Med-Surge

Answer:Impaired Gas Exchange Rationale: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.

Answer: A diet rich in protein. Rationale: For a client with lung abscess, a diet rich in protein and calories is integral because chronic infection is associated with a catabolic state. A carbohydrate-dense diet or diets with limited fat are not advisable for a client with lung abscess.

Answer: For maintaining muscle strength Rationale: The nurse should always encourage active ROM exercises three times a day. Active ROM exercises maintain muscle strength and joint ROM. Assessment of pain level and other factors provide a baseline for treatment and evaluation. Proper pain assessment and appropriate analgesic administration provide more effective pain control. The nurse typically instructs the client to administer medication 1 hour before or 2 hours after meals because food interferes with medication absorption.

Answer: Impaired Gas Exchange Rationale: Anxiety and pain are both possible during treatment for ARDS. However, maintenance of the patient's airway with the goal of facilitating gas exchange is an absolute priority. The patient's risk of aspiration is low due to NPO status and the presence of inline suctioning.

Answer: Paradoxical chest movement Rationale: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

Answer: Putting on an individually fitted mask when entering the client's room Rationale: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

Answer: Receiving Vaccinations Rationale: Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections. The nurse should encourage early mobilization as indicated through agency protocol, administer prescribed opioids and sedatives as indicated, and teach or reinforce appropriate technique for incentive spirometry to prevent atelectasis.

Answer: Draining secretions, air, and blood from the thoracic cavity is necessary. Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. This makes options B, C, and D are incorrect.

Answer: A stroke patient with dysarthria Rationale: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. The muscles that become paralyzed in dysarthria are the same ones used for swallowing. This increases the patient's risk of aspiration. Patients with Alzheimer's disease who are still ambulatory probably don't have the voluntary muscle problems that occur later in the disease. Patients who need help with ADLs or have severe arthritis shouldn't have difficulty swallowing unless it exists secondary to another problem.

Answer: Localized calf tenderness Rationale: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.

Answer: See if there are leaks in the system Rationale: Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

Answer: Incentive Spirometry Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as PEEP, continuous or intermittent positive pressure-breathing (IPPB), or bronchoscopy may be used.

Answer: Collection of sputum sample for submission to the hospital lab. Rationale: Choice of antibiotic therapy is based primarily on the patient's history and the results of sputum cultures. Blood work and chest auscultation confirm the diagnosis of pneumonia but do not typically inform the choice of antibiotic.

Answer: Tense and relax muscles in the lower extremities. Rationale: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism

Answer: Flail chest Rationale: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

Answer: acute respiratory distress syndrome (ARDS). Rationale: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

Answer: A positive reaction indicates that the client has been exposed to the disease. Rationale: A positive reaction means the client has been exposed to TB; it isn't conclusive for the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

Answer: Pain in the calf Rationale: When assessing the client's potential for pulmonary emboli, the nurse tests for a positive Homan's sign. The client lies on his or her back and lifts his or her leg and his or her foot. If the client reports calf pain (positive Homan's sign) during this maneuver, he or she may have a deep vein thrombosis.

Answer: The importance of adhering to the prescribed treatment regimen Rationale: Successful treatment of TB is wholly dependent on the patient's conscientious adherence to treatment. Patient education relating to this fact is a priority over MDIs, incentive spirometry, or nutrition, although each may be necessary.

Answer: Crackles in the lung bases Rationale: When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

Answer: continue to take antibiotics for the entire 10 days. Rationale: The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

Answer: Ineffective Airway Clearance Rationale: The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.

Answer: "You must consume a diet rich in protein, such as chicken, fish, and beans." Rationale: The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.

Answer: 0-4 mm Rationale: The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.

Answer: "You should switch to wearing your glasses while taking this medication." Rationale: The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.

Answer: "I'll stay in isolation for 6 weeks." Rationale: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease.

Answer: Localized calf tenderness Rationale: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.

Answer: Received Vaccinations Rationale: Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections.

Answer: Vitamin B6 Rationale: Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

Answer: Chest Pain & Dyspnea Rationale: As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.

Answer: "The people I have contact with at work should be checked regularly." Rationale: The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements.

Answer: A nurse washes her hands before beginning client care. Rationale: HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

Answer: Interdermal injection into the inner forearm Rationale: The PPD is injected into the intradermal layer of the inner aspect of the forearm.

Answer: Blood-Tinged Sputum. Rationale: The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.