Lower Respiratory (L) Flashcards
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
a. Purpose of antibiotic therapy
b. Ways to limit oral fluid intake
c. Appropriate use of cough suppressants
d. Safety concerns with home oxygen therapy
c. Appropriate use of cough suppressants
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
a. Providing supportive care to patients diagnosed with pertussis
b. Teaching family members about the need for careful hand washing
c. Teaching patients about the need for adult pertussis immunizations
d. Encouraging patients to complete the prescribed course of antibiotics
c. Teaching patients about the need for adult pertussis immunizations
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%
a. Weak, nonproductive cough effort
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
a. Increased tactile fremitus
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.
a. Assist the patient to splint the chest when coughing.
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
b. I will continue to do the deep breathing and coughing exercises at home
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
b. Place patients with altered consciousness in side-lying positions.
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
c. The patients white blood cell (WBC) count is 9000/L
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patients 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 tube placement with continuous drainage
c. Frequent use of an incentive spirometer
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
a. Chest x-ray via stretcher
b. Blood cultures from two sites
c. Ciprofloxacin (Cipro) 400 mg IV
d. Acetaminophen (Tylenol) rectal suppository
b. Blood cultures from two sites
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
a. Codeine
b. Guaifenesin (Robitussin)
c. Acetaminophen (Tylenol)
d. Piperacillin/tazobactam (Zosyn)
d. Piperacillin/tazobactam (Zosyn)
A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
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 supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
a. UAP splint the patients chest during coughing
b. UAP assist the patient to ambulate to the bathroom
c. UAP help the patient to a bedside chair for meals
d. UAP lower the head of the patients bed to 15 degrees
d. UAP lower the head of the patients bed to 15 degrees
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) whenever I take a deep breath. Which action will the nurse take next?
a. auscultate breath sounds
b. Administer the PRN morphine
c. Have the patient cough forcefully
d. Notify the patients health care provider
a. auscultate breath sounds
