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[Osborn] chapter 35

Learning Outcomes [Number and Title ]


Learning Outcome 1
Differentiate between restrictive and obstructive lung diseases.
Learning Outcome 2
Compare and contrast the etiology, pathophysiology, clinical
manifestations, nursing management, and prevention of the
various pulmonary infections.
Learning Outcome 3
Explain the etiology, pathophysiology, and nursing
management of COPD, chronic bronchitis, asthma, cystic
fibrosis, pulmonary embolism, and cor pulmonale.
Learning Outcome 4
Compare and contrast the etiology and nursing management for
patients with a variety of chest trauma and thoracic injuries.
Learning Outcome 5
Describe nursing management for patients experiencing chest
trauma and thoracic injuries.
Learning Outcome 6
Discuss the etiology, pathophysiology, and nursing
management for patients with lung cancer and lung transplant.
Learning Outcome 7
Discuss the etiology, pathophysiology, and nursing
management of occupational lung diseases.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

1. Of the following group of individuals, which one has the least risk for development of
restrictive lung disease?
1.
2.
3.
4.

75-year-old male with alpha-antitrypsin (AAT) deficiency


70-year-old female with severe kyphoscoliosis
56-year-old morbidly obese male
40-year-old female with newly diagnosed sarcoidosis

Correct Answer: 75-year-old male with alpha-antitrypsin (AAT) deficiency


Rationale: Alpha-antitrypsin (AAT) deficiency is a genetic risk factor associated with
chronic obstructive lung disease. Restrictive lung disorders may occur in kyphoscoliosis,
the morbidly obese, and sarcoidosis.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

2. When assessing a client diagnosed with a restrictive lung disease due to intrinsic cause,
the nurse would not expect which of these findings?
1.
2.
3.
4.

Chronic productive cough of prolonged duration


Progressive exertional dyspnea
Dry cough
Hemoptysis

Correct Answer: Chronic productive cough of prolonged duration


Rationale: Chronic productive cough for 3 months during each of two consecutive years
is indicative of chronic bronchitis, an obstructive lung disorder. Symptoms of restrictive
lung disorders from intrinsic disease include progressive exertional dyspnea, dry cough,
and hemoptysis.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

3. A patient with chronic obstructive lung disease tells the nurse that he does not always
wear the prescribed oxygen at home because it is cumbersome and he is rarely short of
breath. Which of the following is the nurses best response to this patient?
1. Wearing it will help keep your blood oxygen saturation levels up so your heart
does not have to work as hard and will not become enlarged.
2. You really should wear it at least while sleeping.
3. It seems like you are doing fine without it.
4. Keep the oxygen at home and if you become short of breath, you know to put it
on until you are able to breathe normally again.
Correct Answer: Wearing the oxygen will help keep your blood saturated so your heart
does not have to work as hard and will not become enlarged.
Rationale: The nurse should instruct the patient on the benefits of using long-term oxygen
therapy to prevent the development of polycythemia vera. Polycythemia vera is an
increase in the hematocrit level above normal as a compensatory mechanism to hypoxia.
Cor pulmonale can develop, which is an enlargement of the right side of the heart, and
can lead to mortality in the patient with chronic obstructive lung disease. The nurse
should encourage the patient to wear the oxygen at all times and not just during sleep. It
may be misleading to state that the patient is doing fine without the oxygen. The nurse
should also not just instruct the patient to wear the oxygen when he becomes short of
breath but to wear it at all times as prescribed.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

4. A client diagnosed with active tuberculosis is in a negative pressure room for


respiratory airborne isolation. How long should the nurse maintain the client in this type
of isolation?
1.
2.
3.
4.

Until three consecutive sputum specimens for acid fast bacilli are negative
Until the Mantoux test (PPD) converts from positive to negative
Until the client has orders for discharge
Until the chest x-ray is normal

Correct Answer: Until three consecutive sputum specimens for acid fast bacilli are
negative
Rationale: The client should remain in isolation until three consecutive sputum cultures
have tested negative. Until that time and in spite of treatment, there is no certainty that
the client is not infectious. A positive PPD indicates that an individual has been exposed
to tuberculosis and has developed antibodies, so the PPD will not convert back to
negative. The chest x-ray validates the amount of lung involvement; the client may
experience chronic changes, such as nodules. The client should not be discharged without
evidence that he or she is no longer infectious.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

5. The nurse is providing teaching to a client who will be discharged on isoniazide (INH).
Which of the following statements made by the client indicates a need for further
medication instruction?
1.
2.
3.
4.

