Chp 27 Lower respiratory

The nurse determines that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." Rationale: The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? "I will call my health care provider if I still feel tired after a week." "I will continue to do deep breathing and coughing exercises at home." "I will schedule two appointments for the pneumonia and influenza vaccines." "I will cancel my follow-up chest x-ray appointment if I feel better next week."

"I will continue to do deep breathing and coughing exercises at home."

The nurse teaches a patient with a pulmonary embolism how to administer enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."

"The medicine will be prescribed for 10 days." Rationale: Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.

A nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. The sputum, which is yellow, has been sent for laboratory testing, but the lab report is pending. What should be the next step in managing the patient? 1 Administer antibiotics. 2 Wait for the lab report. 3 Refer the patient for chest physiotherapy. 4 Retake sputum sample and send to another la

1 Culture and Gram stain of sputum is required for prescribing specific antibiotics. However, if there is a delay in obtaining the lab reports, antibiotic administration should not be delayed. Deferring the antibiotics may lead to increased morbidity and mortality because the infection can worsen. Taking the sample again to send to a different lab would not be helpful because the lab will take a similar amount of time to provide the report. Chest physiotherapy can be advised later once the antibiotic therapy is started.

To ease pleuritic pain caused by pneumonia, what nursing interventions should be performed? 1 Instructing the patient to splint the chest when coughing 2 Offering the patient an incentive spirometer every four hours 3 Instructing the patient in how to perform abdominal breathing 4 Encouraging the patient use shallow breathing during episodes of pain

1 Pleuritic chest pain is triggered by chest movement and is particularly severe during coughing and deep breathing. Splinting the chest wall will reduce movement and thus ease discomfort during coughing. Use of an incentive spirometer and practicing abdominal breathing may help increase respiratory efficiency, remove secretions, and increase oxygenation, but they will not ease pleuritic pain. The patient should not be encouraged to breathe shallowly because this will increase the risk for atelectasis and decrease oxygenation.

While obtaining a health history for a patient with suspected tuberculosis, the nurse expects the patient to report which signs or symptoms? Select all that apply. 1 Fever 2 Fatigue 3 Dyspnea 4 Night sweats 5 Chest tightness

1,2,4 The patient with tuberculosis presents with night sweats, fatigue, and fever. Chest tightness and dyspnea are not present in the patient with tuberculosis.

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do? Select all that apply. 1 Maintain adequate fluid intake 2 Splint the chest when coughing 3 Maintain a 30-degree elevation 4 Maintain a semi-Fowler's position 5 Instruct patient to cough at end of exhalation

1,2,5 Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

A patient with pneumonia is being treated at home and has reported fatigue to the nurse. What instructions should the nurse include when teaching the patient about care and recovery at home? Select all that apply. 1 Get adequate rest. 2 Restrict fluid intake. 3 Avoid alcohol and smoking. 4 Resume work to build strength. 5 Take every dose of the prescribed antibiotic.

1,3,5 To ensure complete recovery after pneumonia, the patient should be advised to rest, avoid alcohol and smoking, and take every dose of the prescribed antibiotic. The patient should not resume work if feeling fatigued and should be encouraged to drink plenty of fluids during the recovery period.

A patient had an intradermal tuberculin skin test (Mantoux) administered 48 hours ago. The nurse assesses the injection site and identifies a 12-mm area of palpable induration. How should the nurse interpret this result? 1 Definitive evidence that the patient does not have tuberculosis 2 A significant indication that the patient has been exposed to tuberculosis 3 Delayed hypersensitivity with a high likelihood of infection with tuberculosis 4 A negative test that cannot be interpreted as ruling out the presence of tuberculosis

2 An area of 12 mm of induration at the injection site 48 hours after a Mantoux test is considered significant for a past or current tuberculin infection. An induration of less than 5 mm is considered a negative result. The other answer options are incorrect conclusions related to the findings.

The family of a patient with newly diagnosed tuberculosis is tested for infection with Mycobacterium tuberculosis. The patient's wife, who has a history of alcoholism, has had two negative Mantoux (PPD) tests. Both of their children have positive Mantoux results. The nurse recognizes that a course of preventive treatment with isoniazid will be required for which family member(s)? 1 The spouse only 2 Both children only 3 The spouse and the children 4 Neither the spouse nor the children

2 The children would be given isoniazid (INH) because of exposure and conversion from a negative to a positive Mantoux result. The wife would not be treated because she has not converted to positive and may be susceptible to INH hepatitis, a susceptibility that increases with age. She may also be susceptible to hepatotoxicity because of her age and history of alcoholism. The children definitely require preventive treatment with INH.

