pneumonia

The clinical instructor is reviewing common complications of pneumonia with the students. She knows that further instruction is needed when the students identify which of these? A. sepsis B. ventilation/perfusion issues C. hypoxemia D. pleural effusion E. respiratory failure F. atelectasis

B pneumonia is a ventilation problem not perfusion

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F

C A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

A pt who has recently traveled to Mexico comes to the ED with fatigue, night sweats, lethargy, and a low-grade fever. What is the nurse's first action? A. Contact the physician for tuberculosis (TB) medications. B. Give the pt a TB skin test. C. Place a respiratory mask on the pt. D. Test all family members for TB.

C The concern is that this client has TB. A respiratory mask should be placed on the client immediately.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? A) Contact the health care provider for tuberculosis (TB) medications. B) Perform a TB skin test. C) Place a respiratory mask on the client. D) Test all family members for TB.

C) Place a respiratory mask on the client.

The nurse is giving med instructions to a TB pt. The nurse knows the teaching was effective when the pt states A. I will take 3 drugs--isoniazid, rifampin, and pyrazinamide, then ethambutol may be added later B. The isoniazid combines with the TB bacteria. I may have to take rifampin and pyrazinamide if my symptoms continue C. combining the drugs all in one pill is a convenient way for me to take all the medications. D. combining the meds is best so I will take the isoniazid, rifampin, and pyrazinamide all at the same time

A 3 drugs--isoniazid, rifampin, and pyrazinamide, then ethambutol may be added later

The nurse knows, in caring for her ventilated pt, that the goal is to prevent VAP. She identifies the following as important in reaching this goal. Select All That Apply A. she should avoid wearing jewelry B. HOB should be up C. Administer chest physiotherapy D. Provide oral care every 12 hours E. Hand hygeine

A, B, E chest physiotherapy is not an intervention for this pt oral care should be provided every 8 hours, not 12 hours

Which medications would be used in four drug treatment for the initial phase of TB (select all that apply) A Isoniazid B Pyrazinamide C Rifampin (Rifadin) D Rifabutin (Mycobutin) E Levofloxacin (Levaquin) F Ethambutol (Myambutol)

A, B, E, F

d

Which diagnostic test is used to detect antibodies to infecting respiratory​ organisms? a Pulse oximetry b Chest​ x-ray c Blood cultures d Serology testing

Which statement(s) describe(s) the management of a patient following lung transplantation (select all that apply)? a. The lung is biopsied using a transtracheal method b. High doses of oxygen are administered around the clock c. The use of a home spirometer will help to monitor lung function d. Immunosuppressant therapy usually involves a three-drug regimen e. Most patients experience an acute rejection episode in the first 3 days.

a, c, & d

A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to: a. candidiasis b. aspergillosis c. histoplasmosis d. coccidioidomycosis

a. candidiasis

Palliative treatment for airway collapse or external compression

Airway stenting

This TB test is a done with a sputum sample and can show TB and drug resistance to the main drug for treating it. The results are ready in 2 hours or less. A. Nucleic Acid Amplification Test (NAAT) B. Quantiferon-TB Gold (QFT-G) C. Mantoux test D. CXR

A NAAT

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. 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.

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. 1. The inhaler is held upright. 2. The head is tilted down while inhaling the medicine. 3. The client waits 5 minutes between puffs. 4. The mouth is rinsed with water following administration. 5. The client lies supine for 15 minutes following administration.

1, 4. The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright.

Which condition contributes to secondary pulmonary arterial hypertension by causing pulmonary capillary and alveolar damage A COPD B Sarcoidosis C Pulmonary fibrosis D Pulmonary embolism

A COPD

Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma? 1. Cough productive of yellow sputum. 2. Bilateral expiratory wheezing. 3. Chest tightness. 4. Respiratory rate of 30 breaths/ minute.

1. A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms- wheezing, chest tightness, and increased respiratory rate- are all findings associated with an asthma attack and do not necessarily mean an infection is present.

Ampicillin 1 gm IVPB is supplied in 50mL of D5W to be delivered over 30minutes. Nurse should set the IV pump at how many mL/hr?

100

When obtaining a health history from a 76 year old patient with suspected CAP, what does the nurse expect the patient or caregiver to report? A Confusion B A recent loss of consciousness C An abrupt onset of fever and chills D A gradual onset of headache and sore throat

A Confusion-related from hypoxia

How domicroorganisms reach the lungs and cause pneumonia (select all that apply) A Aspiriation B Lymphatic spread C Inhalation of microbes in the air D Touch contact with the infectious microbes E Hematogenous spread from infections elsewhere in the body

A, C, E

Drug activated by laser light that destroys cancer cells

Photodynamic therapy

Excess fat restricts chest wall and diaphragmatic excursion

Pickwickian syndrome

When caring for a patient with a lung abscess, what is the nurse's priority intervention? a. Postural drainage b. Antibiotic administration c. Obtaining a sputum specimen d. Patient teaching regarding home care

b. Antibiotic administration

Which instruction should nurse provide pt for an acute episode of asthma?

"Use Ventolin inhaler for acute asthma attacks"-- albuterol is a bronchodilator for acute asthmatic attacks

Nurse observes pt as he uses his inhalers. Using the spacer, pt takes 2 puffs of albuterol, followed a minute later by 2 puffs of the beclomethasone. After observing pt, the nurse should initiate what teaching?

"Wait at least 1 minute between each puff of the same med"-- wait 5 minutes before using the second med

Pt scowls and complains that his breakfast is cold, his family has not yet been to visit him, and it was so noisy during the nigh he was unable to sleep. The nurse recognizes he may displacing his anger as a defense mechanism. What is the best statement for the nurse to use to promote effective communication?

"you seem pretty upset this morning"-- allows for communication

Pt, his son, nurse discuss use of anti-smoking hypnosis tapes, along with other measures to promote good health upon his discharge. Pt agrees to follow all of the d/c instructions and states that he understands use of meds, including the correct use of metered dose inhaler. Which add'l d/c instruction(s) should the nurse include in teaching plan to promote optimal health for pt?

- avoid crowds and people w/infections-- and pneumovax - store prescribed inhalers away from extreme heat & cold-- extreme alterations can alter inhaler meds and render it ineffective

A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply. 1. Activation of the MDI is not coordinated with inspiration. 2. The client inspires rapidly when using the MDI. 3. The client holds his breath for 3 seconds after inhaling with the MDI. 4. The client shakes the MDI after use. 5. The client performs puffs in rapid succession.

1, 2, 3, 4, 5. Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a sufficient amount of time between puffs to provide an adequate amount of inhalation medication.

Which of the following is 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. Occurence of chest pain. 4. Amount of peripheral edema. 5. Color of nail beds.

1, 3, 5. 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.

A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? 1. Irregular heartbeat. 2. Constipation. 3. Pedal edema. 4. Decreased pulse rate.

1. Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to: 1. Develop respiratory infections easily. 2. Maintain current status. 3. Require less supplemental oxygen. 4. Show permanent improvement.

1. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? 1. Maintaining functional ability. 2. Minimizing chest pain. 3. Increasing carbon dioxide levels in the blood. 4. Treating infectious agents.

1. A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

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

1. 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.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the head of the bed 30 to 45 degrees. 2. Encourage the client to cough and deep breathe. 3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the physician.

1. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

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. 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.

Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)? 1. Increased anteroposterior chest diameter. 2. Underdeveloped neck muscles. 3. Collapsed neck veins. 4. Increased chest excursions with respiration.

1. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? 1. Incorporate physical exercise as tolerated into the daily routine. 2. Monitor peak flow numbers after meals and at bedtime. 3. Eliminate stressors in the work and home environment. 4. Use sedatives to ensure uninterrupted sleep at night.

1. Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.

A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2 58; HCO3 26. Which of the following orders should the nurse perform first? 1. Albuterol (Proventil) nebulizer. 2. Chest x-ray. 3. Ipratropium (Atrovent) inhaler. 4. Sputum culture.

1. The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.

A 79-year-old female 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. 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.

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included? 1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. 2. Lie flat on the back, splint the thorax, take two deep breaths, and cough. 3. Take several rapid, shallow breaths and then cough forcefully. 4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

1. The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation (" huff" cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.

Which test results are indicative of active TB? A. induration of 11mm and positive sputum B. sputum tests positive for blood C. positive chest x-ray for TB D. positive chest x-ray and clinical symptoms

A induration 11mm and positive sputum

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply) A Patient with seizures B Patient with head injury C Patient who had thoracic surgery D Patient who had myocardial infarction E Patient who is receiving NG tube feeding

A, B, E

The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client? 1. "Breathe in normally through your nose for 2 counts (while counting to yourself, one, two)." 2. "Relax your neck and shoulder muscles." 3. "Pucker your lips as if you were going to whistle." 4. "Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four)."

2, 1, 3, 4. The nurse should instruct the client to first relax the neck and shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and finally breathe out through pursed lips.

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/ minute. 2. The ability to perform activities of daily living without dyspnea. 3. A maximum loss of 5 to 10 lb of body weight. 4. Chest pain that is minimized by splinting the rib cage.

2. 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/ minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb 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.

When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract? 1. Friction between the cilia. 2. Force of gravity. 3. Sweeping motion of cilia. 4. Involuntary muscle contractions.

2. The principle behind using postural drainage is that gravity will help move secretions from smaller to larger airways. Postural drainage is best used after percussion has loosened secretions. Coughing or suctioning is then used to remove secretions. Movement of cilia is not sufficient to move secretions. Muscle contractions do not move secretions within the lungs.

A client with bacterial pneumonia is to be started on I.V. 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. A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Neither a urinalysis, a chest radiograph, nor a red blood cell count needs to be obtained before initiation of antibiotic therapy for pneumonia.

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD? 1. High oxygen concentrations will cause coughing and dyspnea. 2. High oxygen concentrations may inhibit the hypoxic stimulus to breathe. 3. Increased oxygen use will cause the client to become dependent on the oxygen. 4. Administration of oxygen is contraindicated in clients who are using bronchodilators.

2. Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should: 1. Apply a 100% non-rebreather mask. 2. Assess the vital signs. 3. Reposition the client. 4. Prepare for intubation.

2. Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation.

When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: 1. While inhaling through an open mouth. 2. While exhaling through pursed lips. 3. After exhaling but before inhaling. 4. While taking a deep breath and holding it.

2. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −, 36 mEq/ L. The nurse should assess the client for? 1. Cyanosis. 2. Flushed skin. 3. Irritability. 4. Anxiety.

2. The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? 1. Occupational exposure to toxins. 2. Viral respiratory infections. 3. Exposure to cigarette smoke. 4. Exercising in cold temperatures.

2. The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.

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. 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.

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 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.

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. 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.

The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan? 1. Clubbing of nail beds. 2. Hypertension. 3. Peripheral edema. 4. Increased appetite.

3. Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

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. Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary 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.

A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? 1. Promote bronchodilation. 2. Act as an expectorant. 3. Have an anti-inflammatory effect. 4. Prevent development of respiratory infections.

3. Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care? 1. Infection. 2. Confusion. 3. Ineffective coughing and deep breathing. 4. Difficulty chewing solid foods.

3. In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

The nurse administers theophylline (Theo-Dur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate? 1. Suppression of the client's respiratory infection. 2. Decrease in bronchial secretions. 3. Relaxation of bronchial smooth muscle. 4. Thinning of tenacious, purulent sputum.

3. Theophylline (Theo-Dur) is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

A client who has been taking flunisolide (AeroBid), two inhalations a day, for treatment of asthma.has painful, white patches in his mouth. Which response by the nurse would be most appropriate? 1. "This is an anticipated adverse effect of your medication. It should go away in a couple of weeks." 2. "You are using your inhaler too much and it has irritated your mouth." 3. "You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent." 4. "Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem."

