MS - Lower Respiratory Problems Chapter 27

Question 1

After 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 cough effort
b. Profuse green sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%

Answer 1

a. Weak cough effort

ANS: A
The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

Question 2

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

Answer 2

a. Increased tactile fremitus

ANS: A
Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

Question 3

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?

a. Restrict oral fluids during the day.
b. Teach pursed-lip breathing technique.
c. Assist the patient to splint the chest when coughing.
d. Encourage the patient to wear the nasal O2 cannula.

Answer 3

c. Assist the patient to splint the chest when coughing.

ANS: C
Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

Question 4

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 my health care provider if I still feel tired after a week.”
b. “I will continue to do deep breathing and coughing exercises at home.”
c. “I will schedule two appointments for the pneumonia and influenza vaccines.”
d. “I will cancel my follow-up chest x-ray appointment if I feel better next week.”

Answer 4

b. “I will continue to do deep breathing and coughing exercises at home.”

ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

Question 5

Which action should the nurse plan to prevent aspiration in a high-risk patient?

a. Turn and reposition an immobile patient at least every 2 hours.
b. Place a patient with altered consciousness in a side-lying position.
c. Insert a nasogastric tube for feeding a patient with high calorie needs.
d. Monitor respiratory symptoms in a patient who is immunosuppressed.

Answer 5

b. Place a patient with altered consciousness in a side-lying position.

ANS: B
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

Question 6

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 is 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.

Answer 6

c. The patient’s white blood cell (WBC) count is 9000/µL

ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

Question 7

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach the patient about providing specimens for 3 consecutive days.
d. Instruct the patient to collect several separate sputum specimens today.

Answer 7

c. Teach the patient about providing specimens for 3 consecutive days.

ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

Question 8

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider’s order to discontinue airborne precautions unless which assessment finding is documented?

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. Sputum smears for acid-fast bacilli are negative.

Answer 8

d. Sputum smears for acid-fast bacilli are negative.

ANS: D
Repeated negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

Question 9

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

a. “I will take the bus instead of driving.”
b. “I will stay indoors whenever possible.”
c. “My spouse will sleep in another room.”
d. “I will keep the windows closed at home.”

Answer 9

c. “My spouse will sleep in another room.”

ANS: C
Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

Question 10

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?

a. Ask the patient about any visual changes in red-green color discrimination.
b. Question the patient about experiencing shortness of breath, hives, or itching.
c. Explain that orange discolored urine and tears are normal while taking this medication.

Answer 10

c. Explain that orange discolored urine and tears are normal while taking this medication.

ANS: C
Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol, which is a different tuberculosis medication.

Question 11

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

a. Yellow-tinged sclera
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices

Answer 11

a. Yellow-tinged sclera

ANS: A
Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

Question 12

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

a. Repeat warnings about the high risk for infecting others several times.
b. Give the patient written instructions about how to take the medications.
c. Arrange for a daily meal and drug administration at a community center.
d. Arrange for the patient’s friend to administer the medication on schedule.

Answer 12

c. Arrange for a daily meal and drug administration at a community center.

ANS: C
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be

Question 13

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

a. Teach about drug-resistant TB.
b. Schedule directly observed therapy.
c. Ask the patient whether medications have been taken as directed.
d. Discuss the need for an injectable antibiotic with the health care provider.

Answer 13

c. Ask the patient whether medications have been taken as directed.

ANS: C
The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

Question 14

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

a. Use and side effects of isoniazid
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 side effects of isoniazid

ANS: A
The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

Question 15

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?

a. The patient is offered a tissue from the box at the bedside.
b. A surgical face mask is applied before visiting the patient.
c. A snack is brought to the patient from the unit refrigerator.
d. Hand washing is performed before entering the patient’s room.

Answer 15

b. A surgical face mask is applied before visiting the patient.

ANS: B
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient’s room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

Question 16

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?

a. Treat workers with pulmonary fibrosis.
b. Teach about symptoms of lung disease.
c. Require the use of protective equipment.
d. Monitor workers for coughing and wheezing.

Answer 16

c. Require the use of protective equipment.

ANS: C
Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.

