Lecture 3: Pneumonia Flashcards
A 72-year-old patient with a history of chronic obstructive pulmonary disease (COPD) presents with sudden fever, chills, and a productive cough with purulent sputum. Auscultation reveals crackles in the lower lobes, and pulse oximetry shows an oxygen saturation of 88%. What is the nurse’s priority intervention?
A) Administer supplemental oxygen to maintain SpO₂ >92%.
B) Perform a sputum culture to identify the causative organism.
C) Encourage the patient to increase oral fluid intake.
D) Notify the healthcare provider about the decreased oxygen saturation.
A) Administer supplemental oxygen to maintain SpO₂ >92%.
Explanation:
Correct: Administering oxygen ensures the patient’s oxygen saturation improves, addressing hypoxia immediately, which is critical in pneumonia management
.
Incorrect:
B: Sputum culture is important but not the priority when the patient is hypoxic.
C: Fluids are beneficial but do not address the immediate concern of low oxygen levels.
D: Notifying the provider is essential but comes after stabilizing oxygenation.
A patient admitted with aspiration pneumonia has decreased level of consciousness (LOC). What is the nurse’s priority action to prevent further complications?
A) Elevate the head of the bed to 30 degrees.
B) Encourage the patient to cough and deep breathe.
C) Administer prescribed bronchodilators.
D) Perform regular oral care.
A) Elevate the head of the bed to 30 degrees.
Explanation:
Correct: Elevating the head of the bed reduces the risk of further aspiration, a common complication in patients with decreased LOC
.
Incorrect:
B: Deep breathing is useful but not feasible for a patient with reduced LOC.
C: Bronchodilators do not prevent aspiration.
D: Oral care is essential but not the priority to prevent aspiration.
Which of the following findings in a patient with pneumonia indicates a need for immediate medical intervention?
A) Respiratory rate of 28 breaths/minute.
B) SpO₂ of 90% on room air.
C) Productive cough with rust-colored sputum.
D) Blood pressure of 85/50 mmHg.
D) Blood pressure of 85/50 mmHg.
Explanation:
Correct: Hypotension may indicate sepsis or septic shock, requiring immediate intervention
.
Incorrect:
A, B, C: These are expected findings in pneumonia and do not indicate immediate danger.
A patient with pneumonia has a decreased gag reflex and is at risk of aspiration. What intervention should the nurse prioritize?
A) Administer prescribed antibiotics immediately.
B) Position the patient side-lying during oral care.
C) Monitor the patient’s intake and output.
D) Educate the patient about spirometry use.
B) Position the patient side-lying during oral care.
Explanation:
Correct: Side-lying prevents aspiration during oral care, reducing the risk of further complications
.
Incorrect:
A, C, D: These interventions do not directly prevent aspiration.
A nurse is caring for a patient with sepsis. Which finding requires immediate intervention?
A) Heart rate of 110 beats/min.
B) Urine output of 20 mL/hr.
C) Warm, flushed skin.
D) Respiratory rate of 24 breaths/min.
B) Urine output of 20 mL/hr.
Explanation:
Correct: Low urine output indicates poor perfusion and possible progression to septic shock
.
Incorrect:
A, C, D: These are early signs of sepsis and do not require as urgent an intervention.
A 45-year-old patient with community-acquired pneumonia is started on antibiotics. What should the nurse prioritize to evaluate the effectiveness of the treatment?
A) Assess for reduced sputum production.
B) Monitor white blood cell (WBC) count daily.
C) Check for resolution of fever.
D) Evaluate oxygen saturation levels.
D) Evaluate oxygen saturation levels.
Explanation:
Correct: Oxygenation reflects the patient’s ability to exchange gases effectively and is the priority in evaluating pneumonia treatment
.
Incorrect:
A, B, C: These are important but secondary to assessing oxygenation.
Which intervention should the nurse include in the care plan for a patient with hospital-acquired pneumonia?
A) Reposition the patient every 4 hours.
B) Encourage oral fluid intake of at least 500 mL per day.
C) Elevate the head of the bed to at least 30 degrees.
D) Perform chest physiotherapy twice a day.
C) Elevate the head of the bed to at least 30 degrees.
Explanation:
Correct: This prevents aspiration and promotes better lung expansion
.
Incorrect:
A, B, D: These are supportive interventions but not as effective for prevention.