3. Use of oral inhalant corticosteroids such as flunisolide (AeroBid) can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem.

Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? 1. To promote oxygen intake. 2. To strengthen the diaphragm. 3. To strengthen the intercostal muscles. 4. To promote carbon dioxide elimination.

4. Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

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. 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.

Which of the following is an appropriate expected outcome for an adult client with well-controlled asthma? 1. Chest X-ray demonstrates minimal hyperinflation. 2. Temperature remains lower than 100 ° F (37. 8 ° C). 3. Arterial blood gas analysis demonstrates a decrease in PaO2. 4. Breath sounds are clear.

4. Between attacks, breath sounds should be clear on auscultation with good air flow present throughout lung fields. Chest X-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.

When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following? 1. Participate regularly in aerobic exercises. 2. Maintain a high-protein diet. 3. Avoid exposure to people with known respiratory infections. 4. Abstain from cigarette smoking.

4. Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although beneficial, will not decrease the risk of COPD. Insufficient protein intake and exposure to people with respiratory infections do not increase the risk of COPD.

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected? 1. Normal breath sounds. 2. Prolonged inspiration. 3. Normal chest movement. 4. Coarse crackles and rhonchi.

4. Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.

A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/ minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client? 1. Initiate oxygen therapy and reassess the client in 10 minutes. 2. Draw blood for an arterial blood gas analysis and send the client for a chest X-ray. 3. Encourage the client to relax and breathe slowly through the mouth. 4. Administer bronchodilators.

4. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur). Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis and obtaining a chest X-ray. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan? 1. The client promises to do pursed-lip breathing at home. 2. The client states actions to reduce pain. 3. The client says that he will use oxygen via a nasal cannula at 5 L/ minute. 4. The client agrees to call the physician if dyspnea on exertion increases.

4. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/ minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia. .

Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? 1. Low-fat, low-cholesterol diet. 2. Bland, soft diet. 3. Low-sodium diet. 4. High-calorie, high-protein diet.

4. The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods.

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. 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.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A. Check the resident's oxygen saturation. B. Do a complete neurologic assessment. C. Give the prescribed PRN lorazepam (Ativan). D. Notify the resident's primary care provider

A A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN.

A pt is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the pt asks the nurse how long the treatment will be. The nurse knows? A. The pt will be treated for 5 to 7 days. B. The pt will require IV antibiotics for 7 to 10 days. C. The pt will complete 6 days of therapy. D. The pt must be afebrile for 24 hours.

A Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised pt or one with hospital-acquired pneumonia

A pt is taking isoniazid, rifampin, pyrazinamide, and ethambutol for TB. The pt calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A. Ethambutol B. Isoniazid C. Pyrazinamide D. Rifampin

A Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained and oral contraceptives will be less effective.

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.

A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of: A. Meats and citrus fruits B. Grains and broccoli C. Eggs and spinach D. Potatoes and fish

A Needs to increase intake of protein, iron, and vitamin C

A critical concern for a post op pt returning to the floor is r/t impaired oxygenation caused by inadequate ventilation. The ABG and assessment finding that alerts the nurse to use oxygen and the ICS is A. PaO2 is 90mm Hg with crackles B. PaO2 is 45mm Hg with atelectasis C. PaO2 is 90mm Hg with wheezing D. PaO2 is 38mm Hg with clear lung sounds

A PaO2 is 90mm Hg with crackles

A nurse is caring for an 89-year-old client admitted with pneumonia. He has an IV of normal saline running at 100 mL/hr and antibiotics that were initiated in the emergency department 3 hours ago. He has oxygen at 2 liters/nasal cannula. What assessment finding by the nurse indicates that goals for a priority diagnosis have been met for this client? A. The client is alert and oriented to person, place, and time. B. Blood pressure is within normal limits and client's baseline. C. Skin behind the ears demonstrates no redness or irritation. D. Urine output has been >30 mL/hr per Foley catheter.

A Rationale: One of the first manifestations of pneumonia in an older adult is acute confusion as a result of impaired gas exchange. A client with pneumonia who is alert and oriented to person, place, and time is responding well to appropriate therapy for the disorder. The blood pressure is not an indicator of effective management of pneumonia, and neither is urine output. The skin behind his ears being intact is important and desirable but is not an outcome indicator for pneumonia management.

A client was infected with TB 10 years ago but never developed the disease. He's now being treated for cancer. The client begins to develop signs of TB. This is known as which of the following types of infection? A. Active infection B. Primary infection C. Superinfection D. Tertiary infection

A Some people carry dormant TB infections that may develop into active disease. In addition, primary sites of infection containing TB bacilli may remain inactive for years and then activate when the client's resistance is lowered, as when a client is being treated for cancer. There's no such thing as tertiary infection, and superinfection doesn't apply in this case.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? A. Arrange for a health care worker to watch the client take the medication. B. Give the client written instructions about how to take prescribed medications. C. Have the client repeat medication names and side effects. D. Instruct the client about the possible consequences of nonadherence.

A The client is unlikely to adhere to long-term treatment unless med administration is directly supervised. The best option is to arrange for DOT.

A pt who has spent the past 9 months living in homeless shelters has been dx with confirmed tuberculosis (TB). The nurse anticipates the physician will order which medications for the pt? A. Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) B. Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C. Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) D. Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

A The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB. Metronidazole is used to treat anaerobic bacteria and some parasites, but is not effective against TB. Acyclovir is used to treat viral infection. Flunisolide is a corticosteroid that is useful in asthma or other airway disease to prevent wheezing. Prednisone is a steroid. Guaifenesin is a mucolytic. Ketorolac is a nonsteroidal anti-inflammatory drug that is used for short-term pain relief. Salmeterol and cromolyn sodium would most likely be given to clients with respiratory difficulties such as poorly controlled asthma from allergic sources. Dexamethasone is a steroid.

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 Bronchial 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.

Which pneumonia complication does the nurse recognize as creating pain that increases on inspiration because of inflammation of the parietal pleura? A. pleuritic CP B. meningitis C. COPD D. Pulmonary emboli

A Pleuritic CP

A nurse is auscultating the lower lung fields of a pneumonia pt. She hears coarse crackles and ids the problem as impaired oxygenation. She knows the underlying physiologic condition associated with pt condition is A. hypoxemia B. hyperemia C. hypocapnia D. hypercapnia

A hypoxemia

Place the most common pathophysiologic stages of pneumonia in order. Number the first stage with 1 and the last stage with 4 A Macrophages lyse the debris and normal lung tissue and function is restored B Mucus production increases an can obstruct airflow and further decrease gas exchange C Inflammatory response in the lungs with neutrophils is activated to engulf and kill the offending organism. D Increased capillary permeability contributes to alveolar filling with organisms and neutrophils leading to hypoxia.

A 4 B 3 C 1 D 2

A patient with actie TB continues to have positive sputum cultures after 6 months of treatment. She says she cannot remember to take the medication all the tie. What is the best action for the nurse to take? A Arrange for directly observed therapy (DOT) by a public health nurse B Schedule the patient to come to the clinic every day to take the medicaiton C Have a patient who has recovered from TB tell the patient about his successful treatment D Schedule more teaching sessions so that the patient will understand the risks of noncompliance

A Arrange for directly observed therapy (DOT) by a public health nurse

When caring for a patient with acute bronchitis, the nurse will prioritize A Auscultating lung sounds B Encouraging fluid restricitons C Administering antibiotic therapy D Teaching the patient to avoid cough suppresants

A Auscultating lung sounds

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should A Continue to monitor the patient B Check all connections for a leak in the system C Lower the drainage collector further from the chest D Clamp the tubing at progressively distal points away from the patient until the tidaling stops.

A Continue to monitor the patient

During an annual health assessment of a 66 year old patient at the clinic, the patient tells the nurse he has not had the pneumonia vaccine. What should the nurse advise him about the best way for him to prevent pneumonia? A Obtain a pneumococcal vaccine now and get a booster 12 months later B Seek medical care and antibiotic therapy for all upper respiratory infections C Obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia D Obtain only the influenza vaccine every year because he should have immunity to the pneumococcus because of his age

A Obtain a pneumococcal vaccine now and get a booster 12 months later

Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. What is the first action that the nurse should take? A Raise the head of the bed B Notify the health care provider C Take the patents pulse and blood pressure D Determine the patient's Sp02 with an oximeter

A Raise the head of the bed

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding? A Sp02 of 86% B Crackles in both lower lobes C Temp of 101.4 F D Production of greenish purulent sputum

A Sp02 of 86%

When should the nurse check for leaks in the chest tube and pleural drainage system? A There is continuous bubbling in the water-seal chamber B There is constant bubbling of water in the suction control chamber C Fluid in the water-seal chamber fluctuates with the patient's breathing D The water levels in the water-seal and suction control chambers are decreased

A There is continuous bubbling in the water-seal chamber

A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is A administering ordered analgesia B Monitoring chest tube drainage C Sending pleural fluid for laboratory analysis D Monitoring the patients level of consciousness

A administering ordered analgesia

A patient with a lung mass found on chest x-ray is undergoing further testing. The nurse explains that a definitive diagnosis of lung cancer can be confirmed using with diagnostic test? A lung biopsy B Lung tomograms C Pulmonary angiography D Computed tomography scans

A lung biopsy

b

A nurse is showing a student nurse how to care for Tonisha​ Bennete, a​ 32-year-old female who has pneumonia. The student nurse asks the nurse to explain why Ms. Bennete is placed in Fowler position. What is the​ nurse's best response to the student​ nurse? ​a "It is the position in which the client will be most​ comfortable." ​b "It is an intervention for ineffective airway​ clearance." ​c "It is an intervention for activity​ intolerance." d ​"It is an intervention for ineffective breathing​ pattern."

a,b,c,e

A patient diagnosed with pneumonitis would be likely to have all of the following symptoms. Select all that apply. a Dry cough b Tachypnea c Chest pain d Bloody sputum e Shortness of breath

b,e

A patient has been diagnosed with pneumonia secondary to a mycoplasma infection. The healthcare provider knows the following is true about mycoplasmas. Select all that apply. a Mycoplasmas are easily treated with penicillins. b Mycoplasmas have no cell wall. c Mycoplasmas are the largest pathogen identified to affect humans. d Mycoplasmas cause "whooping cough". e Mycoplasmas share characteristics of both viruses and bacteria.

a

A patient is admitted with pneumonia. Sputum cultures show that the patient is infected with a gram positive bacterium. The patient is allergic to Penicillin. Which medication would the patient most likely be prescribed? A. Macrolide B. Cephalosporins C. Pencillin G D. Tamiflu

b

A patient is admitted with rupture of the Achilles tendon. The patient was recently treated with antibiotics for pneumonia. Which of the following medications below can cause this adverse effect? A. Penicillin B. Fluroquinolones C. Tetracyclines D. Macrolides

c

A patient is presenting with mild symptoms of pneumonia. The doctor diagnoses the patient with "walking pneumonia". From your nursing knowledge, you know this type of pneumonia is caused by what type of infectious agent? A. Fungi B. Streptococcus pneumoniae C. Mycoplasma pneumoniae D. Influenza

c

A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the healthcare provider would expect to hear which breath sound? a Rhonchi b Stridor c Crackles d Wheezes

Identify the a, b, c, d, and e labels on the chest drainage devices

A suction control chamber B Water-seal chamber C Air leak monitor D collection chamber E suction monitor bellows

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? Select all that apply. A) Combination drug therapy is effective in preventing transmission. B) Combination drug therapy is the most effective method of treating TB. C) Combination drug therapy will decrease the length of required treatment to 2 months. D) Multiple drug regimens destroy organisms as quickly as possible. E) The use of multiple drugs reduces the emergence of drug-resistant organisms.

