chapter 30

Question 1

Following assessment of a client with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which of the following 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%

Answer 1

a. Weak, nonproductive cough effort

Question 2

The nurse is conducting a chest assessment on a client with pneumococcal pneumonia. Which of the following findings should the nurse expect to assess?
a. Vesicular breath sounds
b. Increased tactile fremitus
c. Dry, nonproductive cough
d. Hyper-resonance to percussion

Answer 2

b. Increased tactile fremitus

Question 3

The nurse is caring for a client with bacterial pneumonia who has pleurisy. Which of the following actions should the nurse implement to promote airway clearance?
a. Assist the client to splint the chest when coughing.
b. Educate the client about the need for fluid restrictions.
c. Encourage the client to wear the nasal oxygen cannula.
d. Instruct the client on the pursed lip breathing technique.

Answer 3

a. Assist the client to splint the chest when coughing.

Question 4

The nurse is providing teaching to a client with pneumonia. Which of the following client statements indicate 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.”

Answer 4

c. “I will continue to do the deep-breathing and coughing exercises at home.”

Question 5

Which of the following nursing actions is most effective in preventing aspiration pneumonia in clients who are at risk?
a. Turn and reposition immobile clients at least every 2 hours.
b. Place clients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in clients who are immuno-suppressed.
d. Provide for continuous subglottic aspiration in clients receiving enteral feedings.

Answer 5

b. Place clients with altered consciousness in side-lying positions.

Question 6

The nurse is caring for a client with right lower-lobe pneumonia who has been treated with intravenous (IV) antibiotics for 2 days. Which of the following 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 client coughs up small amounts of green mucus.
c. The client’s white blood cell (WBC) count is 9 ́ 109 /L.
d. Increased tactile fremitus is palpable over the right chest.

Answer 6

c. The client’s white blood cell (WBC) count is 9 ́ 109 /L.

Question 7

The health care provider writes a prescription for bacteriological testing for a client who has a positive tuberculosis skin test. Which of the following actions should 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 client for 3 days.
d. Instruct the client to expectorate three specimens as soon as possible.

Answer 7

c. Obtain consecutive sputum specimens from the client for 3 days.

Question 8

Which of the following information about a client 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.

Answer 8

d. Three sputum smears for acid-fast bacilli are negative.

Question 9

The nurse is providing teaching to a client with pulmonary tuberculosis (TB) regarding the transmission of TB. Which of the following client actions indicate that the teaching has been effective?
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.

Answer 9

c. Covers the mouth and nose when coughing.

Question 10

Which of the following information should the nurse include in the teaching plan for a client who is receiving rifampin for treatment of tuberculosis?
a. “Your urine, sweat, and tears will be orange coloured.”
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.”

Answer 10

a. “Your urine, sweat, and tears will be orange coloured.”

Question 11

The nurse is teaching a client who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications. Which of the following findings should the nurse instruct the client to report to the health care
provider?
a. Yellow-tinged skin
b. Changes in hearing
c. Orange-coloured sputum
d. Thickening of the fingernails

Answer 11

a. Yellow-tinged skin

Question 12

The nurse is caring for clients with active tuberculosis (TB) who misuse alcohol and/or are homeless. Which of the following interventions by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Educating the client about the long-term impact of TB on health
b. Giving the client written instructions about how to take the medications
c. Teaching the client about the high risk for infecting others unless treatment is followed
d. Arranging for a daily noontime meal at a community centre and giving the
medication then

Answer 12

d. Arranging for a daily noontime meal at a community centre and giving the
medication then

Question 13

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

Answer 13

a. Ask the client whether medications have been taken as directed.