A patient with pneumonia is experiencing pleuritic chest pain. Which intervention is most appropriate to provide comfort?
A) Administer prescribed analgesics.
B) Place the patient in a supine position.
C) Restrict fluid intake to reduce congestion.
D) Apply a cold compress to the chest.
A) Administer prescribed analgesics.
Explanation:
Correct: Analgesics relieve inflammation-associated pain, improving patient comfort
.
Incorrect:
B, C, D: These do not address the inflammation or pain directly.
What is the most reliable method to identify the causative organism in a patient with pneumonia?
A) Chest X-ray.
B) Blood culture.
C) Sputum culture and sensitivity.
D) Complete blood count (CBC).
C) Sputum culture and sensitivity.
Explanation:
Correct: Sputum culture identifies the organism and determines the most effective antibiotic
.
Incorrect:
A, B, D: These provide supporting information but not direct identification.
Which patient is at greatest risk for developing aspiration pneumonia?
A) A 60-year-old patient receiving corticosteroids for asthma.
B) A 45-year-old patient with a recent history of alcohol intoxication.
C) A 30-year-old patient recovering from laparoscopic appendectomy.
D) A 70-year-old patient with a history of chronic obstructive pulmonary disease (COPD).
B) A 45-year-old patient with a recent history of alcohol intoxication.
Explanation:
Correct: Alcohol intoxication reduces LOC and impairs the gag reflex, increasing aspiration risk
.
Incorrect:
A, C, D: These conditions do not specifically predispose to aspiration.
A patient with pneumonia has crackles and decreased breath sounds in the right lower lobe. What intervention should the nurse prioritize?
A) Perform chest percussion to mobilize secretions.
B) Administer prescribed bronchodilators.
C) Encourage deep breathing and coughing exercises.
D) Position the patient on their right side.
C) Encourage deep breathing and coughing exercises.
Explanation:
Correct: This helps mobilize secretions and improve ventilation
.
Incorrect:
A, B, D: Supportive but not as effective for immediate secretion clearance.
A patient with sepsis has a lactate level of 5 mmol/L and hypotension persisting after fluid resuscitation. What should the nurse prepare to administer next?
A) Broad-spectrum antibiotics.
B) Vasopressor medications.
C) Intravenous corticosteroids.
D) Antipyretic medications.
B) Vasopressor medications.
Explanation:
Correct: Vasopressors support blood pressure when fluids alone are insufficient
.
Incorrect:
A, C, D: These address infection and symptoms but not the critical issue of hypotension.
Which clinical finding indicates the development of multi-organ dysfunction syndrome (MODS) in a patient with septic shock?
A) Increased urine output.
B) Decreased peripheral pulses.
C) Increased gastrointestinal motility.
D) Improved mental status.
B) Decreased peripheral pulses.
Explanation:
Correct: Reduced pulses indicate poor perfusion, characteristic of MODS
.
Incorrect:
A, C, D: These suggest improvement or unrelated findings.
A nurse is caring for an elderly patient with pneumonia who suddenly becomes confused. What is the most appropriate action?
A) Administer prescribed antipyretics.
B) Assess oxygen saturation levels immediately.
C) Perform a focused neurological examination.
D) Notify the healthcare provider.
B) Assess oxygen saturation levels immediately.
Explanation:
Correct: Confusion in older adults is often an early sign of hypoxia
.
Incorrect:
A, C, D: Useful but not as urgent as addressing potential hypoxia.
Which intervention should the nurse implement to prevent complications in a patient recovering from pneumonia?
A) Limit ambulation to reduce fatigue.
B) Encourage the patient to complete the prescribed antibiotic course.
C) Recommend a low-protein diet to decrease metabolic demand.
D) Avoid using incentive spirometry to prevent overexertion.
B) Encourage the patient to complete the prescribed antibiotic course.
Explanation:
Correct: Completing antibiotics ensures eradication of the infection, preventing recurrence or resistance
.
Incorrect:
A, C, D: These do not prevent complications effectively.
A nurse is caring for a patient diagnosed with hospital-acquired pneumonia. Which of the following assessment findings would require immediate intervention?
A) Increased fremitus in the left lower lobe.
B) Decreased SpO₂ of 88% on room air.
C) Purulent sputum production.
D) Dullness to percussion in the right middle lobe.
B) Decreased SpO₂ of 88% on room air.
Explanation:
Correct: Oxygen saturation below 90% indicates significant hypoxia, requiring immediate oxygen supplementation
.