A) Combination drug therapy is effective in preventing transmission. B) Combination drug therapy is the most effective method of treating TB. D) Multiple drug regimens destroy organisms as quickly as possible. E) The use of multiple drugs reduces the emergence of drug-resistant organisms.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? Select all that apply. A) Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B) The medications may cause nausea. The client should take them at bedtime. C) The client is generally not contagious after 2 to 3 consecutive weeks of treatment. D) These medications must be taken for 2 years. E) These medications may cause kidney failure.

A) Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. B) The medications may cause nausea. The client should take them at bedtime.

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? A. Asbestos exposure B. Exposure to uranium C. History of cigarette smoking D. Geographic area in which he was born E. Chronic interstitial fibrosis

A, B, C Non-small cell carcinoma 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 pt recently released from prison has just tested positive for TB. What teaching points does the community health nurse want to stress for this pt about the meds? Select All That Apply A. Not taking the meds could lead to an infection that is difficult to treat or to total drug resistance. B. The meds may cause nausea, so take them at bedtime. C. The pt is not contagious after 2 to 3 consecutive weeks of treatment. D. These meds have to be taken for 2 years.

A, B, C Not taking the meds as prescribed can lead to an infection that is difficult to treat or to total drug resistance. The meds may cause nausea and are best taken at bedtime to prevent this. The pt is generally not contagious after 2 to 3 weeks of consecutive treatment BUT must show improvement in the condition. The combination regimen for treatment of TB has decreased treatment time from 6 to 12 months to 6 months. TB meds can cause liver failure, but not kidney failure.

During a health promotion program, why should the nurse plan to target women in a discussion of lung cancer prevention (select all that apply) A Women develop lung cancer at a younger age than men B More women die of lung cancer than die from breast cancer C Women have a worse prognosis from lung cancer than do men D Nonsmoking women are at great

A, B, D

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? A. Heart rate of 120 beats/min B. A productive cough with yellow sputum C. Reports of unable to have a bowel movement for 2 days D. A temperature of 101.4°F E. Respiratory rate of 20 breaths/min

A, B, D 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.

The TB pt is receiving isoniazid (INH). The nurse should include which important teaching points A. Do not take meds such as Maalox with INH B. Avoid alcohol C. Urine may be orange D. Need to take a B complex vitamin E. Wear protective clothing and sunscreen when outdoors F. INH can reduce oral contraceptive effectiveness

A, B, D No Maalox No alcohol Need vit B complex supplement

A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A. Rifampin (Rifadin); contact lenses can become stained orange B. Isoniazid (INH); report yellowing of the skin or darkened urine C. Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D. Ethambutol (Myambutol); report any changes in vision E. Amoxicillin (Amoxil); take this drug with food or milk

A, B, D Rationale: Amoxicillin is not prescribed for TB. Pyrazinamide, although prescribed for TB, calls for an increase in fluids, not fluid restriction. Rifampin, isoniazid, and ethambutol are first-line drugs for TB therapy and have side effects. The side effects listed with these drugs are appropriate to teach the client.

The nurse is caring for a pt who often coughs and chokes while eating and taking his meds, but the pt insists he is fine. The nurse recognizes this as a priority pt problem of risk for aspiration. The nursing interventions she would implement to prevent aspiration pneumonia are Select All That Apply A. HOB always elevated during meals B. Monitor pt ability to swallow small bites C. Give small frequent drinks of thin liquid D. Consult a nutritionist and obtain swallow studies E. Monitor the patient's ability to swallow saliva F. Place pt on NPO status til swallowing returns to normal

A, B, D, E

A pt with TB is homeless and been living in shelters for the past 7 months, he asks the nurse why he must take so many meds. What information will the nurse provide in answering this question? Select All That Apply A. Combination drug therapy is effective in preventing transmission. B. Combination drug therapy is the most effective method of treating TB. C. Combination drug therapy will decrease the length of required treatment to 2 months. D. Multiple drug regimens destroy organisms as quickly as possible. E. The use of multiple drugs reduces the emergence of drug-resistant organisms.

A, B, D, E Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens can destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? A. Splint the chest when coughing. B. Instruct patient to cough at end of exhalation. C. Maintain a 30-degree elevation. D. Maintain a semi-Fowler's position. E. Maintain adequate fluid intake.

A, B, E 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.

Which conditions does the nurse recognize as a risk for developing aspiration pneumonia? Select All That Apply A. continuous tube feed B. bronchoscopy procedure C. MRI D. decreased LOC E. stroke F. chest tube

A, B. D. E continuous tube feed bronchoscopy procedure decreased LOC stroke

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? A. Malignancy B. Pneumonia C. Prolonged air travel D. Obesity E. Cigarette smoking

A, C, D, E An increased risk of pulmonary embolism is associated with obesity, malignancy, 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.

The nurse is speaking at a community event about the risks of getting TB. She acknowledges that which of the following people are at greatest risk? Select All That Apply A. an alcoholic homeless man that stays in a shelter sometimes B. A college dormitory resident with a roommate C. A man with HIV or other immune dysfunction D. A woman that does volunteer work at a local homeless shelter E. Foreign immigrants (esp from Mexico and Phillipines)

A, C, E alcoholic, homeless HIV, other immune dysf foreign immigrants

Which microorganisms are associated with both CAP and HAP? (select all that apply) A Klebsiella B Acinetobacter C Staphylococcus aureus D Mycoplasma pneumoniae E Pseudomonas aeruginosa F Streptococcus pneumoniae

A, C, E, F

A pt is seen in the HCP office and dx with community-acquired pneumonia. The nurse knows the most common symptoms that this pt may have is A. dyspnea B. abdominal pain C. back pain D. hypoxemia E. chest discomfort F. a smoker

A, D, E dyspnea hypoxemia chest discomfort

A pt is suspected on having community-acquired pneumonia. The nurse anticipates which of the following tests to be done to dx pt A. sputum gram stain B. Pulmonary function test C. fluorescein bronchoscopy D. peak flow meter measurement E. chest x-ay

A, E sputum gram stain CXR

The nurse recognizes that isoniazid, rifampin and pyrazinamide can cause impairment of the liver. She will look for the following s/s of liver impairment: A. dark urine B. weight gain C. diarrhea D. tremors E. yellowing of skin, eyes , and/or hard palate

A,, E will have anorexia not wt gain diarrhea and tremors are not s/s of liver issues pt wil have clay-colored stools

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

A. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." 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 of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? A. Antibiotic B. Corticosteroid C. Bronchodilator D. Cough suppressant

A. Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella 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.

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

A. 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.

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? A. Sudden onset of confusion B. Clutching chest on inspiration C. Coarse crackles in lung bases D. Oral temperature of 102.3oF

A. Sudden onset of confusion 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.

Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? A. Basilar crackles B. Respiratory rate of 28 C. Oxygen saturation of 85% D. Presence of greenish sputum

A. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.

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

A. Bronchiolitis obliterans (BOS) 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 transplant.

A patient has been receiving high-dose corticosteroids and broad spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to A. Candidiasis B. Aspergillosis C. Histoplasmosis D. Coccidioidomhcosis

A. Candidiasis

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

A. Cover the chest wound with a nonporous dressing taped on three sides. 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 a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions

A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

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

A. Increased vocal fremitus on palpation 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.

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? A. Maintain adequate fluid intake. B. Splint the chest when coughing. C. Maintain a 30-degree elevation. D. Maintain a semi-Fowler's position. E. Instruct patient to cough at end of exhalation.

A. Maintain adequate fluid intake. B. Splint the chest when coughing. E. Instruct patient to cough at end of exhalation. 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.

During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guerin (BCG)

A. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus 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 (TB) is prevalent.

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? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guérin (BCG)

A. Pneumococcal 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 Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzaevaccine 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 emergency department nurse is caring for patients exposed to a chlorine leak from a local factory. The nurse would closely monitor these patients for A. Pulmonary edema B. Anaphylactic shock C. Respiratory Alkalosis D. Acute tubular necrosis E. Acute tubular necrosis

A. Pulmonary edema

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository

ANS: B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done. DIF: Cognitive Level: Analysis REF: 549 | 551 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiolog

The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done. DIF: Cognitive Level: Analysis REF: 549 | 551 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiolog

The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.

ANS: C Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance

A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

ANS: A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance. DIF: Cognitive Level: Application REF: 552-553 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails.

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. DIF: Cognitive Level: Application REF: 555 | 556 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. "Your urine, sweat, and tears will be orange colored." b. "Read a newspaper daily to check for changes in vision." c. "Take vitamin B6 daily to prevent peripheral nerve damage." d. "Call the health care provider if you notice any hearing loss."

ANS: A Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange. DIF: Cognitive Level: Application REF: 567 | 569 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patient's bed to 10 degrees. b. splint the patient's chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.

ANS: A Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.

ANS: A The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Guérin (BCG) vaccine.

ANS: A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurse's first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patient's health care provider. d. offer emotional support and reassurance.

ANS: A The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). DIF: Cognitive Level: Application REF: 580 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.

ANS: A The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy. DIF: Cognitive Level: Application REF: 573-574 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. DIF: Cognitive Level: Application REF: 551-552 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

ANS: A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance. DIF: Cognitive Level: Application REF: 552-553 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails.

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. DIF: Cognitive Level: Application REF: 555 | 556 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. "Your urine, sweat, and tears will be orange colored." b. "Read a newspaper daily to check for changes in vision." c. "Take vitamin B6 daily to prevent peripheral nerve damage." d. "Call the health care provider if you notice any hearing loss."

ANS: A Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange. DIF: Cognitive Level: Application REF: 567 | 569 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patient's bed to 10 degrees. b. splint the patient's chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.

ANS: A Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.

ANS: A The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Guérin (BCG) vaccine.

ANS: A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurse's first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patient's health care provider. d. offer emotional support and reassurance.

ANS: A The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). DIF: Cognitive Level: Application REF: 580 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.

ANS: A The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy. DIF: Cognitive Level: Application REF: 573-574 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. DIF: Cognitive Level: Application REF: 551-552 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age b. Blood pressure c. Respiratory rate d. Oxygen saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring.

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

ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

pneumonia may present differently in the older adult than in the younger adult? A) Crackles on auscultation B) Fever C) Headache D) Wheezing

B) Fever

When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about a. computed tomography (CT) screening for lung cancer. b. options for smoking cessation. c. reasons for annual sputum cytology testing. d. erlotinib (Tarceva) therapy to prevent tumor risk.

ANS: B Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors. DIF: Cognitive Level: Application REF: 563 | 565 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.

ANS: B Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.

ANS: B Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

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? a. "I will call the doctor if I still feel tired after a week." b. "I will continue to do the deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."

ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.

ANS: B Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "Is there any family history of TB?" b. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" c. "How long have you lived in the United States?" d. "Do you take any over-the-counter (OTC) medications?"

ANS: B Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. DIF: Cognitive Level: Application REF: 557 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the BP is less than 140/90 mm Hg. b. the patient reports decreased exertional dyspnea. c. the heart rate is between 60 and 100 beats/minute. d. the patient's chest x-ray indicates clear lung fields.

ANS: B Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective. DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will avoid being outdoors whenever possible." b. "My husband will be sleeping in the guest bedroom." c. "I will take the bus instead of driving to visit my friends." d. "I will keep the windows closed at home to contain the germs."

ANS: B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), 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 treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.

