N300 Exam 2: Lower Respiratory Infections
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms would the nurse look for when assessing the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT 3 seconds. 4. Substernal chest pain and diaphoresis.
***1. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough. 2. Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax, and the client would be cyanotic from decreased oxygenation. 3. The client would have leukocytosis, not leukopenia, and a capillary refill time (CRT) of 3 seconds is normal. 4. Substernal chest pain and diaphoresis are symptoms of MI. TEST-TAKING HINT: Options "1" and "4" have chest pain as part of the answer. The adjectives describing the chest pain determine the correct answer.
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1000 mL per day. 4. Restrict the client's smoking to two (2) to three (3) cigarettes per day. 5. Monitor the client's pulse oximetry readings every four (4) hours.
***1. The client diagnosed with pneumonia will have some degree of gas-exchange deficit. Administering oxygen would help the client. ***2. Activities of daily living require energy and therefore oxygen consumption. Spacing the activities allows the client to rebuild oxygen reserves between activities. 3. Clients are encouraged to drink at least 2000 mL daily to thin secretions. 4. Cigarette smoking depresses the action of the cilia in the lungs. Any smoking should be pro- hibited. ***5. Pulse oximetry readings provide the nurse with an estimate of oxygenation in the periphery. TEST-TAKING HINT: Maslow's Hierarchy of Needs lists oxygenation as the top priority. Therefore the test taker should select interventions addressing oxygenation.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms would the nurse expect to find when assessing the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention.
***1. The elderly client diagnosed with pneumo- nia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symp- toms of pneumonia. 2. Fever and chills are classic symptoms of pneu- monia, but they are usually absent in the elderly client. 3. Frothy sputum and edema are signs and symp- toms of heart failure, not pneumonia. 4. The client has tachypnea (fast respirations), not bradypnea (slow respirations), and jugular vein distention accompanies heart failure. TEST-TAKING HINT: The question gives an age range—"elderly"—so age can be expected to affect the disease process—in this case, causing atypical symptoms. The prefix "brady" means "slow" when attached to a word. Knowing the definition of medical prefixes can assist the test taker in determining the correct answer.
The nurse in a long-term care facility is planning the care for a client with a percuta- neous gastrostomy (PEG) feeding tube. Which interventions would the nurse include in the plan of care? 1. Inspect the insertion line at the nare prior to instilling formula. 2. Elevate the head of the bed after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.
1. A gastrostomy tube is placed directly into the stomach through the abdominal wall; the nare is the opening of the nostril. ***2. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration. 3. The Sims position is the left lateral side-lying flat position. This position is used for adminis- tering enemas and can be used to prevent aspiration in clients sedated by anesthesia. The sedated client would not have a full stomach. 4. Dressings on PEG tubes should be changed at least daily. If there is no dressing, the insertion site is still assessed daily. TEST-TAKING HINT: The test taker should try to picture the positioning of the client to deter- mine the correct answer. In "4" the test taker should question if the time given, three (3) days, is the correct time interval for perform- ing this intervention.
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis. Which statement indi- cates the need for radiological evaluation instead of skin testing? 1. The client's first skin test indicates a purple flat area at the site of injection. 2. The client's second skin test indicates a red area measuring four (4) mm. 3. The client's previous skin test was read as positive. 4. The client has never shown a reaction to the tuberculin medication.
1. A purple flat area indicates that the client became bruised when the intradermal injection was given, but it has no bearing on whether the test is positive. 2. A positive skin test is 10 mm or greater with induration, not redness. ***3. If the client has ever reacted positively, then the client should have a chest x-ray to look for causation and inflammation. 4. These are negative findings and do not indicate the need to have x-ray determination of disease. TEST-TAKING HINT: The test taker should note descriptive adjectives such as "purple," "flat," or "4 mm" before determining the correct answer. Option "4" has the absolute word "never" and absolutes usually indicate incorrect answers.
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority? 1. Administer the oral antibiotic stat. 2. Order the meal tray to be delivered as soon as possible. 3. Obtain a sputum specimen for culture and sensitivity. 4. Have the unlicensed nursing assistant weigh the client.
1. Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is impor- tant to obtain culture specimens to determine the correct antibiotic for the client's infection. Clients are placed on oral medications only after several days of IVPB therapy. 2. Meal trays are not priority over cultures. ***3. To determine the antibiotic that will effec- tively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibiotics prior to cultures may make it impossible to determine the actual agent causing the pneumonia. 4. Admission weights are important to determine appropriate dosing of medication, but they are not priority over sputum collection. TEST-TAKING HINT: Answer option "1" has a medication classification and a route, and the test taker should question if the route is appropriate for the client being admitted. Clients will not die from a delayed meal, but a client could die from delayed IV antibiotic therapy.