Question 14

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. Which of the following information should the occupational health nurse provide to the staff nurse?
a. Use and adverse 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

Answer 14

a. Use and adverse effects of isoniazid (INH)

Question 15

The nurse is caring for a client who is hospitalized with active tuberculosis (TB) and the nurse observes a family member who is visiting the client. Which of the following actions by the visitor should cause the nurse to intervene?
a. Washes hands before entering the client’s room
b. Hands the client a tissue from the box at the bedside
c. Puts on a surgical face mask before visiting the client
d. Brings food from a “fast-food” restaurant to the client

Answer 15

c. Puts on a surgical face mask before visiting the client

Question 16

Which of the following actions by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust is 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.

Answer 16

d. Require the use of protective equipment.

Question 17

The nurse is developing a teaching plan for a client with a 42 pack-year history of cigarette smoking. Which of the following information should the nurse include in the plan of care?
a. Computed tomography (CT) screening for lung cancer
b. Options for smoking cessation
c. Reasons for annual sputum cytology testing
d. Erlotinib therapy to prevent tumour risk

Answer 17

b. Options for smoking cessation

Question 18

The nurse is caring for a client with stage I non–small cell lung cancer who is scheduled for a lobectomy. The client tells the nurse, “I would rather have radiation than surgery.” Which of the following responses by the nurse is best?
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.”

Answer 18

d. “Tell me what you know about the various treatments available.”

Question 19

The nurse is caring for a client who had a thoracotomy 1 hour ago and reports 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 of the following actions is best for the nurse to take next?
a. Administer the prescribed PRN morphine.
b. Assist the client 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.

Answer 19

a. Administer the prescribed PRN morphine.

Question 20

A client with newly diagnosed lung cancer tells the nurse, “I think I am going to die pretty soon.” Which of the following responses 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?”

Answer 20

b. “Can you tell me what it is that makes you think you will die so soon?”

Question 21

The health care provider inserts a chest tube in a client with a hemo-pneumothorax. When monitoring the client after the chest tube placement, which of the following findings is of greatest concern?
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

Answer 21

b. 400 mL of blood in the collection chamber

Question 22

The nurse is caring for a client who has a steering wheel injury as a result of an
automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?
a. Paradoxical 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

Answer 22

a. Paradoxical chest movement

Question 23

The nurse is assessing a client who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate?
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

Answer 23

d. Insertion of a chest tube with a chest drainage system

Question 24

The nurse is caring for a client who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?
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

Answer 24

d. Take no further action with the collection device

Question 25

The nurse is providing preoperative instruction for a client who is scheduled for a left pneumonectomy for cancer of the lung. Which of the following information should the nurse include related to postoperative care? 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

Answer 25

c. Frequent use of an incentive spirometer

Question 26

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

Answer 26

d. Peripheral edema

Question 27

The nurse is caring for a client with primary pulmonary hypertension (PPH) who is receiving nifedipine. Which of the following findings indicate that the treatment is effective? a. BP is less than 140/90 mm Hg b. Client reports decreased exertional dyspnea c. Heart rate is between 60 and 100 beats/minute d. Client’s chest x-ray indicates clear lung fields

Answer 27

b. Client reports decreased exertional dyspnea

Question 28

The nurse is caring for a client with a pleural effusion who is scheduled for a thoracentesis. Which of the following actions should the nurse implement prior to the procedure? a. Start a peripheral intravenous line to administer the necessary sedative drugs. b. Position the client sitting upright on the edge of the bed and leaning forward. c. Remove the water pitcher and remind the client not to eat or drink anything for 6 hours. d. Instruct the client about the importance of incentive spirometer use after the procedure.

Answer 28

b. Position the client sitting upright on the edge of the bed and leaning forward.

Question 29

The nurse has completed discharge teaching for a client who has had a lung transplant. Which of the following client statements indicate that the teaching was effective? 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.”

Answer 29

d. “I will call the health care provider right away if I develop a fever.”

Question 30

Which of the following prescriptions should the nurse implement first for a client 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 400 mg IV. d. Obtain blood cultures from two sites.

Answer 30

d. Obtain blood cultures from two sites.

Question 31

The nurse is caring for a client who has just had a thoracentesis. Which of the following information 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.