ANS: B The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. DIF: Cognitive Level: Application REF: 572 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate. DIF: Cognitive Level: Application REF: 565 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.

Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. DIF: Cognitive Level: Application REF: 551 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. DIF: Cognitive Level: Application REF: 576 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about a. computed tomography (CT) screening for lung cancer. b. options for smoking cessation. c. reasons for annual sputum cytology testing. d. erlotinib (Tarceva) therapy to prevent tumor risk.

ANS: B Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors. DIF: Cognitive Level: Application REF: 563 | 565 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.

ANS: B Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "Is there any family history of TB?" b. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" c. "How long have you lived in the United States?" d. "Do you take any over-the-counter (OTC) medications?"

ANS: B Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. DIF: Cognitive Level: Application REF: 557 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the BP is less than 140/90 mm Hg. b. the patient reports decreased exertional dyspnea. c. the heart rate is between 60 and 100 beats/minute. d. the patient's chest x-ray indicates clear lung fields.

ANS: B Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective. DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. DIF: Cognitive Level: Application REF: 572 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate. DIF: Cognitive Level: Application REF: 565 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. DIF: Cognitive Level: Application REF: 551 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. DIF: Cognitive Level: Application REF: 576 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a "fast-food" restaurant to the patient.

ANS: C A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit up at the bedside. b. Splint the patient's chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given. DIF: Cognitive Level: Application REF: 574 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.

ANS: C Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)

ANS: C Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. DIF: Cognitive Level: Application REF: 573 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? a. Ask if the patient is experiencing shortness of breath, hives, or itching. b. Ask the patient about any visual abnormalities such as red-green color discrimination. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication.

Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. "I will call the doctor if I still feel tired after a week." b. "I will need to use home oxygen therapy for 3 months." c. "I will continue to do the deep breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

ANS: C Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time. DIF: Cognitive Level: Application REF: 552 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: C Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. DIF: Cognitive Level: Application REF: 577-578 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patient's bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

ANS: C The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing. DIF: Cognitive Level: Application REF: 567 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The BP is 98/56 mm Hg. b. The oxygen saturation is 94%. c. The patient's central intravenous line is disconnected. d. The international normalized ratio (INR) is prolonged.

ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. DIF: Cognitive Level: Application REF: 581 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

ANS: C The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

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 has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µl. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Guérin (BCG) vaccine

ANS: C The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible.

ANS: C Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a "fast-food" restaurant to the patient.

ANS: C A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit up at the bedside. b. Splint the patient's chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given. DIF: Cognitive Level: Application REF: 574 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)

ANS: C Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. DIF: Cognitive Level: Application REF: 573 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. "I will call the doctor if I still feel tired after a week." b. "I will need to use home oxygen therapy for 3 months." c. "I will continue to do the deep breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

ANS: C Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time. DIF: Cognitive Level: Application REF: 552 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: C Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. DIF: Cognitive Level: Application REF: 577-578 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patient's bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

ANS: C The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing. DIF: Cognitive Level: Application REF: 567 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The BP is 98/56 mm Hg. b. The oxygen saturation is 94%. c. The patient's central intravenous line is disconnected. d. The international normalized ratio (INR) is prolonged.

ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. DIF: Cognitive Level: Application REF: 581 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µl. d. Increased tactile fremitus is palpable over the right chest.

ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible.

ANS: C Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and symptoms would the client show if therapy is inadequate? A. Decreased shortness of breath B. Improved chest x-ray C. Nonproductive cough D. Positive acid-fast bacilli in a sputum sample after 2 months of treatment

D Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection.

Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease. DIF: Cognitive Level: Application REF: 556 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease. DIF: Cognitive Level: Application REF: 556 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.

ANS: D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.

ANS: D Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled. DIF: Cognitive Level: Application REF: 572 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. Peripheral edema

ANS: D Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale. DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.

ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Educating the patient about the long-term impact of TB on health b. Giving the patient written instructions about how to take the medications c. Teaching the patient about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community center and giving the medication then

ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient. DIF: Cognitive Level: Application REF: 556 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

ANS: D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites.

ANS: D Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. "I will make an appointment to see the doctor every year." b. "I will not turn the home oxygen up higher than 2 L/minute." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. DIF: Cognitive Level: Application REF: 583 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."

ANS: D More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. DIF: Cognitive Level: Application REF: 565 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

ANS: D Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

ANS: D Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. "Is there any family history of TB?" b. "How long have you lived in the United States?" c. "Do you take any over-the-counter (OTC) medications?" d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"

ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP splint the patient's chest during coughing. b. UAP assist the patient to ambulate to the bathroom. c. UAP help the patient to a bedside chair for meals. d. UAP lower the head of the patient's bed to 15 degrees.

ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? a. Teach about symptoms of lung disease. b. Treat workers who inhale dust particles. c. Monitor workers for shortness of breath. d. Require the use of protective equipment.

ANS: D Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease, but will not be effective in prevention of lung damage. DIF: Cognitive Level: Application REF: 560-561 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems. DIF: Cognitive Level: Application REF: 567 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.

ANS: D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. What is an expected outcome for this patient? A Sp02 90% B Lungs clear to auscultation C Patient tolerates walking in hallway D Patient takes three or four shallow breaths before coughing to minimize pain

B Lungs clear to auscultation

The mircoorganisms Pneumocystis jiroveci (PJP) and cytomegalovirus (CMV) are asociated with which type of pneumonia A Necrotizing pneumonia B Opportunistic pneumonia C HAP D CAP

B Opportunistic infection

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.

ANS: D Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled. DIF: Cognitive Level: Application REF: 572 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. Peripheral edema

ANS: D Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale. DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Educating the patient about the long-term impact of TB on health b. Giving the patient written instructions about how to take the medications c. Teaching the patient about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community center and giving the medication then

ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient. DIF: Cognitive Level: Application REF: 556 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites.

ANS: D Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. "I will make an appointment to see the doctor every year." b. "I will not turn the home oxygen up higher than 2 L/minute." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

ANS: D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. DIF: Cognitive Level: Application REF: 583 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."

ANS: D More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. DIF: Cognitive Level: Application REF: 565 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

ANS: D Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? a. Teach about symptoms of lung disease. b. Treat workers who inhale dust particles. c. Monitor workers for shortness of breath. d. Require the use of protective equipment.

ANS: D Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease, but will not be effective in prevention of lung damage. DIF: Cognitive Level: Application REF: 560-561 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

To what was the resurgence in TB resulting from the emergence of multi-drug resistant (MDR) strains of Mycobacterium tuberculosis related? A A lack of effective means to diagnose TB B Poor compliance with drug therapy in patients with TB C Indiscriminate use of antitubercular drugs in treatment of other infections D Increased population of immunosuppressed individuals with AIDS

B Poor compliance with drug therapy in patients with TB

When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems. DIF: Cognitive Level: Application REF: 567 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

To reduce the risk for many occupational lung diseases, what is the most important measure the occupational nurse should promote? A Maintaining smoke-free environments for all employees B Using masks and effective ventilation systems to reduce exposure to irritants C Inspection and monitoring of workplaces by national occupational safety agencies D Requiring periodic chest x-rays and pulmonary function tests for exposed employees

B Using masks and effective ventilation systems to reduce exposure to irritants

Which action should the nurse implement to ensure accurate O2 sat readings via pulse oximeter?

Assess adequacy of circulation prior to applying the sensor-- move the sensor to new site at regular intervals

Presence of collapsed, airless alveoli

Atelectasis

When planning care for a patient at risk for pulmonary embolism the nurse prioritizes A maintaining the patient on bed rest B Using sequential compression devices C Encouraging the patient to cough and deep breathe D Teaching the patient how to use the incentive spirometer

B Using sequential compression devices

62M comes to ED w/a 4 day history of increased sputum production, change in character of sputum, increased SOB, and fever 101F. History of smoking 2packs/day prior, beginning at age 14. He reports he had asthma as a child and he's been treated with Albuterol inhalers as an adult. Has been hospitalized 2x w/pneumonia; the most recent was 2 years ago. Physical exam: VS: 101F, P 115, R 30, BP 120/80 Respirations shallow and labored, w/use of accessory muscles Increased AP diameter of chest Skin dry and warm touch, inelastic skin turgor, fingernail clubbing. Which assessment is most important for nurse to complete next?

Auscultate breath sounds Rationale: This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress

Pt's condition improves, son expresses concern that pt will continue to smoke. Son asks nurse if anti-smoke hypnosis tapes could be played during the night while pt sleeps. Which ethical principle is most important for the nurse to consider when responding to son?

Autonomy-- the ethical principle refers to the individual's right to make own decisions. Consent

A pt with HIV is admitted to the hospital with reports of bloody sputum, feeling very tired, night sweats, SOB and has a temp of 99.8F. The nurse recognizes these assessment findings as A. Asthma B. Tuberculosis C. Superinfection resulting from a low CD4 count D. Chronic brochitis

B

An older adult pt presents to the ED with a 4-day history of cough, SOB, pain on inspiration, and dyspnea. The pt never had a pneumococcal vaccine. The chest x-ray shows density in bilateral lung bases. The pt has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this pt? A. It would not be beneficial for this pt. B. It would help decrease the bronchospasm. C. It would clear up the density in the pts lung bases. D. The pt would have a decrease in the pain on inspiration.

B A bronchodilator would would open up the airways and help decrease bronchospasm , so it would be beneficial for this pt. It would decrease dyspnea and feelings of shortness of breath.

INH treatment is associated with the development of peripheral neuropathies. Which of the following interventions would the nurse teach the client to help prevent this complication? A. Adhere to a low cholesterol diet B. Supplement the diet with pyridoxine (vitamin B6) C. Get extra rest D. Avoid excessive sun exposure

B INH competes with the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed.

The nurse has just been assigned the client with pneumonia caused by aspiration after alcohol intoxication recently admitted. The client is agitated and febrile. Which physician order is the nurse's priority? A. Administer the banana bag IV route. B. Draw aerobic and anaerobic blood cultures. C. Give lorazepam (Ativan) as needed for agitation. D. Administer levofloxacin (Levaquin) 500 mg IV.

B Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action; the question indicates that the client is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation.

Which symptom of pneumonia may present differently in the older adult pt than in the younger adult pt? A. Crackles on auscultation B. Fever C. Headache D. Wheezing

B Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. The other answers may be seen in all age groups of pneumonia pts

A pt with TB has taken the med treatment correctly for 3 weeks and showing signs of clinical improvement. The pt wife asks the nurse if the pt is still infectious. The nurses reply should be A. Pt is still infectious until the entire treatments is complete B. Pt is not infectious but needs to continue treatment for at least 6 months C. Pt may or may not be infectious, so a PPD test needs to be performed D. Pt is infectious until there is a neg chest x-ray result

B Pt is not infectious but needs to continue treatment for at least 6 months

This TB test is used in acute care settings to test a symptomatic patient, with results being available within 24 hours A. Nucleic Acid Amplification Test (NAAT) B. Quantiferon-TB Gold (QFT-G) C. Mantoux test D. CXR

B Quantiferon-TB Gold (QFT-G)

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A. Client with acute ashma who has stridor B. Client with pulmonary tuberculosis who is receiving multiple medications C. Client that has returned to the unit after his bronchoscopy procedure 8 hours ago. D. Client with chronic bronchitis with congestion and difficulty swallowing

B The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a difficulty swallowing is at risk for deterioration and needs careful assessment and monitoring by the RN

To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? A dull percussion sounds on the injured side B sever respiratory distress and tracheal deviation C Muffled and distant heart sounds with decreasing blood pressure D Decreased movement and diminished breath sounds on the affected side

B sever respiratory distress and tracheal deviation

A pt is being d/c home with active TB. Which information does the nurse include in the discharge teaching? A. "You are not contagious unless you stop taking your medication." B. "You will not be contagious to the people you have been living with." C. "You will have to take these medications for at least 1 year." D. "Your sputum may turn a rust color as your condition gets better."