Incorrect:
A, C, D: These findings are consistent with pneumonia but do not require immediate action compared to hypoxia.
A patient with aspiration pneumonia is found to have decreased breath sounds and crackles in the right lung. What is the nurse’s priority intervention?
A) Position the patient with the head of the bed elevated at 30 degrees.
B) Prepare the patient for bronchoscopy.
C) Administer prescribed bronchodilators.
D) Initiate chest physiotherapy immediately.
A) Position the patient with the head of the bed elevated at 30 degrees.
Explanation:
Correct: Elevating the head of the bed minimizes further aspiration risk and promotes lung expansion
.
Incorrect:
B, C, D: These are secondary or situational interventions.
A nurse is teaching a patient about the risk factors for community-acquired pneumonia. Which of the following statements by the patient indicates the need for further teaching?
A) “I should avoid smoking to decrease my risk.”
B) “Staying active and healthy will help protect me.”
C) “Antibiotics I’ve taken recently might put me at risk.”
D) “Wearing a mask in crowded places isn’t necessary.”
D) “Wearing a mask in crowded places isn’t necessary.”
Explanation:
Correct: Masks help reduce exposure to respiratory pathogens, especially in crowded areas, during flu season
.
Incorrect:
A, B, C: These are accurate statements about pneumonia risk.
A patient with sepsis is being closely monitored for complications. Which finding is most concerning?
A) Heart rate of 102 beats/min.
B) Capillary refill time of 5 seconds.
C) Temperature of 38.5°C (101.3°F).
D) Blood pressure of 110/70 mmHg.
B) Capillary refill time of 5 seconds.
Explanation:
Correct: Prolonged capillary refill indicates poor perfusion and may signal progression to septic shock
.
Incorrect:
A, C, D: These findings can occur in sepsis but are less critical than impaired perfusion.
Which patient is at the highest risk for developing sepsis?
A) A 55-year-old with untreated diabetes mellitus.
B) A 35-year-old with a urinary tract infection.
C) A 40-year-old post-appendectomy patient.
D) A 28-year-old with mild seasonal allergies.
A) A 55-year-old with untreated diabetes mellitus.
Explanation:
Correct: Diabetes impairs immune function, increasing the risk of severe infections like sepsis
.
Incorrect:
B, C, D: While these conditions may predispose to infection, they are not as high-risk as uncontrolled diabetes.
A nurse is evaluating the effectiveness of pneumonia treatment. Which finding indicates improvement?
A) Crackles in the lung bases persist.
B) Respiratory rate decreases to 18 breaths/min.
C) White blood cell (WBC) count remains elevated.
D) The patient reports fatigue and malaise.
B) Respiratory rate decreases to 18 breaths/min.
Explanation:
Correct: A normalized respiratory rate suggests improved oxygenation and recovery
.
Incorrect:
A, C, D: These indicate ongoing infection or generalized symptoms of recovery.
A patient with pneumonia reports pleuritic chest pain that worsens with deep breathing. What intervention should the nurse prioritize?
A) Encourage the use of an incentive spirometer.
B) Administer prescribed analgesics.
C) Position the patient on the unaffected side.
D) Provide a warm compress to the chest.
B) Administer prescribed analgesics.
Explanation:
Correct: Pain relief promotes comfort and encourages effective breathing exercises
.
Incorrect:
A, C, D: These can support recovery but do not directly address pain.
Which laboratory finding supports the diagnosis of sepsis in a patient with suspected infection?
A) Decreased lactate level.
B) Increased platelet count.
C) Elevated white blood cell (WBC) count.
D) Low blood glucose level.
) Elevated white blood cell (WBC) count.
Explanation:
Correct: An elevated WBC count indicates an inflammatory response to infection, a hallmark of sepsis
.
Incorrect:
A, B, D: These findings are not consistent with the acute inflammatory changes seen in sepsis.
A nurse is caring for a patient with opportunistic pneumonia caused by P. jiroveci. Which patient condition likely contributed to this infection?
A) History of asthma.
B) Recent chemotherapy for leukemia.
C) Diagnosis of type 2 diabetes mellitus.
D) Long-term use of antihypertensive medication.
B) Recent chemotherapy for leukemia.
Explanation:
Correct: Chemotherapy suppresses the immune system, increasing susceptibility to opportunistic infections like P. jiroveci
.