Question 17

Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking?

a. Resources for support in smoking cessation
b. Reasons for annual sputum cytology testing
c. Erlotinib (Tarceva) therapy to prevent tumor risk
d. Computed tomography (CT) screening for cancer

Answer 17

a. Resources for support in smoking cessation

ANS: A
Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Sputum cytology is a diagnostic test, but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

Question 18

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, “I would rather have chemotherapy 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. “Tell me what you know about the treatments available.”
d. “Surgery is the treatment of choice for stage I lung cancer.”

Answer 18

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

ANS: C
More assessment of the patient’s concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, “Surgery is the treatment of choice” is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient’s reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.

Question 19

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

a. Clamp the chest tube in two places.
b. Administer the prescribed morphine.
c. Milk the chest tube to remove any clots.
d. Assist the patient with incentive spirometry.

Answer 19

b. Administer the prescribed morphine.

ANS: B
Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

Question 20

A patient with newly diagnosed lung cancer tells the nurse, “I don’t think I’m going to live to see my next birthday.” Which is the best initial response by the nurse?

a. “Are you ready to talk with your family members about dying now?”
b. “Would you like to talk to the hospital chaplain about your feelings?”
c. “Can you tell me what it is that makes you think you will die so soon?”
d. “Do you think that taking an antidepressant medication would be helpful?”

Answer 20

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

ANS: C
The nurse’s initial response should be to collect more assessment data about the patient’s statement. The answer beginning “Can you tell me what it is” is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

Question 21

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

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

ANS: B
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

Question 22

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

a. Paradoxical chest movement
b. Complaint of chest wall pain.
c. Heart rate of 110 beats/minute
d. Large bruised area on the chest

Answer 22

a. Paradoxical chest

ANS: A
Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Question 23

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

a. Emergency pericardiocentesis
b. Stabilization of the chest wall
c. Bronchodilator administration
d. Chest tube connected to suction

Answer 23

d. Chest tube connected to suction

ANS: D
The patient’s history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient’s clinical manifestations are not consistent with these problems.

Question 24

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?

a. Adjust the dial on the wall regulator.
b. Continue to monitor the collection device.
c. Document the presence of a large air leak.
d. Notify the surgeon of a possible pneumothorax.

Answer 24

b. Continue to monitor the collection device.

ANS: B
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

Question 25

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient’s postoperative care?

a. Bed rest for the first 24 hours
b. Positioning only on the right side
c. Frequent use of an incentive spirometer
d. Chest tube placement to continuous suction

Answer 25

c. Frequent use of an incentive spirometer

ANS: C
Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

Question 26

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?

a. Observe for distended neck veins.
b. Auscultate for crackles in the lungs.
c. Palpate for heaves or thrills over the heart.
d. Monitor for elevated white blood cell count.

Answer 26

a. Observe for distended neck veins.

ANS: A
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

Question 27

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient’s condition is improving?

a. Patient’s chest x-ray indicates clear lung fields.
b. Heart rate is between 60 and 100 beats/minute.
c. Patient reports a decrease in exertional dyspnea.
d. Blood pressure (BP) is less than 140/90 mm Hg.

Answer 27

c. Patient reports a decrease in exertional dyspnea.

ANS: C
Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective

Question 28

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

a. Start a peripheral IV line to administer sedatives.
b. Position the patient sitting up on the side of the bed.
c. Obtain a collection device to hold 3 liters of pleural fluid.
d. Remind the patient not to eat or drink anything for 6 hours.

Answer 28

b. Position the patient sitting up on the side of the bed.

ANS: B
When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

Question 29

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?

a. “I will make an appointment to see the doctor every year.”
b. “I will stop taking the prednisone if I experience a dry cough.”
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.”

ANS: D
Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

Question 30

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

Answer 30

b. Blood cultures from two sites

ANS: B
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic

Question 31

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

a. O2 saturation is 88%.
b. Blood pressure is 155/90 mm Hg.
c. Pain level is 5 (on 0 to 10 scale) with a deep breath.
d. Respiratory rate is 24 breaths/minute when lying flat.

Answer 31

a. O2 saturation is 88%.

ANS: A
O2 saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.