B The people the pt has been living with have already been exposed and need to be tested. They cannot be re-exposed just b/c the dx has been confirmed. The pt w/ active TB is contagious, even while taking medication. The length of time for treatment is 6 months Rust-colored sputum is indication of worsening TB

A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if which of the following were noted in the laboratory report? A. 5 mcg/mL B. 15 mcg/mL C. 25 mcg/mL D. 30 mcg/mL

B The therapeutic theophylline blood level range from 10-20 mcg/mL.

Which statement best describes pneumonia? A. an infection of just the windpipe because the lungs are clear of any problems B. a serious inflammation, caused by various things, of the bronchioles C. only an infection of the lungs with mild to severe effects on breathing D. an inflammation resulting from damage to the lungs due to long-term smoking

B a serious inflammation, caused by various things, of the bronchioles

The pt with pneumonia has a priority problem of ineffective airway clearance with bronchospasms. Pt has no previous chronic resp disorders. The nurse will obtain an order for which intervention? A. increased liters of humidified oxygen via facemask B. scheduled and prn aerosol nebulizer bronchodilator treatments C. handheld bronchodilator inhaler prn D. corticosteroid via inhaler or IV to reduce inflammation

B scheduled and prn aerosol nebulizer bronchodilator treatments

Which pt is at higher risk for developing pneumonia? A. any hospitalized pt between 19 - 64 y.o. B. 36 y.o. trauma pt on mechanical ventilator C. disabled 51 y.o. with abdominal pain, d/c home D. Any pt who has not received the pneumonia vaccine

B 36 y.o. trauma pt on mechanical ventilator

A HIV pt has a TB result of induration less than 10mm and no clinical TB symptoms. The nurse anticipates that the physician will prescribe which med for the pt to take for a 12 month period? A. Baccille Calmette-Guerin (BCG) vaccine B. Isoniazid (INH) C. Streptomycin D. Ethambutol

B INH

The home health nurse is visiting the home of an older adult pt recovering from a knee replacement. She ids a priority pt problem of risk for respiratory infection. Which is a normal aging factor contributing to the risk A. inability of a forced cough B. decreased strength of resp. muscles C. increased macrophages in alveoli D. increased elastic recoil of alveoli

B decr strength resp muscles

A patient diagnosed with class 3 TB 1 week ago is admitted to the hospital with symptoms of chest pain and coughing. What nursing action has the highest priority? A Administering the patient's antitubercular drugs B Admitting the patient to an airborne infection isolation room C Preparing the patient's room with suction equipment and extra linens D Placing the patient in an intensive care unit, where he can be closely monitored

B Admitting the patient to an airborne infection isolation room

When caring for a patient with a lung abscess, what is the nurses's priority intervention? A Postural drainage B Antibiotic administration C Obtaining a sputum specimen D Patient teaching regarding home care

B Antibiotic administration

A patient with advance lung cancer refuses pain medication saying I deserve everything this cancer can give me. What is the nurse's best response to this patient? A Would talking to a counselor help you? B Can you tell me what the pain means to you? C Are you using the pain as a punishment for your smoking D Pain control will help you to deal more effectively with your feelings

B Can you tell me what the pain means to you?

Which chest surgery is used for the stripping of a fibrous membrane? A Lobectomy B Decortication C Thoracotomy D Wedge resection

B Decortication

While caring for a patient with idiopathic pulmonary arterial hypertension (IPAH), the nurse observes that the patient has exertional dyspnea and chest pain in addition fo fatigue. To what are these symptoms related? A Decreased left ventricular output B Dilating the pulmonary arteries C Strengthening the cardiac muscle D Treating the underlying pulmonary condition

B Dilating the pulmonary arteries

When obtaining a health history from a patient suspected of having early TB, the nurse should ask the patient about what manifestations? A Chest pain, hemoptysis, and weight loss B Fatigue, low grade fever, and night sweats C Cough with purulent mucus and fever with chills D Pleuritic pain, nonproductive cough, and temperature elevation at night

B Fatigue, low grade fever, and night sweats

Which one of the following are incorrect about TB? Select All That Apply A. The bacterium that causes TB is aerobic, rod shaped and secretes niacin B. Primarily affects the pulmonary system, especially the lower lobes. C. The goal of treatment is to cure the TB D. It is spread via the airborne route E. It is an acid-fast strain

B, C It does primarily affect the pulmo system, but it especially affect the UPPER lobes, where O2 content is highest The goal of treatment is to prevent transmission, control symptoms, and prevent progression of the disease

The nurse is caring for a TB pt. She knows that which statements about TB pt care are true Select All That Apply A. HCPs must wear a mask covering face and mouth B. Negative airflow room is required C. HCP must wear an N95 or HEPA mask D. Gloves and Gown are included in PPEs for this pt E. Strict contact precautions must be maintained at all times

B, C, D

Which statement describes the management of a patient following lung transplantation (select all that apply) A high doses of 02 are administered around the clock B the use of a home spirometer will helpt to monitor lumg function C Immunosuppressant therapy usually involves a three-drug regimen D Most patients experience an acute rejection episode in the first days E The lung is biopsied using a transtracheal method if rejection is suspected

B, C, E

A man presents to the providers office with reports of not feeling well for the past several weeks. A TB test is given in the office. If it is positive, which assessment findings does the nurse expect to find Select All That Apply A. Wt gain B. Fatigue C. Chest soreness D. Low-grade fever E. Night sweats

B, D, E Fatigue Night sweats Fever

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

B. "I need to be isolated from my family and friends so they won't get it." 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 receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will A. Call the health care provider to question the order B. Administer both vaccines at the same time in different arms C. Administer the flu shot and tell the patient to come back 1 week later to receive the pneumococcal vaccine D. Administer the pneumococal vaccine and suggest FluMist (nasal vaccine) instead of the influenza injection

B. Administer both vaccines at the same time in different arms

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? A. Respiratory rate of 28 breaths/min B. Basilar crackles C. Presence of greenish sputum D. Oxygen saturation of 85%

B. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.

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

B. Less discomfort and faster return to normal activity 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.

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

B. Obtain a physician's order for supplemental oxygen. 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? A. Take the temperature, pulse, and respiratory rate. B. Obtain a sputum specimen for culture and Gram stain. C. Teach the patient to cough and deep breathe. D. Check the patient's oxygen saturation by pulse oximetry.

B. Obtain a sputum specimen for culture and Gram stain. 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.

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? A. Culture and sensitivity tests are needed for 1 year after resolving the abscess B. Oral antibiotics will be used until there is evidence of improvement. C. IV antibiotic therapy will be used for a 6-month period of time. D. Lobectomy surgery is usually needed to drain the abscess.

B. Oral antibiotics will be used until there is evidence of improvement. V 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.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for AM

B. Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as 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 BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

Medications that block molecules involved in tumor growth

Biologic and targeted therapy

Palliative treatment by bronchoscope to remove obstructing bronchial tumors

Bronchoscopic laser

The nurse reads the pts skin test and tells him it is positive for TB. The pt asks the nurse what that means. The nurse explains A. There is active disease but you are not yet infectious to others you are in contact with B. you will need immediate treatment for the active disease C. you have been infected but does not mean active TB is present D. you will need a repeat skin test b/c the test could be a false-positive result

C

A patient with TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the patient be taught? (select all that apply) A expect routine TST to evaluate infection B Visitors will not be allowed while in airborne isolation C Take all medications for full length of tie to prevent multidrug-resistant TB D Wear a standard isolation mask if leaving the airborne infection isolation room E Maintain precautions in airborne infection isolation room by coughing into a paper tissue

C, D, E

The pneumonia pt asks the nurse why she needs to draw labs to check his electrolytes. The nurses correct response is A. To monitor for possible acidosis B. To check for elevated WBCs C. To evaluate the sodium level for possible hypernatremia D. To check for possible septicemia

C Because of dehydration from fever, may be hypernatemic/ dehydrated Electrolytes don't show acidosis, that is ABGS It is important to check the WBC count but its not an electrolyte A blood culture would need to be done for septicemia

This TB test shows if the pt has been exposed to TB, with a positive result being an induration that's 10mm or larger. A. Nucleic Acid Amplification Test (NAAT) B. Quantiferon-TB Gold (QFT-G) C. Mantoux test D. CXR

C Mantoux test aka PPD purified protein derivative Nurse reads it 48-72 hours after the injection under the skin

The nurse identifies the priority nursing dx for a pneumonia pt to be ineffective airway clearance related to fatigue, CP, excessive secretions and muscle weakness. To correct the problem the nurse will implement which intervention A. administer oxygen to prevent hypoxemia and atelectasis B. push fluids to greater than 3000 mL/day to ensure adequate hydration C. administer bronchodilator therapy in a timely manner to decrease bronchospasms D. maintain semi-fowlers position to facilitate breathing and prevent further fatigue

C bronchodilator

A pt is admitted to the hospital with bronchopneumonia. The nurse knows that this pt has pneumonia that A. has only affected a certain lobe of the lung B. has affected bilateral lower lobes C. is scattered throughout the lung, with affected patches throughout. D. will cause aspiration, so pt should be monitored

C bronchopneumonia is scattered affected areas throughout multiple lobes of the lungs A. = a definition of lobar pneumonia

Six days after a heart-lung transplant, the patient develops a low-grade fever, dyspnea, and decreased Sp02 What should the nurse recognize that this y indicate? A A normal response to extensive surgery B A requently fatal cytomegalovirus infection C Acute rejection that will be treated with corticosteroids D Bronchiolitis obliterans, which plugs terminal bronchioles

C Acute rejection that will be treated with corticosteroids

Why is the classification of pneumonia as community-acquired (CAP) or hospial-acquired (HAP) clinically useful? A Atypical pneumonia syndrome is more likely to occur in HAP B Diagnostic testing does not have to be used to identify causative agents C Causative agents can be predicted, and empiric treatment is often effective D IV antibiotic therapy is necessary hor HAP, but oral therapy is adequate for CAP

C Causative agents can be predicted, and empiric treatment is often effective

Following a pneumonectomy, an appropriate nursing intervention is A monitoring chest tube drainage and functioning B Positioning the patient on the unaffected side of the neck C Doing range-of motion exercises on the affected upper limb D Auscultating frequently for lung sounds on the affected side

C Doing range-of motion exercises on the affected upper limb

A pulmonary embolus is suspected in a patient with a DVT who develops dyspnea, tachycardia, and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? A D-dimer B Chest x-ray C Spiral (helical) CT scan D Ventilation-perfusion lung scan

C Spiral (helical) CT scan

After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which order should the nurse implement first? A anterior/posterior and lateral chest x-rays B Start IV levofloxacin (Levaquin) C Sputum specimen for Gram stain and culture and sensitivity D Complete blood count (CBC) with white blood cell (WBC) count and differential

C Sputum specimen for Gram stain and culture and sensitivity

An unlicensed assitive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP? A looping the drainage tubing on the bed B securing the drainage container in an upright position C Stripping or milking the chest tube to promote drainage D Reminding the patient to cough and deep breathe every 2 hours

C Stripping or milking the chest tube to promote drainage

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

C. "The medicine will be prescribed for 10 days." 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.

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation

C. Increased vocal fremitus on palpation 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 nurse identifies a flail chest in a trauma patient when A. multiple rib fractures are determined by x-ray B. A tracheal deviation to the unaffected side is present C. Paradoxical chest movement occurs during respiration D. There is decreased movement of the involved chest wall

C. Paradoxical chest movement occurs during respiration

A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? A. Acute asthma B. Chronic bronchitis C. Pneumonia D. Spontaneous pneumothorax

D A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.

