AH2 - Exam 1 - Lippincott 11ed - Test 4 - The Client with Pneumonia

44. The nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing which of the following? Select all that apply. 1. Decreased pain when breathing. 2. Prolonged clotting time. 3. Decreased temperature. 4. Decreased respiratory rate. 5. Increased ability to expectorate secretions.

1, 3 1. Decreased pain when breathing. 3. Decreased temperature. Aspirin is administered to clients with pneumonia because it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. Aspirin has an anticoagulant effect, but that is not the reason for prescribing it for a client with pneumonia, and the use of the drug will be short term. Aspirin does not affect the respiratory rate and does not facilitate expectoration of secretions

35. Which of the following are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Quality of breath sounds. 2. Presence of bowel sounds. 3. Occurrence of chest pain. 4. Amount of peripheral edema. 5. Color of nail beds.

1, 3, 5 1. Quality of breath sounds. 3. Occurrence of chest pain. 5. Color of nail beds. 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 client with pneumonia.

34. A 79-year-old client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most likely be a predisposing factor for the diagnosis of pneumonia? 1. Age. 2. Osteoarthritis. 3. Vegetarian diet. 4. Daily bathing.

1. Age. The client's age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated clients. Other predisposing factors include smoking, upper respiratory tract infections, malnutrition, immunosuppression, and the presence of a chronic illness. Osteoarthritis, a nutritionally sound vegetarian diet, and frequent bathing are not predisposing factors for pneumonia.

40. Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's: 1. Decreased cellular demand for oxygen. 2. Reduced episodes of coughing. 3. Diminished pain when breathing deeply. 4. Ability to expectorate secretions more easily.

1. Decreased cellular demand for oxygen. Exudate in the alveoli interferes with ventilation and the diffusion of gases in clients with pneumonia. During the acute phase of the illness, it is essential to reduce the body's need for oxygen at the cellular level; bed rest is the most effective method for doing so. Bed rest does not decrease coughing or promote clearance of secretions, and it does not reduce pain when taking deep breaths.

46. The client with pneumonia develops mild constipation, and the nurse administers docusate sodium (Colace) as prescribed. This drug works by: 1. Softening the stool. 2. Lubricating the stool. 3. Increasing stool bulk. 4. Stimulating peristalsis.

1. Softening the stool. Docusate sodium (Colace) is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis.

33. An elderly client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. The nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? 1. Perform circulation checks to bilateral upper extremities each shift. 2. Attach the ties of the restraints to the bedframe. 3. Reevaluate the need or restraints and document weekly. 4. Ensure the restraint order has been signed by the physician within 72 hours.

2. Attach the ties of the restraints to the bedframe. Restraints should be secured to the bed-frame, not the siderails, to ensure that the siderails can be raised and lowered safely. Circulation checks, re-evaluating need for restraints, and documentation should be done every 1 to 2 hours. Medical restraint prescriptions must be renewed and signed by a physician every 24 hours.

36. A client with bacterial pneumonia is to be started on IV antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? 1. Urinalysis. 2. Sputum culture. 3. Chest radiograph. 4. Red blood cell count.

2. Sputum culture. A sputum specimen is obtained or culture to determine the causative organism. After the organism is identifed, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Urinalysis, a chest radiograph, and a red blood cell count do not need to be obtained before initiation of antibiotic therapy for pneumonia.

48. Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? 1. A respiratory rate of 25 to 30 breaths/min. 2. The ability to perform activities of daily living without dyspnea. 3. A maximum loss of 5 to 10 lb (2.27 to 4.53 kg) of body weight. 4. Chest pain that is minimized by splinting the rib cage.

2. The ability to perform activities of daily living without dyspnea An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/min indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss o 5 to 10 lb (2.27 to 4.53 kg) 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.

39. 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? 1. Position changes every 4 hours. 2. Nasotracheal suctioning to clear secretions. 3. Frequent linen changes. 4. Frequent offering of a bedpan.

3. Frequent linen changes. Frequent linen changes are appropriate for this client because of the 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.

45. Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? 1. Coma. 2. Apathy. 3. Irritability. 4. Depression.

3. Irritability. 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.

42. A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: 1. A mild but constant aching in the chest. 2. Severe midsternal pain. 3. Moderate pain that worsens on inspiration. 4. Muscle spasm pain that accompanies coughing.

3. Moderate pain that worsens on inspiration. Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, sec-ondary to chest wall movement. Pleuritic chest pain is usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm.

37. When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values? 1. Serum sodium. 2. Serum potassium. 3. Serum creatinine. 4. Serum calcium.

3. Serum creatinine. It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.

38. Penicillin has been prescribed for a client admitted to the hospital for treatment of pneumonia. Prior to administering the first dose of penicillin, the nurse should ask the client: 1. "Do you have a history of seizures?" 2. "Do you have any cardiac history?" 3. "Have you had any recent infections?" 4. "Have you had a previous allergy to penicillin?"

4. "Have you had a previous allergy to penicillin?" The nurse should determine if the client is allergic to penicillin prior to administering the drug. History of seizures, recent infections, and a cardiac history are not contraindications to for this client for receiving penicillin. While important to know, recent infections will not preclude this client receiving penicillin at this time.

41. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? 1. Decreased cardiac output. 2. Pleural effusion. 3. Inadequate peripheral circulation. 4. Decreased oxygenation of the blood.

4. Decreased oxygenation of the blood. 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. Decreased cardiac output may be a comorbid condition in some clients with pneumonia; however, it is not the cause of cyanosis. Pleural effusions are a potential complication of pneumonia but are not the primary cause of decreased oxygenation. Inadequate peripheral circulation is also not the cause of the cyanosis that develops with bacterial pneumonia.

43. Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? 1. Encourage the client to breathe shallowly. 2. Have the client practice abdominal breathing. 3. Offer the client incentive spirometry. 4. Teach the client to splint the rib cage when coughing.

4. Teach the client to splint the rib cage when coughing. The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain.