Chapter 20 - Acute Respiratory Disorders

Question 1

A nurse is monitoring a group if 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 postoperative and has received local anesthesia
E. Client who has a closed head injury and is receiving mechanical ventilation
F. Client who has myasthenia gravis

Answer 1

A. Client who has dysphagia
B. Client who has AIDS
E. Client who has a closed head injury and is receiving mechanical ventilation
F. Client who has myasthenia gravis

Question 2

A nurse is caring for a client who, upon awakening, was disoriented to person, place and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?
A. Obtain baseline vital signs and oxygen saturation
B. Obtain a sputum culture
C. Obtain a complete history from the client
D. Provide a pneumococcal vaccine

Answer 2

A. Obtain baseline vital signs and oxygen saturation

Question 3

A nurse is caring for a client who has pneumonia. Assessment findings include temp 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91 % on room air. Prioritize the following nursing interventions.
A. Administer antibiotics
B. Administer oxygen therapy
C. Perform sputum culture
D. Instruct the client to obtain a yearly influenza vaccination

Answer 3

B. Administer oxygen therapy
C. Perform sputum culture
A. Administer antibiotics
D. Instruct the client to obtain a yearly influenza vaccination

Question 4

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations to this disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas

Answer 4

D. Palpation of the orbital areas

Question 5

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?
A. I should wash my hands after blowing my nose to prevent spreading the virus
B. I need to avoid drinking fluids if I develop symptoms
C. I need a flu shot every 2 years because of the different flu strands
D. I should cover my mouth with my hand when I sneeze

Answer 5

A. I should wash my hands after blowing my nose to prevent spreading the virus