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

C. Positioning patient with "good lung" down 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.

Identify four clinical situations in which hospitalized patients are at risk for aspiration pneumonia and one nursing intervention for each situation that is indicated to prevent pneumonia

Clinical situation-Patient with altered consciousness Nursing Intervention-Position to side, protect airway Clinical situation-Patient with a feeding tube Nursing Intervention-Check placement of the tube before feeding and residual feeding: Keep head of bed up after feedings or continuously with continuous feedings Clinical situation-Patient with local anesthetic to throat Nursing Intervention-Check gag reflex before feeding or offering fluids Clinical situation-Patient wit difficulty swallowing Nursing Intervention-Cut food in small bites, encourage thorough chewing, and provide soft foods that are easier to swallow than liquids

Considered primary treatment for small cell lung cancer (SCLC)

Chemotherapy

The nurse notices a visitor walking into the room of a pt on airborne isolation with no protective gear. What does the nurse do? A. Ensures that the pt is wearing a mask B. Tells the visitor that the pt cannot receive visitors at this time C. Gives a particulate air respirator to the visitor D. Gives a mask to the visitor

D Because the visitor is entering the pt's isolation environment, the visitor must wear a mask. The pt typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator.

A client's ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

D Respiratory Acidosis

The nurse is reviewing the lab results for an older adult pneumonia pt. The lab value frequently seen in pneumonia pts that may not be seen in this pt is A. RBC 4.0 - 5.0 B. Hgb 12 - 16 C. Hct 36 - 48 D. WBC 12 - 18

D WBC

A pt is dx with TB, agrees to therapy as prescribed. In the teaching the nurse should instruct the pt to take the meds when A. before breakfast B. midday C. after breakfast D. bedtime

D bedtime

The nurse is reviewing a pneumonia pts lab results. What does she expect to see A. decreased Hgb B. increased RBCs C. decreased neutrophils D. increased WBCs

D incr WBCs

A pt returns to the office in the 48 to 72 hour period to have the subcutaneous mantoux skin test results read. The nurse knows that which finding is indicative of a positive result? A. test area is red, warm and tender when touched B. induration/hardened area measures 6mm or greater C. induration/hardened nodule of any size at the site D. induration/hardened area measuring 10mm or greater

D induration 10 mm or greater

A pt is at the office for a follow up visit and has been compliant with drug therapy for TB. Which result indicates the TB is no longer infectious A. a negative chest x-ray B. three negative sputum cultures and a negative chest x-ray C. no clinical symptoms present D. three negative sputum cultures

D three negative sputum cultures

A patient with a 40 pack year smoking history has recently stopped smoking because of the fear of developing lung cancer. The patient asks the nurse what he can do to learn about whether he develops lung cancer. What is the best response from the nurse? A you should get a chest xray every 6 months to screen for any new growths B It would be very rare for you to develop lung cancer now that you have stopped smoking C You should monitor for any persistent cough, wheezing, or difficulty breathing, which could indicate tumor growth D Adults aged 55 to 80 with a history of heavy smoking who quit in the past 15 years should be screened yearly with low-dose computed tomography

D Adults aged 55 to 80 with a history of heavy smoking who quit in the past 15 years should be screened yearly with low-dose computed tomography

What is the initial antibiotic treatment for pneumonia based on? A The severity of symptoms B The presence of characteristic leukocytes C Gram stains and cultures of sputum specimens D History and physical examination and characteristic chest x-ray findings

D History and physical examination and characteristic chest x-ray findings

Following a thoracotomy, the patient has a nursing diagnosis of ineffective breathing pattern related to inability to cough as a result of pain and positioning. What is the best nursing intervention for this patient? A have the patient drink 16 oz of water before attempting to deep breath B Auscultate the lung before and after deep-breathing and coughing regimens C Place the patient in the Trendelenburg position for 30 minutes before the coughing exercises D Medicate the patient with analgesics 20-30 minutes before assisting to cough and deep breath

D Medicate the patient with analgesics 20-30 minutes before assisting to cough and deep breath

A male patient has COPD and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occuring? A Tension pneumothorax B Iatrogenic pneumothorax C Traumatic pneumothorax D Spontaneous pneumothorax

D Spontaneous pneumothorax

What is a primary treatment goal for cor pulmonale? A controlling dysrhythmias B Dilating the pulmonary arteries C Strengthening the cardiac muscle D Treating the underlying pulmonary condition

D Treating the underlying pulmonary condition

Following a motor vehicle accident, the nurse assess the driver for which distinctive sign of flail chest? A sever hypotension B chest pain over ribs C absence of breath sounds D paradoxical chest movement

D paradoxical chest movement

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be A perform postural drainage every hour B provide analgesics as ordered to promote patient comfort C administer 02 as prescribed to maintain optimal 02 levels D teach the patient how to couch effectively to bring secretions to the mouth

D teach the patient how to couch effectively to bring secretions to the mouth

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

D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray 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 of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

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

D. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. 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.

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? A. No new drainage in collection chamber B. Small pneumothorax at CT insertion site C. Water-seal chamber has 5 cm of water. D. Chest tube with a loose-fitting dressing

D. Chest tube with a loose-fitting dressing 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, but 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.

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

D. Increase fluid intake to 3 L/day if tolerated. 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.

What is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able. B. Administer cough suppressant q4hr. C. Teach patient to splint the affected area. D. Increase fluid intake to 3 L/day if tolerated.

D. Increase fluid intake to 3 L/day if tolerated. 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 developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? A. Cough reflex B. Reflex bronchoconstriction C. Ability to filter particles from the air D. Mucociliary clearance

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

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? A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems. C. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. 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.

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? A. Notify the health care provider. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen.

D. Sit the patient up in bed as tolerated and apply oxygen. 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 physician. 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 physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? A. Serum laboratory studies ordered for AM B. Orthostatic blood pressures C. Pulmonary function evaluation D. Sputum culture and sensitivity

D. Sputum culture and sensitivity 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.

Continuous monitoring of pt's O2 sat indicates readings between 90-91 (normal O2 sat values are 90-100). After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention?

Elevate the head of bed to high-Fowler's position-- semi to high-Fowler's positions decrease the pressure on diaphragm and allow from improved lung expansion. Pt's w/COPD prefer to lean forward and rest in tripod

Lung expansion restricted by pus in intrapleural space

Empyema

b,c,d,e

The nurse is instructing a group of college students on symptoms of "walking pneumonia." Which symptoms should the nurse include in the teaching​ session? ​(Select all that​ apply.) a Productive cough b Joint pain c Muscle aches d Fever e Headache

Excessive scar tissue in connective tissue in lungs

Idiopathic pulmonary fibrosis

Which nursing diagnosis has the highest priority when the nurse is planning care for pt?

Ineffective airway clearance-- There are adventitious breath sounds, tachypnea, changes in depth of respirations, fever, and cough, all of which support this as a priority diagnosis.

Later the UAP helps pt transfer from bedside--> commode. After pt is back in bed, nurse enters room and observes O2 sat is 85% and he's not wearing nasal cannula. He states that the tubing wouldn't reach to the commode so UAP removed it. What is best nursing action

Instruct the UAP involved regarding the inappropriate removal of the nasal cannula-- Helping pt to commode is appropriate action for UAP to perform, but the UAP requires some add'l instruction and individual supervision

Spinal angulation restricting ventilation

Kyphoscoliosis

d

Michael Harrison is a​ 65-year-old man with type 2 diabetes. He has presented to the emergency department complaining of​ headache, fatigue, muscle​ aches, and fever. Mr.​ Harrison's symptoms resemble the flu. Which form of pneumonia does Mr.​ Harrison's nurse suspect he​ has? a Walking pneumonia b Aspiration pneumonia c Primary atypical pneumonia d Viral pneumonia

Which assessment is most important for nurse to perform while pt is receiving albuterol?

Monitor pulse and BP-- it's a beta adrenergic agonist. B/c replicates sympathetic stimulation, pt should be monitored for arrhythmia, HTN, nervousness and restlessness

Paralysis of respiratory nuscles

Muscular dystrophy

Pt admitted and HCP prescribes: -Bedrest w/bedside commode -O2 at 2L/min nasal cannula -diet as tolerated -continuous O2 sat monitoring via pulse oximeter -IV fluid 5%Dextrose and 0.45% NS at 3L/day -obtain sputum culture Meds: -ampicillin 1gm IVPB Q6H -Neb Tx Q4H and prn saline & albuterol - beclomethasone inhaler 2puffs 2x/day -albuterol 2puffs 4x/day methylprednisolone 125mg IVPB Q8H Which nursing action should be implemented before Ampicillin is administered?

Obtain sputum culture-- the sputum culture will be compromised if broad-spectrum is taken first. The sputum specimen should

Pt O2 sat returns to 91% after nasal cannula. Remainder is uneventful. VS: 99F, P84, R 22, BP 130/78. Lung sounds are diminished, crackles less audible, and pt is producing only min clear sputum. During night pt calls nurse cannot catch his breath. Upon assessment, the nurse notes pt's RR has increased to 40 w/dyspnea. O2 sat is 55, Pulse is 110, weak and thread and BP 70/40 Which intervention should the nurse initiate immediately?

Place resuscitation equipment in the room-- This is priority b/c pt's sat is dangerously low. Nurse should prepared to transfer him to CCU

Lung expansion restricted by fluid in pleural space

Pleural effusion

Inflammation of the pleura restricting lung movement

Pleurisy

Used to prevent metastasis to the brain with SCLC

Prophylactic cranial radiation

Which assessment finding supports pt's diagnosis of pneumonia

Pulse of 115-- tachycardia is most consistent w/infectious process, in addition pt's fever and rapid RR are also VS findings that indicate a problem--> infection Rationale: Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection.

Used to treat both NSCLC and SCLC

Radiation therapy

Electric current hearts and destroys tumor cells

Radiofrequency ablation

In response to nurse, pt explains "it seems like I've been sick so much. It's all the fault of those cigarette companies. I wouldn't be so sick if they had warned us about the dangers of smoking. I'll probably end up with cancer, and then I'll sue them." What's nurse's best response?

Remain silent.

Crackles ABG: pH 7.28 pCO2 55 HCO3 25 pO2 89 These ABG results indicate that pt is experiencing which acid-base imbalance

Respiratory acidosis-- Rationale: The low pH indicates that acidosis is present. The elevated pCO2 indicates that the problem is respiratory in nature. Clients w/any condition that depresses respirations are prone to the development of respiratory acidosis. Even though pt has a rapid RR, his underlying COPD causes retention of CO2

The Nat'l Council of State Boards of Nursing has defined 5 rights of delegation. Which one of these rights was violated in this situation

Right Direction/Communication-- Since continuous O2 was a high priority, the nurse's directions to the UAP should have emphasized the nasal cannula to be left on at all times, especially during activity. the Right Supervision includes direction/guidance, eval/monitoring and follow-up

The remainder of pt's hospital stay is uneventful. Which outcome statement is best indicator that pt's pneumonia is resolved and he is ready to be discharged?