When caring for a patient with tuberculosis, what measures should the nurse instruct the patient to take to avoid the spread of infection? Select all that apply. 1 Drink plenty of water and maintain an erect posture. 2 Throw used tissues in a paper bag and dispose with the trash. 3 Carefully wash hands after handling sputum and soiled tissues. 4 Wear a standard isolation mask when outside the patient's room. 5 Cover the nose and mouth with a tissue while coughing and sneezing. 6 Get out of bed and move freely about the hospital to keep up strength.

2,3,4,5 In order to prevent the spread of infection, patients with tuberculosis should be encouraged to cover the nose and mouth with tissues while coughing and sneezing, to throw used tissues in a paper bag and dispose of them with the trash, to carefully wash hands after handling sputum and soiled tissues, and to wear a standard isolation mask while moving out of their room. Increasing the frequency of prolonged visits to other parts of the hospital is not advisable because it can increase the chances of infection spread; instead, such visits should be limited. Drinking plenty of water and maintaining erect posture have no effect on controlling infection.

The nurse is monitoring a patient who has pneumonia with thick secretions. The patient is having difficulty clearing the secretions. Which of these would be appropriate nursing interventions for this patient? Select all that apply. 1 Perform postural drainage every hour. 2 Encourage the patient to rest and limit activity. 3 Provide adequate hydration by encouraging fluid intake. 4 Provide analgesics as prescribed to promote patient comfort. 5 Teach the patient how to cough effectively to bring secretions to the mouth.

2,3,5 Interventions for pneumonia include teaching the patient how to cough effectively to remove secretions, providing adequate hydration, and encouraging rest. Hydration is important in the supportive treatment of pneumonia to prevent dehydration and loosen secretions. Individualize and carefully monitor fluid intake if the patient has heart failure. It is not necessary to provide postural drainage every hour. Providing analgesics will not help the patient clear secretions.

Which findings indicates that a client has TB? Positive PPD Chest Xray with infiltrates and nodules 3 positive consecutive sputum cultures BCG vaccine

3 positive consecutive sputum cultures

A patient presenting with pneumonia scores 5 on the CURB-65 scale. What action should the nurse take? 1 Advise no treatment. 2 Advise treating at home. 3 Consider hospital admission. 4 Consider admission to an intensive care unit.

4 CURB-65 is used in addition to clinical judgment in determining the severity of pneumonia and the need for advanced medical care. A patient scoring 5 on the CURB-65 scale means the condition is severe and needs advanced medical care. Hence, the nurse should consider admission to an intensive care unit. If the patient has symptoms of pneumonia, advising no treatment is not an option. Treating at home is advised when the score on CURB-65 scale is 0. Hospital admission is considered when the score on the CURB-65 scale is 1 to 2.

A patient who has tuberculosis (TB) is being treated with combination drug therapy. The nurse explains that combination drug therapy is essential because of what reason? 1 It minimizes the required dosage of each of the medications. 2 It helps reduce the unpleasant side effects of the medications. 3 It shortens amount of time that the treatment regimen will be needed. 4 It discourages the development of resistant strains of the TB organism.

4 Recommendations for the initial treatment of tuberculosis (TB) include a four-drug regimen until drug susceptibility tests are available. After susceptibility is established, the regimen can be altered, but patients should still receive at least two drugs to prevent emergence of drug-resistance organisms. Dosage, side effects, and duration of the regimen are not reasons for combination drug therapy in a patient with TB.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 26-yr-old patient with continuous enteral feedings through a nasogastric tube A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

A 26-yr-old patient with continuous enteral feedings through a nasogastric tube Rationale: Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without enteral nutrition. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? The patient is offered a tissue from the box at the bedside. A surgical face mask is applied before visiting the patient. A snack is brought to the patient from the unit refrigerator. Hand washing is performed before entering the patient's room.