I will take the INH hour after eating breakfast.


I will make sure I tell all my health care providers that I am taking INH.
Tuna fish is one of my favorite foods. I will hate having to give it up.
I will make sure I get my laboratory tests drawn to monitor my liver function.

Correct Answer: I will take the INH hour after eating breakfast.
Rationale: INH should be taken 1 hour before meals or on an empty stomach because
food interferes with the absorption of the drug. Clients should advise all health care
providers that they are taking the medication to avoid drugdrug interactions. Clients
should avoid foods containing tyramine and/or histamine, such as tuna, aged cheese, red
wine, and soy sauce. Consumption of these foods can lead to experiencing headaches,
flushing, or palpitations. Because of the risk of hepatotoxicity, the client should have
baseline and monthly evaluations of liver function while on INH.
Cognitive Level: Synthesis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

6. The nurse determines that a 60-year-old client requires further teaching regarding
measures to prevent pulmonary infection if the client makes which of the following
statements?
1. Even though I have diabetes, I wont need to obtain the pneumococcal vaccine
until Im 65 years old.
2. I will make sure I carefully wash my hands after blowing my nose, after using
the restroom, and before eating.
3. Since I have diabetes, I will make sure I get the influenza vaccine each year.
4. I will be participating in a smoking cessation support group after discharge.
Correct Answer: Even though I have diabetes, I wont need to obtain the pneumococcal
vaccine until Im 65 years old.
Rationale: Clients with chronic conditions such as diabetes are candidates for both the
influenza and pneumococcal vaccines regardless of age. Even though the client is 60
years old, the client should receive the vaccine because it is 60% effective in preventing
bacterial pneumococcal infections in adults. Meticulous hand hygiene and smoking
cessation are integral in prevention of pulmonary infection.
Cognitive Level: Analysis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

7. The nurse determines that the asthmatic client does not understand discharge
instructions if which of the following statements is made?
1.
2.
3.
4.

I know I shouldnt smoke, but one or two cigarettes a day shouldnt be harmful.
I should monitor my peak flow daily and record it in a diary.
I should rinse my mouth after each use of my corticosteroid inhaler.
Using a spacer with my inhaler will allow for better and more accurate
medication delivery.

Correct Answer: I know I shouldnt smoke, but one or two cigarettes a day shouldnt be
harmful.
Rationale: Environmental pollutants, smoking, allergens, chemicals, and inhalants can all
trigger an asthmatic attack and should be avoided. Maintaining a diary of peak flow
measurements allows the client to monitor for decreases that indicate
bronchoconstriction. Inhaled corticosteroids increase risk for thrush, so the mouth should
be rinsed after inhaler use. When a spacer is attached to an inhaler, it allows the
medication to accumulate while the client inhales and prevents escape outside the clients
mouth.
Cognitive Level: Synthesis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

8. Which of the following clients does the nurse determine is not at risk for developing
cor pulmonale?
1.
2.
3.
4.

Client with left ventricular heart failure


Client experiencing a massive pulmonary embolism
Client with chronic obstructive pulmonary disease (COPD)
Client with polycythemia vera

Correct Answer: Client with left ventricular heart failure


Rationale: Cor pulmonale is an alteration in the structure and function of the right
ventricle caused by a primary disorder of the respiratory system or a blood disorder.
Primary disorders of the respiratory system include pulmonary embolism, interstitial lung
disease, COPD, and primary pulmonary hypertension. Blood disorders leading to cor
pulmonale include polycythemia vera, sickle cell disease, and macrohemoglobinemia.
Right ventricular disease caused by a primary abnormality of the left ventricle is not
considered cor pulmonale.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

9. A client with chronic bronchitis has the following nursing diagnosis listed on the care
plan: Ineffective Airway Clearance related to inadequate cough and excess mucous
production. Which of the following interventions is of the least value in resolving the
nursing diagnosis?
1.
2.
3.
4.