The 56-year-old client diagnosed with tuberculosis (TB) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions? 1. "I will take my medication for the full three (3) weeks prescribed." 2. "I must stay on the medication for months if I am to get well." 3. "I can be around my friends because I have started taking antibiotics." 4. "I should get a TB skin test every three (3) months to determine if I am well."
1. Clients diagnosed with TB will need to take the medications for six (6) months to a year. ***2. Compliance with treatment plans for TB includes multi-drug therapy for six (6) months to one (1) year for the client to be free of the TB bacteria. 3. Clients are no longer contagious when three (3) morning sputum specimens are cultured negative, but this will not occur until after several weeks of therapy. 4. The TB skin test only determines possible exposure to the bacteria, not active disease. TEST-TAKING HINT: The test taker should determine if the time of three (3) weeks in "1," months in "2," or immediately in "3" is the correct time interval.
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which would be an expected outcome for this problem? 1. Performs chest physiotherapy three (3) times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall and back several times during each shift. 4. Alert and oriented to person, place, time, and events.
1. Clients do not perform chest physiotherapy; this is normally done by the respiratory therapist. This is a staff goal, not a client goal. 2. This would be a goal for self-care deficit but not for impaired gas exchange. 3. This would be a goal for the problem of activity intolerance. ***4. Impaired gas exchange results in hypoxia, the earliest sign and symptom of which is a change in the level of consciousness. TEST-TAKING HINT: The test taker should match the answer option to the listed nursing problem. Option "1" is a staff goal to accomplish. When writing goals for the client, it is important to remember they are written in terms of what is expected of the client. Options "2" and "3" are appropriately written client goals, but they do not evaluate gas exchange.
The client is admitted with a diagnosis of rule out tuberculosis. Which type of isolation procedures should the nurse implement? 1. Standard Precautions. 2. Contact Precautions. 3. Droplet Precautions. 4. Airborne Precautions.
1. Standard precautions are used to prevent expo- sure to blood and body secretions on all clients. TB is caused by airborne bacteria. 2. Contact precautions are used for wounds. 3. Droplet precautions are used for infections that are spread by sneezing or coughing but are not transmitted over distances of more than three (3) to four (4) feet. ***4. Tuberculosis bacteria are capable of disseminating over distances on air currents. Clients with tuberculosis are placed in negative air pressure rooms where the air in the room is not allowed to cross- contaminate the air in the hallway. TEST-TAKING HINT: Standard precautions and contact precautions can be ruled out as the correct answer if the test taker is aware that TB is usually a respiratory illness. This at least gives the reader a 1:2 chance of selecting the correct answer if the answer is not known.
While feeding the client diagnosed with aspiration pneumonia, the client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention would the nurse implement first? 1. Suction the client's nares. 2. Turn the client to the side. 3. Place the client in the Trendelenburg position. 4. Notify the health-care provider.
1. The nares are the opening of the nostrils. Suctioning, if done, would be of the posterior pharynx. ***2. Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs. 3. Placing the client in the Trendelenburg position would increase the risk of aspiration. 4. An immediate action is needed to protect the client. TEST-TAKING HINT: In a question that asks the test taker to determine the first action, all the answer options may be correct for the situation. The test taker must determine which has the greatest potential for improving the client's condition.
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the lab. 2. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
1. The specimen needs to be taken to the lab within a reasonable time frame, but an unlicensed nursing assistant can take specimens to the lab. 2. Clogged feeding tubes occur with some regularity. Delay in feeding a client will not result in permanent damage. ***3. A pulse oximetry reading of 92% means that the arterial blood oxygen saturation is somewhere around 60%-70%. 4. Arterial oxygenation normal values are 80%-100%. TEST-TAKING HINT: Be sure to read all the an- swer options. Pulse oximetry readings do not give the same information as arterial blood gas readings.
The nurse observes the unlicensed nursing assistant (NA) entering an airborne isolation room and leaving the door open. Which action would be the nurse's best response? 1. Close the door and discuss the NA's action when the NA comes out of the room. 2. Make the NA come back outside the room and then reenter closing the door. 3. Say nothing to the NA but report the incident to the nursing supervisor. 4. Enter the client's room and discuss the matter with the NA immediately.
***1. Closing the door reestablishes the negative air pressure, which prevents the air from entering the hall and contaminating the hospital environment. When correcting an individual, it is always best to do so in a private manner. 2. The employee is an adult and as such should be treated with respect and corrected accordingly. 3. Problems should be taken care of at the lowest level possible. The nurse is responsible for any task delegated, including the appropriate handling of isolation. 4. Correcting staff should never be done in the presence of the client. This undermines the nursing assistant and creates doubt of the staff's competency in the client's mind. TEST-TAKING HINT: An action must be taken; the test taker must determine which action would have the desired results with the least amount of disruption to client care. Correc- ting the nursing assistant in this manner has the greatest chance of creating a win-win situ- ation.
