuberculin), purified protein derivative (PPD), is injected into the intradermal layer of the inner aspect of the forearm, approximately 4 inches below the elbow

#48. A. ID into inner forearm Brunner p. 534

49. The nurse should explain to an adult patient who has contracted TB that he should implement which of the following to prevent spreading the infection? Cover the mouth when coughing Take isoniazid (INH) as prescribed The patient will remain infectious until 1 week of continuous medication Family members need not to be treated

The nurse instructs the patient and family about infection control procedures, such as proper disposal of tissues, covering the mouth during coughing, and hand hygiene. After 2 to 4 weeks, the disease is no longer infectious and the patient can resume normal activities while continuing to take medication.

#49. A. Cover the mouth when coughing Brunner, p. 538

50. Which of the following should be avoided by a patient who is taking prophylactic medication therapy with isoniazid (INH) for treatment of possible tuberculosis. Red meat Red wine Ham Mushrooms

#50. B. Red wine Brunner, pp. 536, 1100

51. Which of the following is the preferred treatment for pain caused by pleurisy? Morphine sulfate Meperidinesulfate Acetamninophen Indomethacin

Pleurisy (pleuritis) refers to inflammation of both layers of the pleurae (parietal and visceral). Prescribed analgesics and topical applications of heat or cold provide symptomatic relief. Indomethacin (Indocin), a nonsteroidal anti-inflammatory drug (NSAID), may provide pain relief while allowing the patient to take deep breaths and cough more effectively. If the pain is severe, an intercostal nerve block may be required.

#51. D. Indomethacin Brunner, p 540

52. A nurse encourages a patient who is diagnosed with lung disease not to smoke because smoking: Decreases the amount of mucus production Oxygenates the hemoglobin Inflates the alveoli in the lungs Damages the ciliary cleansing mechanism of the respiratory tract

Smoking is contraindicated with excessive sputum production because it: interferes with ciliary action increases bronchial secretions causes inflammation and hyperplasia of the mucous membranes reduces production of surfactant Thus, smoking impairs bronchial drainage. When the person stops smoking, sputum volume decreases and resistance to bronchial infections increases.

#52. D. Damages the ciliary cleansing mechanism of the respiratory tract Brunner, p 474

53. A patient has arrived in the emergency department with suspected acute respiratory distress syndrome (ARDS). The nurse should anticipate which of the following? Prepare to assist with intubating the patient Set up oxygen at 3L/NP Consult physiotherapy Set up a nebulizer

Acute Respiratory Distress Syndrome (ARDS): nonspecific pulmonary response to a variety of pulmonary and nonpulmonary insults to the lung; characterized by interstitial infiltrates, alveolar hemorrhage, atelectasis, decreased compliance, and refractory hypoxemia. Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Supplemental oxygen is used as the patient begins the initial spiral of hypoxemia. As the hypoxemia progresses, intubation and mechanical ventilation are instituted. Oxygen-induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 L/min).

#53. A. Prepare to assist with intubating the patient Brunner, p.545, 601

54. A nurse who assesses an adult patient following a motor vehicular accident observes that the patient has increased use of accessory muscles and is complaining of pain and shortness of breath. The patient is exhibiting symptoms of which of the following? Pneumothorax Anxiety Asthma Cardiac tamponade

Traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. It can occur with blunt trauma (eg, rib fractures) or penetrating chest trauma. The signs and symptoms associated with pneumothorax depend on its size and cause. Sudden, pleuritic pain The patient may have only minimal respiratory distress with slight chest discomfort and tachypnea with a small simple or uncomplicated pneumothorax. If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. Anxious dyspnea and air hunger increased use of the accessory muscles may develop central cyanosis from severe hypoxemia. Severe chest pain accompanied by tachypnea, decreased movement of the affected side of the thorax, a tympanic sound on percussion of the chest wall, and decreased or absent breath sounds and tactile fremitus on the affected side.

#54. A. Pneumothorax Brunner p.561

55. After insertion of a chest tube for a pneumothorax, a patient becomes hypotensive with neck vein distention., tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. For what cause of tension pneumothorax should the nurse check? Infection of the lung Kinked or obstructed chest tube Excessive water in the water seal chamber Excessive chest tube drainage

A tension pneumothoraxoccurs when air is drawn into the pleural space from a lacerated lung or through a small hole in the chest wall. It may be a complication of other types of pneumothorax. Leaking and trapping of air in the pleural space can result in tension pneumothorax. This causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift).

#55. B. Kinked or obstructed chest tube Brunner p. 562, 631

56. The nurse is assisting with a subclavian vein central line insertion when the patient’s oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of pneumothorax include: Diminished or absent breath sounds on the affected side Paradoxical chest wall movement with respirations Tracheal deviation to the unaffected side Muffled or distant heart sounds

Clinical Manifestations of Pneumothorax: Hyperresonance; diminished breath sounds. Reduced mobility of affected half of thorax. Tracheal deviation away from affected side in tension pneumothorax Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax

#56. C. Tracheal deviation to the unaffected side Brunner p. 561 Lippincott’s Manual of Nursing Practice p. 322

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