A surgical face mask is applied before visiting the patient. N95 is needed

The nurse is caring for a patient with a fever due to pneumonia. What assessment data does the nurse obtain that correlates with the patient having a fever? (Select all that apply.) A temperature of 101.4° F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days

A temperature of 101.4° F Heart rate of 120 beats/min A productive cough with yellow sputum Rationale: A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

A patient with a persistent cough is diagnosed with pertussis. What medication does the nurse anticipate administering to this patient? Antibiotic Corticosteroid Bronchodilator Cough suppressant

Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

During admission of a patient diagnosed with non-small cell lung cancer, the nurse questions the patient related to a history of which risk factors for this type of cancer? (Select all that apply.) Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which they were born

Asbestos exposure Exposure to uranium History of cigarette smoking Rationale: Non-small cell cancer is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? Restrict oral fluids during the day. Teach pursed-lip breathing technique. Assist the patient to splint the chest when coughing. Encourage the patient to wear the nasal O2 cannula

Assist the patient to splint the chest when coughing.

The nurse is performing a respiratory assessment. Which finding best supports the presence of impaired airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

Basilar crackles Rationale: The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with impaired airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with other lower respiratory problems.

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and now has exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)

Bronchiolitis obliterans (BOS) Rationale: BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung trans

The nurse is admitting a patient with a diagnosis of pulmonary embolism. Which risk factors are a priority for the nurse to assess? (Select all that apply.) Cancer Obesity Pneumonia Cigarette smoking Prolonged air travel

Cancer Obesity Cigarette smoking Prolonged air travel Rationale: An increased risk of pulmonary embolism is associated with obesity, cancer, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? Water-seal chamber has 5 cm of water No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site

Chest tube with a loose-fitting dressing Rationale: If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water. Having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? IV antibiotic therapy will be started as soon as possible. Lobectomy surgery is usually needed to drain the abscess. Oral antibiotics will be used until there is evidence of improvement. Culture and sensitivity tests are needed for 1 year after resolving the abscess.

IV antibiotic therapy will be started as soon as possible. Rationale: IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of a fungal lung infection with Candida albicans. What patient statement indicates to the nurse that further teaching is required? "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."

IncorrectClose Your Response: "I will be given amphotericin B to treat the fungus." Correct Answer: "I need to be isolated from my family and friends so they won't get it." Rationale: The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

The nurse is caring for a patient with impaired airway clearance. What is the priority nursing action to assist this patient to expectorate thick lung secretions? Humidify the oxygen as able. Administer a cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

Increase fluid intake to 3 L/day if tolerated. Rationale: Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation would the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultatio

Increased vocal fremitus on palpation Rationale: A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse understand is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity.

Less discomfort and faster return to normal activity. Rationale: The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

The nurse is caring for a postoperative patient with impaired airway clearance. What nursing actions would promote airway clearance? (Select all that apply.) Maintain adequate fluid intake. Maintain a 15-degree elevation. Splint the chest when coughing. Have the patient use incentive spirometry. Teach the patient to cough at end of exhalation.

Maintain adequate fluid intake. Splint the chest when coughing. Teach the patient to cough at end of exhalation. Rationale: Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should teach the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. Incentive spirometry promotes lung expansion. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. What should the nurse assess this patient for? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the ai

Mucociliary clearance Rationale: Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

While ambulating a patient with metastatic lung cancer, the nurse observes a decrease in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Continue with ambulation. Obtain a provider's order for arterial blood gas. Obtain a provider's order for supplemental oxygen. Move the oximetry probe from the finger to the earlobe.

Obtain a provider's order for supplemental oxygen. Rationale: An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry

Obtain a sputum specimen for culture and Gram stain. Rationale: A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Rationale: Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)

Pneumococcal Rationale: The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A S. aureus vaccine has been researched but not yet been effective. The H. influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.

The nurse is caring for a patient with unilateral lung cancer. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours

Positioning patient with "good lung" down Rationale: Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department with severe shortness of breath and decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.

Rationale: The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.

Sit the patient up in bed as tolerated and apply oxygen. Rationale: The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the health care provider. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which provider orders must the nurse verify have been completed before administering a dose of cefuroxime? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM

Sputum culture and sensitivity Rationale: The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

An older adult patient living alone is admitted to the hospital with pneumococcal pneumonia. Which clinical manifestation is consistent with the patient being hypoxic? Sudden onset of confusion Oral temperature of 102.3° F Coarse crackles in lung bases Clutching chest on inspiration

Sudden onset of confusion Rationale: Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? Bronchial breath sounds are heard at the right base. The patient coughs up small amounts of green mucus. The patient's white blood cell (WBC) count is 9000/μL. Increased tactile fremitus is palpable over the right chest.

The patient's white blood cell (WBC) count is 9000/μL.

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

a. Weak cough effort

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.

c. Ask the patient whether medications have been taken as directed.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.

c. Teach the patient about providing specimens for 3 consecutive days