Check the pulse oximetry reading.


Increase fluid intake up to 2 liters/day.
Suction the client.
Provide chest physiotherapy.

Correct Answer: Check the pulse oximetry reading.


Rationale: Checking the pulse oximetry reading evaluates the oxygenation status of the
client but has no value in stimulation of cough or expulsion of excess mucous secretions.
Adequate hydration helps to liquefy secretions. Suctioning may be necessary to clear the
airway when the cough is ineffective. Chest physiotherapy assists in the mobilization of
secretions.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

10. The nurse is assisting the health care provider to insert a chest drainage system for a
client with a pneumothorax. Which of the following should the nurse anticipate
immediately after chest tube insertion and connection to the drainage system?
1.
2.
3.
4.

Bubbling in the water seal chamber immediately after insertion


No evidence of tidaling
Vigorous bubbling in the suction control chamber
Large amount of bloody drainage in the drainage collection chamber

Correct Answer: Bubbling in the water seal chamber immediately after insertion
Rationale: When a chest tube is inserted in the pleural space for a pneumothorax, the
trapped air is allowed to escape and bubbling will be observed in the water seal as the
lung is permitted re-expand. The water column in the water seal should rise with
inspiration and fall with expiration (tidaling). There should be gentle bubbling in the
suction control chamber to avoid rapid evaporation of the fluid in the chamber. Large
amounts of bloody drainage would be anticipated after chest tube insertion for
hemothorax.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

11. The nurse is caring for a client on mechanical ventilation with positive end expiratory
pressure (PEEP). When assessing the client, which of the following findings would alert
the nurse to the possibility of tension pneumothorax?
1.
2.
3.
4.

New onset of decreased breath sounds over the right lung


Blood pressure of 170/80
Pulse oximetry readings ranging from 94% to 96%
Crackles and wheezing heard in both lungs

Correct Answer: New onset of decreased breath sounds over the right lung
Rationale: In a tension pneumothorax, air enters the pleural space with each breath but
does not exit. Progressive accumulation of air in the pleural space leads to collapse of the
lung on the affected side and hypoxia. As a result, the client would have decreasing
breath sounds on the affected side rather than adventitious sounds (crackles and
wheezes). As the pressure in the thorax increases, cardiac output declines and the client
becomes hypotensive. A pulse oximetry reading of 94% demonstrates adequate
oxygenation.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

12. When performing a respiratory assessment on a client brought to the emergency


department after a motor vehicle collision, which of the following findings would lead
the nurse to suspect pneumothorax?
1.
2.
3.
4.

Hyperresonance to percussion at the apex of the left lung


Dullness to percussion at the base of the left lung
Crackles throughout the left lung
Shallow breathing

Correct Answer: Hyperresonance to percussion at the apex of the left lung


Rationale: In pneumothorax, the percussion tone is hyperresonant due to the trapped air
in the pleural space. Dullness to percussion is suggestive of fluid accumulation, such as in
hemothorax. Crackles in the left lung suggest fluid accumulation in the alveoli. Shallow
breathing can occur but is not specific to pneumothorax. It would also be seen in rib
fractures and flail chest, for example.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

13. Which of the following is an accurate statement about lung cancers?


1. Small-cell lung cancers (SCLC) are typically spread and widely disseminated by
time of diagnosis.
2. Squamous cell carcinoma and adenocarcinoma are types of small-cell carcinoma
lung cancers (SCLC).
3. Adenocarcinoma typically originates in the proximal bronchi.
4. Squamous cell tumors are rapidly growing and are easily detected.
Correct Answer: Small-cell lung cancers (SCLC) are typically spread and widely
disseminated by time of diagnosis.
Rationale: SCLC has the unique ability to spread and be widely disseminated by the time
of diagnosis, leading to poor prognosis and limited survival time (2 to 4 months).
Squamous cell and adenocarcinoma are types of non-small-cell carcinoma lung cancers
(NSCLC). Squamous cell tumors are slow-growing and difficult to detect initially and
typically originate in the proximal bronchi. Adenocarcinomas are found in the periphery
of the lungs and progress slowly.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

14. The nurse working in the unit caring for clients with end-stage lung disease
determines that which of the following clients in her assignment may qualify for single
lung transplant?
1.
2.
3.
4.