Incorrect:
A, C, D: These conditions do not significantly suppress immune function to the same extent.
A patient recovering from pneumonia reports fatigue and shortness of breath with minimal exertion. What is the nurse’s best response?
A) “These symptoms indicate a worsening of your condition.”
B) “You may need further oxygen therapy at home.”
C) “It is normal to experience some fatigue as you recover.”
D) “Let’s schedule a follow-up chest X-ray immediately.”
C) “It is normal to experience some fatigue as you recover.”
Explanation:
Correct: Post-infection fatigue is common and does not necessarily indicate a complication
.
Incorrect:
A, B, D: These are unnecessary without additional signs of worsening condition.
A patient with community-acquired pneumonia has a productive cough with purulent sputum, pleuritic chest pain, and a fever of 39°C (102.2°F). Which nursing intervention is the priority?
A) Administer prescribed antipyretics.
B) Encourage the patient to increase oral fluid intake.
C) Perform a sputum culture before starting antibiotics.
D) Administer oxygen to maintain SpO₂ above 92%.
D) Administer oxygen to maintain SpO₂ above 92%.
Explanation:
Correct: Oxygen therapy is prioritized to address hypoxia and improve oxygenation, a critical need in pneumonia
.
Incorrect:
A, B: These address symptoms but do not prioritize hypoxia.
C: While a sputum culture is important, it should not delay oxygen therapy.
A nurse is monitoring a patient with pneumonia who develops confusion and restlessness. What is the nurse’s first action?
A) Administer prescribed antipyretics.
B) Assess the patient’s oxygen saturation levels.
C) Notify the healthcare provider immediately.
D) Perform a neurological assessment.
B) Assess the patient’s oxygen saturation levels.
Explanation:
Correct: Confusion and restlessness may indicate hypoxia, making oxygen assessment the priority
.
Incorrect:
A, C, D: These may follow but do not address the immediate need to evaluate oxygenation.
Which assessment finding would indicate a complication of pneumonia?
A) Clear breath sounds bilaterally.
B) Decreased fremitus on palpation.
C) Pleural friction rub auscultated.
D) Blood pressure of 118/78 mmHg.
C) Pleural friction rub auscultated.
Explanation:
Correct: Pleural friction rub suggests pleurisy, a common complication of pneumonia
.
Incorrect:
A, B, D: These findings are either normal or unrelated to complications.
A nurse is caring for a patient with septic shock who has persistent hypotension despite fluid resuscitation. What is the nurse’s next priority?
A) Administer prescribed antibiotics.
B) Prepare to administer vasopressors.
C) Monitor for decreased urine output.
D) Assess for capillary refill time.
B) Prepare to administer vasopressors.
Explanation:
Correct: Vasopressors are necessary to restore perfusion when fluids are insufficient to stabilize blood pressure
.
Incorrect:
A: Antibiotics address the infection but do not resolve hypotension.
C, D: Monitoring does not address the immediate issue of low blood pressure
A patient presents with fever, tachycardia, and increased respiratory rate. The nurse suspects sepsis. What diagnostic test result would confirm this suspicion?
A) Positive blood cultures.
B) Decreased hemoglobin level.
C) Elevated serum glucose level.
D) Increased platelet count.
A) Positive blood cultures.
Explanation:
Correct: Positive blood cultures confirm the presence of a bloodstream infection, a hallmark of sepsis
.
Incorrect:
B, C, D: These findings do not specifically confirm sepsis.
A patient is at risk for hospital-acquired pneumonia. Which intervention is most effective for prevention?
A) Reposition the patient every 4 hours.
B) Encourage the use of an incentive spirometer.
C) Administer prescribed antibiotics prophylactically.
D) Place the patient in a supine position.
B) Encourage the use of an incentive spirometer.
Explanation:
Correct: Using an incentive spirometer promotes lung expansion and prevents atelectasis, reducing pneumonia risk
.
Incorrect:
A, C, D: These do not directly prevent pneumonia.
The nurse observes a new onset of crackles in the lower lobes of a patient with pneumonia. What action should the nurse take first?
A) Notify the healthcare provider immediately.
B) Perform deep suctioning of the patient.
C) Encourage the patient to use the incentive spirometer.
D) Document the finding and reassess in one hour.
C) Encourage the patient to use the incentive spirometer.
Explanation:
Correct: Incentive spirometry helps clear secretions and improves alveolar ventilation
.
