Practice Nurs112Unit 4
Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. A Auscultation of breath sounds B Auscultation of bowel sounds C Presence of chest pain D Presence of peripheral edema E Color of nail beds
A, C, E A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? A It is likely that the client is developing a secondary bacterial pneumonia. B The assessment findings are consistent with influenza and are to be expected. C The client is getting dehydrated and needs to increase her fluid intake to decrease secretions. D The client has not been taking her decongestants and bronchodilators as prescribed.
A. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.
A male client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? A Inflamed lung tissue B Sudden onset C Responsiveness to penicillin D Elevated white blood cell (WBC) count
A. The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Although most types of pneumonia have a sudden onset, a few (such as anaerobic bacterial pneumonia and mycoplasmal pneumonia) have an insidious onset. Antibiotic therapy is the primary treatment for most types of pneumonia; however, the antibiotic must be specific for the causative agent, which may not be responsive to penicillin. A few types of pneumonia, such as viral pneumonia, aren't treated with antibiotics. Although pneumonia usually causes an elevated WBC count, some types, such as mycoplasmal pneumonia, don't.
When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? A Bronchial B Bronchovesicular C Tubular D Vesicular
A. Chest auscultation reveals bronchial breath sounds over areas of consolidation. Bronchovesicular are normal over midlobe lung regions, tubular sounds are commonly heard over large airways, and vesicular breath sounds are commonly heard in the bases of the lung fields.
An elderly client with pneumonia may appear with which of the following symptoms first? A Altered mental status and dehydration B Fever and chills C Hemoptysis and dyspnea D Pleuritic chest pain and cough
A. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
22) A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is: Blood pressure Temperature Output Specific gravity
Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.
165) A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for: Supplemental oxygen Fluid restriction Blood transfusion Delivery by Caesarean section
Answer A is correct. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers B, C, and D are incorrect.
231) A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the: Head of the pancreas Proximal third section of the small intestines Stomach and duodenum Esophagus and jejunum
Answer A is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and in answer D, the esophagus is not removed.
96) A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? High fever Nonproductive cough Rhinitis Vomiting and diarrhea
Answer A is correct. If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect.
216) A client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should include telling the client to: Strain his urine Increase his fluid intake Report urinary frequency Avoid prolonged sitting
Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.
16) A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? Sexual dysfunction related to radiation therapy Anticipatory grieving related to terminal illness Tissue integrity related to prolonged bed rest Fatigue related to chemotherapy
Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin's disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.
3) A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? Taking hourly blood pressures with mechanical cuff Encouraging fluid intake of at least 200mL per hour Position in high Fowler's with knee gatch raised Administering Tylenol as ordered
Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.
202) A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question? TB skin test Rubella vaccine ELISA test Chest x-ray
Answer B is correct. The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.
236) The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: Using oil- or cream-based soaps Flossing between the teeth The intake of salt Using an electric razor
Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect.
15) Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? Oral mucous membrane, altered related to chemotherapy Risk for injury related to thrombocytopenia Fatigue related to the disease process Interrupted family processes related to life-threatening illness of a family member
Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.
14) A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? "Have you noticed a change in sleeping habits recently?" "Have you had a respiratory infection in the last 6 months?" "Have you lost weight recently?" "Have you noticed changes in your alertness?"
Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.
10) The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? BP 146/88 Respirations 28 shallow Weight gain of 10 pounds in 6 months Pink complexion
Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.
6) The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? Roast beef, gelatin salad, green beans, and peach pie Chicken salad sandwich, coleslaw, French fries, ice cream Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie Pork chop, creamed potatoes, corn, and coconut cake
Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.
19) A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client? Place the client in Trendelenburg position for postural drainage Encourage coughing and deep breathing every 2 hours Elevate the head of the bed 30° Encourage the Valsalva maneuver for bowel movements
Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
4) Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? Peaches Cottage cheese Popsicle Lima beans
Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.
232) The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating: Fruits Salt Pepper Ketchup
Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.
12) A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment? The client collects stamps as a hobby. The client recently lost his job as a postal worker. The client had radiation for treatment of Hodgkin's disease as a teenager. The client's brother had leukemia as a child.
Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.
5) A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. Adjust the room temperature Give a bolus of IV fluids Start O2 Administer meperidine (Demerol) 75mg IV push
Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.
9) An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator? Conjunctiva of the eye Soles of the feet Roof of the mouth Shins
Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.
204) A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy: Is the opening on the client's left side Is the opening on the distal end on the client's left side Is the opening on the client's right side Is the opening on the distal right side
Answer C is correct. The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client's right side. The distal end, as in answers A, B, and D, is on the client's left side.
210) A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is: Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels. Total Parenteral Nutrition cannot be managed with oral hypoglycemics. Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels. Total Parenteral Nutrition leads to further pancreatic disease.
Answer C is correct. Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers A, B, and D are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.
35) A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that: Overnight stays by family members is against hospital policy. There is no need for him to stay because staffing is adequate. His wife will rest much better knowing that he is at home. Visitation is limited to 30 minutes when the implant is in place.
Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.
