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A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what?
- A. Pneumothorax
- B. Lung tumors
- C. Infection
- D. Pulmonary edema
Correct Answer: C
Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.
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The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
- A. Have you ever been employed in a factory, smelter, or mill?
- B. Does anyone in your family have any form of lung disease?
- C. Do you currently smoke, or have you ever smoked?
- D. Have you ever lived in an area that has high levels of air pollution?
Correct Answer: C
Rationale: Smoking is the single most important contributor to lung disease, exceeding the significance of environmental, occupational, and genetic factors.
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?
- A. Obtain a sputum sample.
- B. Perform a swallowing assessment.
- C. Inspect the patients tongue and mouth.
- D. Assess the patients nutritional status.
Correct Answer: B
Rationale: Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is relevant in cases of suspected infection. The status of the patients tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.
The nurse is caring for a patient who has just undergone a mediastinotomy. What should be the focus of the nurses postprocedure care?
- A. Assisting with pulmonary function testing (PFT)
- B. Maintaining the patients chest tube
- C. Administering oral suction as needed
- D. Performing chest physiotherapy
Correct Answer: B
Rationale: Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patients unstable health status.
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
- A. Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray.
- B. Turn the patient to enable assessment of all the patients lung fields.
- C. Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall.
- D. Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
Correct Answer: B
Rationale: Assessment of the anterior and posterior lung fields is part of the nurses routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what?
- A. Pleurisy
- B. Emphysema
- C. Asthma
- D. Pneumonia
Correct Answer: C
Rationale: Sibilant wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.