62-year-old female with diabetes mellitus controlled by insulin therapy


50-year-old male with multivessel CAD and chronic renal insufficiency
32-year-old male client with HIV
43-year-old female with hepatitis C confirmed by histologic findings of liver
disease by biopsy

Correct Answer: 62-year-old female with diabetes mellitus controlled by insulin therapy
Rationale: Lung transplant is not contraindicated per se in individuals with systemic
disease such as diabetes mellitus and collagen disease. Current contraindications for lung
transplant include dysfunction of major organs other than the lung, HIV infection,
hepatitis B antigen positivity, hepatitis C with biopsy-proven histologic evidence of liver
disease, and active malignancy within the past 2 years with the exception of basal cell
and squamous cell carcinoma.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

15. The nurse is completing a physical assessment on a 55-year-old male who has been
diagnosed with lung cancer. Which of the following findings should alert the nurse that
the client might be experiencing superior vena cava syndrome?
1.
2.
3.
4.

Face and neck swelling


Hourly urine outputs of 250 to 500 mL
Calcium level of 14.0 mg/dL
Flat jugular veins

Correct Answer: Face and neck swelling


Rationale: Superior vena cava (SVC) syndrome is an oncologic emergency and occurs
when a lung tumor obstructs the SVC. This results in facial swelling; hand, arm, and neck
swelling; distended jugular veins; cyanosis of the upper torso; and dyspnea. Hourly urine
outputs of 250 to 500 mL/hour are suggestive of the complication termed syndrome of
inappropriate ADH (SIADH). A calcium level of 14.0 mg/dL is considered
hypercalcemia, which is a metabolic emergency associated with lung cancers.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

16. Which of the following clinical manifestations is not expected in a client with an
occupational lung disease?
1.
2.
3.
4.

Wet-sounding crackles in the lungs


Chronic cough
Clubbing of the fingers
Excess sputum with varying amounts of black fluid

Correct Answer: Wet-sounding crackles in the lungs


Rationale: The diffuse interstitial fibrosis that occurs leads to dry crackles in up to 90% of
clients. Chronic cough is often a presenting sign. Clubbing of the fingers is frequently
present. Sputum is expectorated in large quantities and often contains varying amounts of
black fluid, particularly in smokers.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

17. A patient comes into the emergency department with acute shortness of breath and
copious secretions. The patient states the problem started a few hours after arriving at
work. Which of the following is the most likely cause of the patients acute respiratory
problem?
1.
2.
3.
4.

Reaction to the agent used to clean the carpeting in the office


Environmental air temperature of 72 degrees
Received annual flu vaccine 1 week ago
Did not finish breakfast but had a protein bar for a snack

Correct Answer: Reaction to the agent used to clean the carpeting in the office
Rationale: Occupational asthma can result from exposure to particulate matter in the
workplace. Exposure leads to bronchospasm and hypersecretion of mucous from the
bronchial mucosa, dyspnea, and wheezing. The patient reports that the carpeting in his
office had been recently cleaned, which would be the reason for the acute onset of
respiratory symptoms. The other choices would not explain the patients sudden onset of
respiratory symptoms.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

18. A patient was an employee of a contracting company for 10 years and has been
diagnosed with a mild form of silicosis. How should the nurse instruct the patient
regarding his ongoing respiratory health care needs?
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

1.
2.
3.
4.

Attain and maintain daily activity status.


Restrict fluids.
Use oxygen sparingly to reduce dependence.
Participate in rest and relaxation activities.

Correct Answer: Attain and maintain daily activity status.


Rationale: A patient with an occupational lung disease should be instructed to attain and
maintain daily activity status to maximize the patients quality of life. Fluids should be
taken liberally to thin secretions and assist with expectoration. Oxygen should be used as
prescribed and not sparingly. Although important, rest and relaxation should not be the
patients primary focus; the focus should be on normal activities to maximize functioning
and feelings of well being.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.