Incorrect:
A, B, D: These actions do not directly address the need to mobilize secretions.
A patient with pneumonia is at risk for developing atelectasis. Which clinical sign should the nurse monitor for?
A) Decreased breath sounds in the affected area.
B) Bilateral chest expansion.
C) Hyperresonance to percussion.
D) SpO₂ of 96% on room air.
A) Decreased breath sounds in the affected area.
Explanation:
Correct: Atelectasis leads to reduced air entry, causing decreased breath sounds
.
Incorrect:
B, C, D: These findings are inconsistent with atelectasis.
A patient recovering from sepsis asks why deep breathing exercises are important. How should the nurse respond?
A) “They improve blood flow to your extremities.”
B) “They prevent the development of respiratory alkalosis.”
C) “They help prevent further lung infections.”
D) “They reduce pain from pleuritic inflammation.”
C) “They help prevent further lung infections.”
Explanation:
Correct: Deep breathing prevents stasis of secretions, reducing the risk of lung infections
.
Incorrect:
A, B, D: These responses do not directly relate to the benefits of deep breathing.
Which finding in a patient with pneumonia suggests that the infection may have progressed to sepsis?
A) Increased fremitus on palpation.
B) Respiratory rate of 22 breaths/min.
C) Blood pressure of 85/50 mmHg.
D) Productive cough with yellow sputum.
C) Blood pressure of 85/50 mmHg.
Explanation:
Correct: Hypotension is a hallmark of sepsis and septic shock, requiring immediate attention
.
Incorrect:
A, B, D: These findings are consistent with pneumonia but not specific to sepsis progression.
A patient with hospital-acquired pneumonia is experiencing increased work of breathing, crackles on auscultation, and an oxygen saturation of 89%. What is the priority nursing action?
A) Administer the prescribed antibiotic therapy immediately.
B) Notify the healthcare provider about the oxygen saturation.
C) Initiate oxygen therapy to maintain SpO₂ >92%.
D) Encourage the patient to use an incentive spirometer.
C) Initiate oxygen therapy to maintain SpO₂ >92%.
Explanation:
Correct: Oxygen therapy is the priority to correct hypoxia and ensure adequate oxygenation
.
Incorrect:
A: Antibiotics are essential but do not address immediate oxygen needs.
B: Notifying the provider can occur after stabilizing oxygenation.
D: While beneficial, incentive spirometry is secondary to correcting hypoxia.
A nurse is assessing a patient with sepsis who has a fever, tachycardia, and decreased urine output. Which of the following lab results would be most concerning?
A) White blood cell count of 15,000/mm³.
B) Lactate level of 4 mmol/L.
C) Hemoglobin level of 12 g/dL.
D) Platelet count of 180,000/mm³.
B) Lactate level of 4 mmol/L.
Explanation:
Correct: An elevated lactate level indicates tissue hypoperfusion, which is a key marker of sepsis progression
.
Incorrect:
A: Elevated WBC count suggests infection but is not as critical as lactate.
C, D: These values are within normal ranges and less indicative of sepsis severity.
A patient with aspiration pneumonia has a history of dysphagia following a stroke. Which intervention should the nurse prioritize?
A) Encourage oral fluids with meals.
B) Position the patient upright at 90 degrees during feeding.
C) Administer antibiotics as prescribed.
D) Perform chest physiotherapy twice daily.
B) Position the patient upright at 90 degrees during feeding.
Explanation:
Correct: Proper positioning minimizes the risk of further aspiration, which is critical for patient safety
.
Incorrect:
A: Oral fluids can increase aspiration risk if swallowing is impaired.
C, D: These do not directly address aspiration prevention.
A patient diagnosed with community-acquired pneumonia has a fever of 38.8°C (101.8°F), tachycardia, and a productive cough. What is the nurse’s best initial action?
A) Administer prescribed antipyretics.
B) Assess respiratory status and oxygenation.
C) Encourage oral fluid intake.
D) Collect a sputum sample for culture.
B) Assess respiratory status and oxygenation.
Explanation:
Correct: Ensuring adequate oxygenation is the priority to prevent hypoxia
.
Incorrect:
A, C, D: While important, these are secondary to assessing and addressing oxygenation.
he nurse is teaching a patient with pneumonia about deep breathing and coughing exercises. Which statement by the patient indicates a need for further education?
