28 Flashcards
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%
a. Weak, nonproductive cough effort
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.
b. increased tactile fremitus.
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.
a. Assist the patient to splint the chest when coughing.
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.”
c. “I will continue to do the deep breathing and coughing exercises at home.”
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.
b. Place patients with altered consciousness in side-lying positions.
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.
c. The patient’s white blood cell (WBC) count is 9000/µl.
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.
c. Obtain consecutive sputum specimens from the patient for 3 days.
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.
d. Three sputum smears for acid-fast bacilli are negative.
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.
c. covers the mouth and nose when coughing.
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.”
a. “Your urine, sweat, and tears will be orange colored.”
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.
a. yellow-tinged skin.
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
d. Arranging for a daily noontime meal at a community center and giving the medication then
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.
a. Ask the patient whether medications have been taken as directed.
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.
a. use and side effects of isoniazid (INH).
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.
c. puts on a surgical face mask before visiting the patient.
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.
d. Require the use of protective equipment.
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.
b. options for smoking cessation.
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.”
d. “Tell me what you know about the various treatments available.”
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.
a. Administer the prescribed PRN morphine.
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?”
b. “Can you tell me what it is that makes you think you will die so soon?”
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.
b. 400 mL of blood in the collection chamber.
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.
a. paradoxic chest movement.
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.
d. insertion of a chest tube with a chest drainage system.
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.
d. take no further action with the collection device.
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.
c. frequent use of an incentive spirometer
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
d. Peripheral edema
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.
b. the patient reports decreased exertional dyspnea.
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.
b. position the patient sitting upright on the edge of the bed and leaning forward.
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.”
d. “I will call the health care provider right away if I develop a fever.”
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.
d. Obtain blood cultures from two sites.
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.
b. Oxygen saturation is 89%.
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)
c. azithromycin (Zithromax)
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.
c. The patient is being treated with antiretrovirals for HIV infection.
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.
d. impaired gas exchange related to respiratory congestion.
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.
a. lower the head of the patient’s bed to 10 degrees.
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.
a. elevate the head of the bed to 45 to 60 degrees.
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)
c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath.
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?”
b. “Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?”
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.
c. Tape a nonporous dressing on three sides over the chest wound.
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.
c. Medicate the patient with the prescribed morphine.
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.
c. The patient’s central intravenous line is disconnected.
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.
a. Listen to the patient’s lungs.