Sputum culture is negative -- SIGNIFICANT

Used with early-stage lung cancers when patient is not a surgical candidate

Stereotactic radiotherapy

Best procedure for cure of early non-small cell lung cancer (NSCLC)

Surgical therapy

Suction monitor bellows

The dry model has the suction monitor bellows, which expands to show that the suction is operating, as this model does not make the bubbling noise made by the models that control the suction with water.

a,b,c

The nurse in the emergency department is caring for a client with a temperature of 102.5 ​°​F, productive​ cough, chills, shortness of breath and malaise. Which diagnostic tests does the nurse expect to have ordered for this​ client? ​(Select all that​ apply.) a Chest​ x-ray b Arterial blood gases c Sputum culture and sensitivity d MRI of the chest e Polysomnography

b

The nurse is assessing a client who is reporting shortness of​ breath, fever, and a productive cough. Which diagnostic test should the nurse anticipate being ordered​ initially? a HIV serology b Sputum culture and sensitivity c Bronchoscopy d CT scan

d

The nurse is caring for a client with Legionnaires' disease. Which one of the following types of isolation should the nurse use when caring for the client? a Droplet precautions b Airborne precautions c Contact precautions d No isolation precautions are needed

a,b,d,e

The nurse is caring for a client with pneumonia who is having difficulty clearing the airway because of​ viscous, copious lung secretions. Which interventions should the nurse use to aid in airway​ clearance? ​(Select all that​ apply.) a Monitor arterial blood gas​ (ABG) results b Assess sputum for color and consistency c Provide a dehumidifier d Encourage fluids e Place in high Fowler position

b

The nurse is caring for a client with suspected pneumonia. The client questions how he could have gotten this condition. The nurse​'s response is based on the knowledge that which factor may cause this​ condition? a Bacteria found in drinking water b Bacteria found in​ water-cooled air conditioning systems c Poor environmental air quality d Poor nutritional intake

a

The nurse is caring for a​ client, admitted with severe​ malnutrition, who required the insertion of a gastrostomy tube. The nurse bases the client​'s care on the understanding that the client is at risk for developing which type of​ pneumonia? a Aspiration pneumonia b Primary atypical pneumonia c Acute bronchial pneumonia d Viral pneumonia

a,b,d

The nurse is conducting a teaching session for new parents on the causes of viral pneumonia. Which etiologies will the nurse include in the​ teaching? ​(Select all that​ apply.) a Adenovirus b Influenza virus c Rotavirus d Cytomegalovirus e Norovirus

d

The nurse is educating a hospitalized young adult male client recently diagnosed with pneumonia about the role of stress in increasing susceptibility to infection. What best explains this relationship? a The number of stressors experienced influences susceptibility more than their nature or duration. b Emotional stressors, but not physical stressors, have an effect on blood cortisol levels. c Lower blood cortisone levels deplete energy stores. d Elevated levels of blood cortisone decrease the body's anti-inflammatory responses. e Physical and emotional stressors decrease blood cortisone.

a

The nurse is providing discharge instructions for a client with pneumonia. What information is essential for the nurse to​ include? a Complete the prescribed medication regimen b Minimize fluid intake to prevent edema c Maintain bed rest for 2 days d Report temperature greater than 99​°F ​(37.2​°​C)

c

The nurse understands that there are several ways that pneumonia is classified. Which type of pneumonia does the nurse suspect in a client who is not a resident of a​ long-term care facility and is diagnosed within 48 hours of admission to the​ hospital? ​a Hospital-acquired pneumonia ​b Healthcare-associated pneumonia ​c Community-acquired pneumonia ​d Ventilator-associated pneumonia

Suction control

This chamber applies suction to the chest drainage system. The water suction type system contains a column of water with the top end vented to the atmosphere to control the amount of suction, with bubbles to indicate it is working. The amount of suction applied is controlled by the amount of water int he chamber, not by the wall suction applied to it. The dry suction device contains no water and uses a regulator to dial the desired negative pressure

Collection

This chamber receives fluid and air from the pleural or mediastinal space. Nurses keep track of the amount of drainage and can mark the container for easy measuring

a

What is the purpose of a sputum Gram stain in the collaborative treatment of​ pneumonia? a To determine the infecting organism b To obtain a more detailed image of the lungs c To see the body​'s response to the infection d To evaluate gas exchange

d

Which infectious lung disease is caused by the entry of gastric contents into the​ lungs? a Viral pneumonia b Pharyngitis c Primary atypical pneumonia d Aspiration pneumonia

a,d,e

Which instructions are correct to give to a client who has pneumonia and is being discharged for home​ care? ​(Select all that​ apply.) a Avoid smoking or exposure to secondhand smoke b Clean surfaces with household disinfectant c Wear a mask when in contact with other household members d Limit activities and increase rest e Maintain adequate fluid intake

water seal chamber

chamber contains 2 cm of water, which act as a one way valve. incoming air enters from the collections chamber and bubbles up through the water. The water prevents backflow of the air into the patient from the system

How should the nurse explain tot he patient and family what the purpose of video assisted thoracic surgery (VATS) is? A removal of a lung B removal of one or more lung segments c removal of lung tissue by multiple wedge excisions d inspection, diagnosis, and management of intrathoracic injuries

d inspection, diagnosis, and management of intrathoracic injuries

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to: a. perform postural drainage every hour b. provide analgesics as ordered to promote patient comfort c. administer O2 as prescribed to maintain optimal oxygen levels d. teach the patient how to cough effectively to bring secretions to the mouth.

d. teach the patient how to cough effectively to bring secretions to the mouth.

Central depression of respiratory rate and depth

opioid and sedative overdose

e a b c d

A 19-year-old patient has been diagnosed with pneumonia. Upon the healthcare provider's initial assessment, she notes the patient's breathing is rapid and shallow. Place the healthcare provider's next steps in the order in which they should be performed. ANSWER WITH SPACES NO COMMAS a Place a pulse oximeter on the patient. b Listen to the patient's breath sounds. c Record the patient's respiratory rate. d Document the findings. e Administer oxygen via nasal cannula.

a

A 25 year-old female patient with pneumonia is prescribed Doxycycline. What question is important to ask the patient prior to administration of this medication? A. "Do you take birth control pills?" B. "Are you allergic to Penicillin?" C. "Are you allergic to eggs?" D. "Do you have a history of diabetes?"

b,e

A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a HISTORY OF SYSTOLIC HEART FAILURE and arthritis. On assessment, you note the patient has a respiratory rate of 21, oxygen saturation 93% on 2L nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply: A. Keep head-of-the-bed less than 30 degrees at all times. B. Collect sputum cultures. C. Encourage 3L of fluids a day to keep secretions thin. E. Provide education about receiving the Pneumovax vaccine every 5 years.

30

A medication order reads 300mg IV of Clindamycin for a patient diagnosed with a pulmonary abscess. The medication is available in 500mg/50mL. How many mL will the healthcare provider administer? ______________mL

a

A nurse in a clinic is caring for a client whose partner states the client woke up this morning and did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the nurses priority? A. Obtain baseline vital signs and O2 Saturation B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccine.

c

A nurse is caring for Ed​ Sampson, a​ 62-year-old male who has been diagnosed with severe​ community-acquired pneumonia. As Mr.​ Sampson's nurse begins to administer chest​ physiotherapy, Mr.​ Sampson's family member asks the purpose of chest physiotherapy. What is Mr.​ Sampson's nurse's best​ response? ​a "It helps eliminate the organisms infecting the​ lungs." ​b "It is an intervention for activity​ intolerance." c ​"The vibration and percussion facilitates the drainage of​ secretions." d ​"It is an intervention for ineffective breathing​ pattern."

B C A D

A nurse is caring for a client who has pneumonia. Assessment findings include temp 100 F, RR 30, BP 130/76, HR 100 bpm, SaO2 91% on room air. Prioritize the following interventions. ( DO NOT PUT COMMAS BETWEEN ANSWERS) A. Administer antibiotics B. Administer O2 Therapy C. Perform a Sputum Culture D. Administer an antipyretic medication to promote client comfort.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? A) Arrange for a health care worker to watch the client take the medication. B) Give the client written instructions about how to take prescribed medications. C) Have the client repeat medication names and side effects. D) Instruct the client about the possible consequences of nonadherence.

A) Arrange for a health care worker to watch the client take the medication.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? A) Check the resident's oxygen saturation. B) Do a complete neurologic assessment. C) Give the prescribed PRN lorazepam (Ativan). D) Notify the resident's primary care provider.

A) Check the resident's oxygen saturation.

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? A) Ethambutol B) Isoniazid C) Pyrazinamide D) Rifampin

A) Ethambutol

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? A) Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) B) Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) C) Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) D) Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

A) Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol)

A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine C) Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D) Ethambutol (Myambutol); report any changes in vision E) Amoxicillin (Amoxil); take this drug with food or milk

A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine D) Ethambutol (Myambutol); report any changes in vision

A nurse is caring for an 89-year-old client admitted with pneumonia. He has an IV of normal saline running at 100 mL/hr and antibiotics that were initiated in the emergency department 3 hours ago. He has oxygen at 2 liters/nasal cannula. What assessment finding by the nurse indicates that goals for a priority diagnosis have been met for this client? A) The client is alert and oriented to person, place, and time. B) Blood pressure is within normal limits and client's baseline. C) Skin behind the ears demonstrates no redness or irritation. D) Urine output has been >30 mL/hr per Foley catheter

A) The client is alert and oriented to person, place, and time.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? A) "You are not contagious unless you stop taking your medication." B) "You will not be contagious to the people you have been living with." C) "You will have to take these medications for at least 1 year." D) "Your sputum may turn a rust color as your condition gets better."

B) "You will not be contagious to the people you have been living with."

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? A) Client with group A beta-hemolytic streptococcal pharyngitis who has stridor B) Client with pulmonary tuberculosis who is receiving multiple medications C) Client with sinusitis who has just arrived after having endoscopic sinus surgery D) Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

B) Client with pulmonary tuberculosis who is receiving multiple medications

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? A) Administer levofloxacin (Levaquin) 500 mg IV. B) Draw aerobic and anaerobic blood cultures. C) Give lorazepam (Ativan) as needed for agitation. D) Refer to social worker for alcohol counseling.

B) Draw aerobic and anaerobic blood cultures.

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A) It would not be beneficial for this client. B) It would help decrease the bronchospasm. C) It would clear up the density in the bases of the client's lungs. D) It would decrease the client's pain on inspiration.