1) A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? Body temperature of 99°F or less Toes moved in active range of motion Sensation reported when soles of feet are touched Capillary refill of < 3 seconds
Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
39) A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to: Treat iron-deficiency anemia caused by chemotherapeutic agents Create a synergistic effect that shortens treatment time Increase the number of circulating neutrophils Reverse drug toxicity and prevent tissue damage
Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.
201) A client with pneumacystis carini pneumonia is receiving trimetrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to: Treat anemia. Create a synergistic effect. Increase the number of white blood cells. Reverse drug toxicity.
Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.
13) An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae? The abdomen The thorax The earlobes The soles of the feet
Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.
2) A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? Side-lying with knees flexed Knee-chest High Fowler's with knees flexed Semi-Fowler's with legs extended on the bed
Answer D is correct. Placing the client in semi-Fowler's position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.
7) Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? A family vacation in the Rocky Mountains Chaperoning the local boys club on a snow-skiing trip Traveling by airplane for business trips A bus trip to the Museum of Natural History
Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.
8) The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment? Palpate the spleen Take the blood pressure Examine the feet for petechiae Examine the tongue
Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.
A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? A Acute pain related to lung expansion secondary to lung infection B Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever C Anxiety related to dyspnea and chest pain D Ineffective airway clearance related to retained secretions
D. Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.
Which of the following best describes pleural effusion? A The collapse of alveoli B The collapse of bronchiole C The fluid in the alveolar space D The accumulation of fluid between the linings of the pleural space
D. The pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion.
5. When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? Bronchial Bronchovestibular Tubular Vesicular
a) Chest auscultation reveals bronchial breath sounds over areas of consolidation. Bronchiovesicular are normal over midlobe lung regions, tubular sounds are commonly heard over large airways, and vesicular breath sounds are commonly heard in the bases of the lung fields.
An elderly client with pneumonia may appear with which of the following symptoms first? Altered mental status and dehydration Fever and chills Hemoptysis and dyspnea Pleuritic chest pain and cough
a) Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
44. Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. Auscultation of breath sounds Auscultation of bowel sounds Presence of chest pain. Presence of peripheral edema Color of nail beds
a, c, e) A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
49. Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia? A respiratory rate of 25 to 30 breaths per minute The ability to perform ADL's without dyspnea A maximum loss of 5 to 10 pounds of body weight Chest pain that is minimized by splinting the ribcage.
b) An expected outcome for a client recovering from pneumonia would be the ability to perform ADL's without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5-10 pounds is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.
1) Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? Dehydration Group living Malnutrition Severe periodontal disease
b) Clients with chronic illnesses generally have poor immune systems. Often, residing in group living situations increases the chance of disease transmission.
47. Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? Coma Apathy Irritability Depression
c) Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
45. A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? Position changes q4h Nasotracheal suctioning to clear secretions Frequent linen changes Frequent offering of a bedpan.
c) Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.
Which of the following organisms most commonly causes community-acquired pneumonia in adults? Haemiphilus influenzae Klebsiella pneumoniae Steptococcus pneumoniae Staphylococcus aureus
c) Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common cause of community-acquired pneumonia. H. influenzae is the most common cause of infection in children. Klebsiella species is the most common gram-negative organism found in the hospital setting. Staphylococcus aureus is the most common cause of hospital-acquired pneumonia.
A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? Antibiotics Bed rest Oxygen Nutritional intake
c) The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the nurse can provide oxygen without waiting for a physicians order. Antibiotics may be warranted, but this isn't a nursing decision. The client should be maintained on bedrest if he is dyspneic to minimize his oxygen demands, but providing additional will deal more immediately with his problem. The client will need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation.
46. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? Decreased cardiac output Pleural effusion Inadequate peripheral circulation Decreased oxygenation of the blood.
d) A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.
48. A client with pneumonia has a temperature ranging between 101* and 102*F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority? Maintain complete bedrest Administer oxygen therapy Provide frequent linen changes. Provide fluid intake of 3 L/day
d) A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result the fever and diaphoresis; this is a high-priority intervention.
Which of the following statements best explains how opening up collapsed alveoli improves oxygenation? Alveoli need oxygen to live Alveoli have no effect on oxygenation Collapsed alveoli increase oxygen demand Gaseous exchange occurs in the alveolar membrane.
d) Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, though by decreasing the surface area available for gas exchange, they decrease oxygenation of the blood.
8. A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? Continued dyspnea Fever of 102*F Respiratory rate of 32 breaths/minute Vesicular breath sounds in right base
d) If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should be examined by the physician before discharge because he may have another source of infection or still have pneumonia.
36. A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? Acute pain related to lung expansion secondary to lung infection Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever. Anxiety related to dyspnea and chest pain. Ineffective airway clearance related to retained secretions.
d) Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.
6. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? ABG analysis Chest x-ray Blood cultures sputum culture and sensitivity
d) Sputum C & S is the best way to identify the organism causing the pneumonia. Chest x-ray will show the area of lung consolidation. ABG analysis will determine the extent of hypoxia present due to the pneumonia, and blood cultures will help determine if the infection is systemic.
Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? Atelectasis Bronchiectasis Effusion Inflammation
d) The common feature of all type of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Atelectasis and bronchiecrasis indicate a collapse of a portion of the airway that doesn't occur in pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.