A) “This will help me clear mucus from my lungs.”
B) “I should do this every hour while awake.”
C) “It will prevent the spread of infection in my lungs.”
D) “It might be uncomfortable, but it’s important for my recovery.”
C) “It will prevent the spread of infection in my lungs.”
Explanation:
Correct: Deep breathing and coughing do not prevent the spread of infection but help mobilize secretions
.
Incorrect:
A, B, D: These are accurate statements about the benefits of the exercises.
A patient with pneumonia complains of pleuritic chest pain. What action should the nurse take first?
A) Encourage the patient to lie on the affected side.
B) Administer prescribed analgesics.
C) Perform chest physiotherapy.
D) Reassess the patient’s vital signs.
B) Administer prescribed analgesics.
Explanation:
Correct: Analgesics reduce pain, allowing the patient to breathe more effectively
.
Incorrect:
A, C, D: These actions are supportive but do not directly address pain management.
A patient recovering from sepsis shows a blood pressure of 90/60 mmHg, a heart rate of 105 beats/min, and cool extremities. What should the nurse suspect?
A) Progression to septic shock.
B) Recovery from the sepsis.
C) Development of a cardiac arrhythmia.
D) Fluid overload from resuscitation.
A) Progression to septic shock.
Explanation:
Correct: Persistent hypotension with signs of poor perfusion, such as cool extremities, suggests septic shock
.
Incorrect:
B, C, D: These do not explain the patient’s clinical presentation.
The nurse is educating a patient on preventing hospital-acquired pneumonia. Which statement by the patient indicates effective teaching?
A) “I will limit my activity to conserve energy.”
B) “I will perform deep breathing exercises regularly.”
C) “I should drink fewer fluids to prevent lung congestion.”
D) “I should avoid repositioning too often to rest better.”
B) “I will perform deep breathing exercises regularly.”
Explanation:
Correct: Deep breathing prevents stasis of secretions and promotes lung expansion
.
Incorrect:
A, C, D: These are misconceptions that do not align with pneumonia prevention strategies.
A nurse is evaluating the response to antibiotic therapy in a patient with pneumonia. Which finding indicates improvement?
A) Increased crackles on auscultation.
B) Respiratory rate of 18 breaths/min.
C) Persistent fever of 38.5°C (101.3°F).
D) White blood cell count of 15,000/mm³.
B) Respiratory rate of 18 breaths/min.
Explanation:
Correct: A normalized respiratory rate is a sign of improved gas exchange and reduced respiratory distress
.
Incorrect:
A, C, D: These findings do not suggest resolution of the infection
A patient with pneumonia is experiencing dyspnea and has a pulse oximetry reading of 85%. Which intervention is most appropriate?
A) Reassess the oxygen saturation after 15 minutes.
B) Position the patient in a high Fowler’s position.
C) Collect a sputum culture for analysis.
D) Notify the healthcare provider immediately.
B) Position the patient in a high Fowler’s position.
Explanation:
Correct: High Fowler’s position optimizes lung expansion and improves oxygenation
.
Incorrect:
A, C, D: These actions do not immediately improve oxygenation.
A nurse is caring for a patient diagnosed with aspiration pneumonia. Which assessment finding would most likely indicate a worsening condition?
A) Productive cough with yellow sputum.
B) SpO₂ of 86% despite oxygen therapy.
C) Dullness to percussion in the affected lung lobe.
D) Increased respiratory rate of 22 breaths per minute.
B) SpO₂ of 86% despite oxygen therapy.
Explanation:
Correct: A low SpO₂ despite oxygen therapy indicates impaired gas exchange, suggesting a worsening condition
.
Incorrect:
A, C: These are common findings in pneumonia but do not necessarily indicate a worsening condition.
D: While an elevated respiratory rate is concerning, it is less critical than oxygen saturation.
A nurse is preparing to administer antibiotics to a patient with pneumonia. What is the priority nursing intervention before administering the first dose?
A) Administer an antipyretic to reduce fever.
B) Encourage the patient to drink water.
C) Collect a sputum sample for culture.
D) Assess the patient’s lung sounds.
C) Collect a sputum sample for culture.
Explanation:
Correct: Collecting a sputum sample ensures the identification of the causative organism and guides antibiotic therapy
.
Incorrect:
A, B, D: These are important but not as critical as ensuring an accurate diagnosis before treatment.