B) It would help decrease the bronchospasm.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A) Client with bacterial pneumonia and a cough productive of green sputum B) Client with neutropenia and pneumonia caused by Candida albicans C) Client with possible pulmonary tuberculosis who currently has hemoptysis D) Client with right empyema who has a chest tube and a fever of 103.2° F

C) Client with possible pulmonary tuberculosis who currently has hemoptysis

a

In order to prevent ventilator associated/ acquired pneumonia (VAP) in an intubated patient, the healthcare provider should: a Provide oral care and suctioning to the patient b Maintain intubation for no more than 72 hours c Give prophylactic antibiotics d Discourage patient visitors

a,d

Select all the medications used to treat pneumonia that are narrow-spectrum? A. Macrolides B. Tamiflu C. Fluroquinolones D. Penicillins

a

The day-shift healthcare provider is receiving report on her patient assignments for the day. It would be most important for the her to see which patient first? a The patient who is complaining of shortness of breath. b The patient with serosanguinous chest tube drainage. c The patient complaining of pain 777 on a 101010 point scale. d The patient who with documented bilateral wheezes.

b

The healthcare provider is conducting teaching during a health fair about the causes of pneumonia. The healthcare provider demonstrates understanding of the causes when she states that community acquired pneumonia (CAP) can be caused by all of the following except: a Mycoplasma b Human papillomavirus c Influenza d Streptococcus pneumoniae

b,c,e

The healthcare provider understands that pneumococcal vaccines work in the following ways: Select all that apply. a The vaccine causes the illness in the individual so an immunity is formed. b The vaccine provides protection against up to 23 different serotypes. c The vaccine assists the individual in forming an immunity to the pathogen. d The vaccine provide protection for up to 2 years from the pneumococci bacteria. e The body creates antibodies against the bacterium.

c

The healthcare provider understands that teaching has been effective when the patient verbalizes the following regarding influenza vaccinations: a "Since the vaccine is the live virus, I can expect to be ill for 4-7 days after receiving my shot." b "Influenza vaccines are a cure for the flu." c "The vaccine is an inactivated virus, but may cause some mild cold-like symptoms." d "If I have already had the vaccine last year, it is not recommended that I get it again this year."

b

The healthcare provider understands that which of the following patients is most at risk for developing pneumocystis carinii pneumonia (PCP)? a A 45-year-old man who smokes 2 packs of cigarettes a day. b A 50-year-old woman with human immunodeficiency virus (HIV). c A 22-year-old man with a history of asthma. d A 36-year-old who works in a coal mine.

c

The healthcare provider working in an immunization clinic is supervising the medical assistant during an influenza vaccine administration. The healthcare provider should question the immunization of which of the following patients scheduled to receive the vaccine? a A 65-year-old man with a history of emphysema. b A 32-year-old man with a allergy to latex. c A 13-year-old boy with an allergy to eggs. d A 76-year-old woman with a history of congestive heart failure.

c

The healthcare provider would anticipate which of the following as a treatment option for pneumonitis? a Emergency thoracotomy b Albuterol nebulization c Corticosteroid administration d Chest tube insertion

c

The home care nurse is visiting a client who reports symptoms of a severe respiratory infection. Which characteristic about the onset of symptoms would the nurse know as consistent with a diagnosis of viral​ pneumonia? a Subclinical onset of symptoms b Acute onset of symptoms c Gradual onset of symptoms d Remitting onset of symptoms

a,b,c,e

The nurse caring for a client with pneumonia administers a variety of classifications of pharmacologic therapies in collaboration with the healthcare team. Which medications may be appropriate for a client with​ pneumonia? ​(Select all that​ apply.) a Broad spectrum antibiotics b Oxygen therapies c Liquefying agents d Laxatives e Bronchodilators

a

The nurse is caring for a client in the emergency department with fever of 102.5 ​°​F, ​chills, dyspnea, and signs of significant respiratory distress. What is the priority nursing​ intervention? a Place the client on oxygen via face mask and notify the physician b Obtain a sputum culture c Administer acetaminophen as ordered d Administer IV fluids of normal saline​ @ 100​ mL/hr

a,b,e,f

The nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (SELECT ALL THAT APPLY) A . Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is post-op and has recieved local anesthesia. E. Client who has a closed head injury and is receiving ventilation. F. Client who has myasthenia gravis.

b

The nurse is performing a nursing assessment on a client who is diagnosed with pneumonia. Which question is important for the nurse to include in the physical examination part of the nursing​ assessment? ​a "What medications are you currently​ taking?" ​b "What is your full​ name?" ​c "Do you have any allergies to​ medications?" d ​"How long have you had a​ cough?"

b

The parents of a newborn child are concerned about bringing the baby home to a household of relatives with various illnesses. For how many weeks can the obstetrical nurse tell the parents that their child is protected by the​ mother's immunoglobulins? a 4 to 7 weeks b 8 to 12 weeks c Under one week d 1 to 3 weeks

b

Which lab value alteration is likely a result of corticosteroid treatment in a Type 1 diabetic patient diagnosed with pneumonitis? a Potassium 5.1 b Glucose 200 mg/dL c Albumin 3.5 /dL d Sodium 138 mEq

b,c,e,g

Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply: A. Stridor B. Coarse crackles C. Oxygen saturation less than 90% D. Non-productive, nagging cough E. Elevated white blood cells F. Low PCO2 of less than 35 G. Tachypnea

a,c,d

Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply: A. A 53 year old female recovering from abdominal surgery. B. A 69 year old patient who recently received the pneumococcal conjugate vaccine. C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.

c,e

Who has the highest incidence and mortality from​ pneumonia? ​(Select all that​ apply.) a Office workers b Infants c People with debilitating diseases d Young adults e Older adults

d

You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately? A. "I'm seeing yellow halos around the light." B. "My mouth tastes like metal." C. "My head hurts." D. "I have this constant ringing in my ears."

a

You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gas readings below represent respiratory acidosis that is NOT compensated? A. pH 7.29, PaCO2 55, HCO3 23, PO2 85 B. pH 7.48, PaCO2 35, HCO3 22, PO2 85 C. pH 7.20, PaCO2 20, HCO3 28, PO2 85 D. pH 7.55, PaCO 63, HCO3 19, PO2 85

c

You're educating a patient with pneumonia on how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device? A. Encourage the patient to use it twice a day. B. The patient exhales into the device rapidly and then coughs. C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales. D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.

b

You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material? A. "I'll use hand sanitizer regularly while I'm out in public." B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia." C. "I will try to avoid large crowds of people during the peak of flu season." D. "It is important I try to quit smoking."

Retractions

______________ are the visible sinking in of the chest wall and are categorized as a late sign of respiratory distress in adults but are considered an early warning sign for infants.

When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? a) Antibiotic b) Corticosteroid c) Bronchodilator d) Cough suppressant

a) Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella 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.

Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? a) Basilar crackles b) Respiratory rate of 28 c) Oxygen saturation of 85% d) Presence of greenish sputum

a) Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? a) Hyperthermia related to infectious illness b) Ineffective thermoregulation related to chilling c) Ineffective breathing pattern related to pneumonia d) Ineffective airway clearance related to thick secretions

a) Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? a) Pneumococcal b) Staphylococcus aureus c) Haemophilus influenzae d) Bacille-Calmette-Guérin (BCG)

a) Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus 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 (TB) is prevalent.

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)? a) Asbestos exposure b) Exposure to uranium c) Chronic interstitial fibrosis d) History of cigarette smoking e) Geographic area in which he was born

a, b, & d Non-small cell carcinoma 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.

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)? a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding

a, b, & e

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? a) Maintain adequate fluid intake. b) Splint the chest when coughing. c) Maintain a 30-degree elevation. d) Maintain a semi-Fowler's position. e) Instruct patient to cough at end of exhalation.*

a, b, & e 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.

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)? a) Obesity b) Pneumonia c) Malignancy d) Cigarette smoking e) Prolonged air travel

a, c, d, & e An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is: a. administering ordered analgesia b. monitoring chest tube drainage c. sending pleural fluid for laboratory analysis d. monitoring the patient's level of consciousness

a. administering ordered analgesia

When caring for a patient with acute bronchitis, the nurse will prioritize: a. auscultating lung sounds b. encouraging fluid restriction c. administering antibiotic therapy d. teaching the patient to avoid cough suppressants

a. auscultating lung sounds

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should: a. continue to monitor the patient b. check all connections for a leak in the system c. lower the drainage collector further from the chest d. clamp the tubing at progressively distal points away from the patient until the tidaling stops

a. continue to monitor the patient

The emergency department nurse is caring for patients exposed to a chlorine leak from a local factory. The nurse would closely monitor these patients for: a. pulmonary edema b. anaphylactic shock c. respiratory alkalosis d. acute tubular necrosis

a. pulmonary edema

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

b) Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as 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 BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of a) cough reflex. b) mucociliary clearance. c) reflex bronchoconstriction. d) ability to filter particles from the air.

b) mucociliary clearance. Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will: a. call the healthcare provider to question the order. b. administer both vaccines at the same time in different arms c. administer the flu shot and tell the patient to come back d. week later to receive the pneumococcal vaccine and suggest FluMist (nasal vaccine) instead of the influenza injection.

b. administer both vaccines at the same time in different arms

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes: a. maintaining the patient on bed rest b. using sequential compression devices c. encouraging the patient to cough and deep breathe d. teaching the patient how to use the incentive spirometer

b. using sequential compression devices

The patient with HIV has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when she says, a) "I will be given amphotericin B to treat the fungus." b) "I got this fungus because I am immunocompromised." c) "I need to be isolated from my family and friends so they won't get it." d) "The effectiveness of my therapy can be monitored with fungal serology titers."

c) "I need to be isolated from my family and friends so they won't get it." 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.

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 interventions? a) Water-seal chamber has 5 cm of water. b) No new drainage in collection chamber c) Chest tube with a loose-fitting dressing d) Small pneumothorax at CT insertion site

c) Chest tube with a loose-fitting dressing 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, but 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.

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? a) Hyperresonance on percussion b) Vesicular breath sounds in all lobes c) Increased vocal fremitus on palpation d) Fine crackles in all lobes on auscultation

c) Increased vocal fremitus on palpation 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.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? a) Continue with ambulation since this is a normal response to activity. b) Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. c) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. d) Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

c) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. 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.

When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? a) Lobectomy surgery is usually needed to drain the abscess. b) IV antibiotic therapy will be used for a prolonged period of time. c) Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. d) No further culture and sensitivity tests are needed if the patient takes the medication as ordered.

c) Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. IV antibiotics are used until the patient and x-ray 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.

What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? a) Positioning patient on right side b) Maintaining adequate fluid intake c) Positioning patient with "good lung" down d) Performing postural drainage every 4 hours

c) Positioning patient with "good lung" down 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 TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the patient be taught (select all that apply)? a. Expect routine TST to evaluate infection. b. Visitors will not be allowed while in airborne isolation. c. Take all medication for full length of time to prevent multi drug-resistant TB. d. Wear a standard isolation mask if leaving the airborne infection isolation room. e. Maintain precautions in airborne infection isolation room by coughing into a paper tissue.

c, d, & e

An appropriate nursing intervention for a patient postpneumonectomy is: a. monitoring chest tube drainage and functioning b. positioning the patient on the unaffected side or back c. doing range-of-motion exercises on the affected upper limb d. auscultating frequently for lung sounds on the affected side

c. doing range-of-motion exercises on the affected upper limb

The nurse identifies a flail chest in a trauma patient when: a. multiple rib fractures are determined by x-ray b. a tracheal deviation to the unaffected side is present c. paradoxic chest movement occurs during respiration d. there is decreased movement of the involved chest wall

c. paradoxic chest movement occurs during respiration

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

d) "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray 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 of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient? a) Pulmonary infarction b) Pulmonary hypertension c) Cytomegalovirus (CMV) d) Bronchiolitis obliterans (BOS)

d) Bronchiolitis obliterans (BOS) Bronchiolitis obliterans (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 transplant.

What is the priority nursing intervention in helping a patient expectorate thick lung secretions? a) Humidify the oxygen as able. b) Administer cough suppressant q4hr. c) Teach patient to splint the affected area. d) Increase fluid intake to 3 L/day if tolerated.

d) Increase fluid intake to 3 L/day if tolerated. 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 patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a) The patient has lung cancer. b) The incision will be medial sternal or lateral. c) Chest tubes will not be needed postoperatively. d) Less discomfort and faster return to normal activity

d) Less discomfort and faster return to normal activity 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.

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient? a) Perform a comprehensive health history with the patient to review prior respiratory problems. b) Complete a full physical examination to determine the effect of the respiratory distress on other body functions. c) Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. d) Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

d) Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. 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 once the patient's acute respiratory distress is being managed.

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? a) Notify the physician. b) Administer a nitroglycerin tablet sublingually. c) Conduct a thorough assessment of the chest pain. d) Sit the patient up in bed as tolerated and apply oxygen.

d) Sit the patient up in bed as tolerated and apply oxygen. 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 physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.