Answer 31

b. Oxygen saturation is 89%.

Question 32

Which of the following information obtained by the nurse about a client who has 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 client is being treated with antiretrovirals for HIV infection. d. The client has a cough that is productive of blood-tinged mucus.

Answer 32

c. The client is being treated with antiretrovirals for HIV infection.

Question 33

The nurse is caring for a client with pneumonia has a fever of 38.4°C (101.1°F), a nonproductive cough, and an oxygen saturation of 89%. The client is very weak and needs assistance to get out of bed. Which of the following nursing diagnoses is priority? a. Hyperthermia related to increase in metabolic rate (illness) b. Impaired transfer ability related to insufficient muscle strength c. Ineffective airway clearance related to retained secretions d. Ineffective breathing pattern related to respiratory muscle fatigue

Answer 33

d. Ineffective breathing pattern related to respiratory muscle fatigue

Question 34

The nurse observes an unregulated care provider doing all the following activities when caring for a client with a pulmonary embolism. Which of the following actions should cause the nurse to intervene with the client’s care? a. Lowers the head of the client’s bed to 10 degrees. b. Splints the client’s chest during coughing. c. Helps the client to ambulate to the bathroom. d. Assists the client to a bedside chair for meals.

Answer 34

a. Lowers the head of the client’s bed to 10 degrees.

Question 35

The nurse is caring for a client with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. Which of the following actions should the nurse implement first? a. Elevate the head of the bed to 45–60 degrees. b. Administer the ordered pain medication. c. Notify the client’s health care provider. d. Offer emotional support and reassurance.

Answer 35

a. Elevate the head of the bed to 45–60 degrees.

Question 36

After the nurse has received change-of-shift report about the following four clients, which client should be assessed first? a. A 77-year-old client with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old client with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old client who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old client who was admitted the previous day with pneumonia and has a temperature of 37.9°C (100.2°F)

Answer 36

c. A 46-year-old client who has a deep vein thrombosis and is complaining of sudden onset shortness of breath.

Question 37

The nurse is performing tuberculosis (TB) screening in a clinic that has many clients who have immigrated to Canada. Before doing a TB skin test on a client, which of the following questions 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 Canada?” d. “Do you take any over-the-counter (OTC) medications?”

Answer 37

b. “Have you received the bacille Calmette–Guérin (BCG) vaccine for TB?”

Question 38

The nurse is caring for a client in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first? a. Position the client so that the right chest is dependent. b. Keep the head of the client’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.

Answer 38

c. Tape a nonporous dressing on three sides over the chest wound.

Question 39

The nurse is caring for a client who has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which of the following actions should the nurse take first? a. Assist the client to sit up at the bedside. b. Splint the client’s chest during coughing. c. Medicate the client with the prescribed morphine. d. Have the client use the prescribed incentive spirometer.

Answer 39

c. Medicate the client with the prescribed morphine.

Question 40

The nurse is caring for a client with primary pulmonary hypertension (PPH) who has been taking a calcium channel blocker with no effect. Which of the following medications should the nurse expect that the client will receive next? a. Nifedipine b. Diltiazem c. Iloprost d. Bosentan

Answer 40

c. Iloprost

Question 41

The nurse is caring for a client with pneumonia who has symptoms of a sharp pain “whenever I take a deep breath.” Which of the following actions should the nurse take next? a. Listen to the client’s lungs. b. Administer the PRN morphine. c. Have the client cough forcefully. d. Notify the client’s health care provider.

Answer 41

a. Listen to the client’s lungs.

Question 42

The nurse is caring for a client who has just been admitted with pneumococcal pneumonia has a temperature of 38.7°C (101.7°F) with a frequent cough and symptoms of severe pleuritic chest pain. Which of the following prescribed medications should the nurse give first? a. Guaifenesin b. Acetaminophen c. Azithromycin d. Codeine phosphate

Answer 42

c. Azithromycin