A patient with pneumonia is experiencing pleuritic chest pain and difficulty breathing. Which intervention should the nurse implement to alleviate the patient’s symptoms?
A) Encourage shallow breathing to minimize pain.
B) Administer prescribed analgesics and position the patient upright.
C) Limit fluid intake to reduce lung congestion.
D) Perform percussion to loosen secretions.
B) Administer prescribed analgesics and position the patient upright.
Explanation:
Correct: Pain management and positioning improve comfort and promote lung expansion
.
Incorrect:
A, C, D: These do not directly address pain relief or promote effective breathing.
A nurse is assessing a patient with sepsis. Which finding requires immediate intervention?
A) Capillary refill time of 4 seconds.
B) Blood pressure of 100/70 mmHg.
C) Warm and flushed skin.
D) Heart rate of 90 beats per minute.
) Capillary refill time of 4 seconds.
Explanation:
Correct: Prolonged capillary refill indicates poor perfusion, a hallmark of worsening sepsis
.
Incorrect:
B, C, D: These findings may occur in early sepsis but are less critical than signs of impaired perfusion.
A patient with pneumonia is prescribed oxygen therapy. The nurse notes that the patient is restless and confused. What is the nurse’s priority action?
A) Increase the oxygen flow rate.
B) Notify the healthcare provider immediately.
C) Reassess the patient’s respiratory rate and depth.
D) Elevate the head of the bed to a high Fowler’s position.
D) Elevate the head of the bed to a high Fowler’s position.
Explanation:
Correct: High Fowler’s position optimizes ventilation and alleviates respiratory distress
.
Incorrect:
A: Increasing oxygen may help but is not the first action.
B, C: These are secondary to ensuring proper positioning and ventilation.
A nurse is reviewing discharge instructions with a patient recovering from pneumonia. Which statement indicates the patient needs further teaching?
A) “I should finish all my prescribed antibiotics.”
B) “I will rest until my fever is gone before resuming activity.”
C) “I need to drink plenty of fluids to stay hydrated.”
D) “I will call my doctor if I feel short of breath again.”
B) “I will rest until my fever is gone before resuming activity.”
Explanation:
Correct: Light activity is encouraged to promote lung expansion and prevent complications, even if a low-grade fever persists
.
Incorrect:
A, C, D: These are correct and align with pneumonia management.
A patient is admitted with pneumonia and reports nausea and vomiting. What is the priority nursing intervention?
A) Provide small, frequent meals.
B) Administer prescribed antiemetics.
C) Assess for signs of dehydration.
D) Encourage the patient to drink clear fluids.
C) Assess for signs of dehydration.
Explanation:
Correct: Dehydration is a potential complication of nausea and vomiting and must be addressed promptly
.
Incorrect:
A, B, D: These are important but do not take priority over assessing hydration status.
A nurse is teaching a patient about preventing pneumonia. Which statement by the patient demonstrates understanding?
A) “I will avoid all physical activity until flu season is over.”
B) “I should get the flu vaccine every year to reduce my risk.”
C) “I only need to wash my hands after coming into contact with sick people.”
D) “I will wear a mask when I feel short of breath.”
B) “I should get the flu vaccine every year to reduce my risk.”
Explanation:
Correct: Annual flu vaccination reduces the risk of respiratory infections, including pneumonia
.
Incorrect:
A, C, D: These are either incorrect or not the most effective preventive strategies.
A patient with pneumonia is placed on a high-protein diet. What is the primary reason for this dietary recommendation?
A) To improve oxygenation.
B) To strengthen the immune response.
C) To reduce mucus production.
D) To minimize fatigue.
B) To strengthen the immune response.
Explanation:
Correct: Protein supports immune function and tissue repair, aiding recovery from infection
.
Incorrect:
A, C, D: These do not directly relate to the benefits of a high-protein diet.
A nurse notes that a patient with pneumonia is reluctant to use the incentive spirometer due to discomfort. What is the best nursing response?
A) “You can skip using it if it’s too painful.”
B) “I’ll give you pain medication so it will be easier.”
C) “Let’s wait until you feel better to try again.”
D) “It’s okay to use it less frequently to avoid pain.”
B) “I’ll give you pain medication so it will be easier.”
Explanation:
Correct: Pain management encourages compliance with incentive spirometry, which is critical for preventing complications
.
Incorrect:
A, C, D: These responses do not address the patient’s discomfort or promote recovery.
