Week 2
Chapter 28
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
a. Weak, nonproducti
...
Week 2
Chapter 28
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
a. Weak, nonproductive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
2. 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
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Teach 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.
4. 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. Ill cancel my chest x-ray appointment if Im feeling better in a couple weeks.
5. 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.
6. 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 patients white blood cell (WBC) count is 9000/L.
d. Increased tactile fremitus is palpable over the right chest.
7. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
d. Instruct the patient to expectorate three specimens as soon as possible.
8. A patient is admitted with active tuberculosis (TB). The nurse should question a health care providers 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.
9. 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.
10. 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.
11. 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?
CONTINUED........
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