Question 32

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
c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

Answer 32

d. Piperacillin/tazobactam (Zosyn)

ANS: D
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

Question 33

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?

a. The Mantoux test had an induration of 7 mm.
b. The chest-x-ray showed infiltrates in the lower lobes.
c. The patient has a cough that is productive of blood-tinged mucus.
d. The patient is being treated with antiretrovirals for HIV infection.

Answer 33

d. The patient is being treated with antiretrovirals for HIV infection.

ANS: D
Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

Question 34

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 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 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

Answer 34

d. Impaired gas exchange related to respiratory congestion

ANS: D
All of these nursing diagnoses are appropriate for the patient, but the patient’s O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

Question 35

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 assist the patient to ambulate to the bathroom.
b. UAP help splint the patient’s chest during coughing.
c. UAP transfer the patient to a bedside chair for meals.
d. UAP lower the head of the patient’s bed to 15 degrees.

Answer 35

d. UAP lower the head of the patient’s bed to 15 degrees

ANS: D
Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

Question 36

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?

a. Administer anticoagulant drug therapy.
b. Notify the patient’s health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler’s position.

Answer 36

d. Elevate the head of the bed to a semi-Fowler’s position.

ANS: D
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

Question 37

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

a. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled
b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath
c. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes
d. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)

Answer 37

b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath

ANS: B
Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

Question 38

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

a. “Do you take any over-the-counter (OTC) medications?”
b. “Do you have any family members with a history of TB?”
c. “How long has it been since you moved to the United States?”
d. “Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?”

Answer 38

d. “Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?”

ANS: D
Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

Question 39

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?

a. Keep the head of the patient’s bed positioned flat.
b. Cover the wound tightly with an occlusive dressing.
c. Position the patient so that the left chest is dependent.
d. Tape a nonporous dressing on three sides over the wound.

Answer 39

d. Tape a nonporous dressing on three sides over the wound.

ANS: D
The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Question 40

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

a. Assist the patient to sit upright in a chair.
b. Splint the patient’s chest during coughing.
c. Medicate the patient with prescribed morphine.
d. Observe the patient use the incentive spirometer.

Answer 40

c. Medicate the patient with prescribed morphine.

ANS: C
A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance, but should be done after the morphine is given.

Question 41

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?

a. The O2 saturation is 90%.
b. The blood pressure is 98/56 mm Hg.
c. The epoprostenol (Flolan) infusion is disconnected.
d. The international normalized ratio (INR) is prolonged.

Answer 41

c. The epoprostenol (Flolan) infusion is disconnected.

ANS: C
The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

Question 42

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) “whenever I take a deep breath.” Which action will the nurse take next?

a. Auscultate for breath sounds.
b. Administer the PRN morphine.
c. Have the patient cough forcefully.
d. Notify the patient’s health care provider.

Answer 42

a. Auscultate for breath sounds.

ANS: A
The patient’s statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

Question 43

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 O2 therapy

Answer 43

c. Appropriate use of cough suppressants

ANS: C
Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

Question 44

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

Answer 44

c. Teaching patients about the need for adult pertussis immunizations

ANS: C
The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

Question 45

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

a. Listening to the patient’s lung sounds several times during the shift
b. Placing the patient on droplet precautions in a private hospital room
c. Monitoring patient serology results to identify the infecting organism
d. Increasing the O2 flow rate to keep the O2 saturation over 90%

Answer 45

b. Placing the patient on droplet precautions in a private hospital room

ANS: B
Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.

Question 46

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

a. Teach the patient to avoid the use of over-the-counter expectorants.
b. Assist the patient with chest physiotherapy and postural drainage.
c. Notify the health care provider immediately about any bloody or foul-smelling sputum.
d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

Answer 46

d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

ANS: D
Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

Question 47

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

a. “I am going to buy a rib binder to wear during the day.”
b. “I can take shallow breaths to prevent my chest from hurting.”
c. “I should plan on taking the pain pills only at bedtime so I can sleep.”
d. “I will use the incentive spirometer every hour or two during the day.”

Answer 47

d. “I will use the incentive spirometer every hour or two during the day.”

ANS: D
Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis

Question 48

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

a. Document the amount of drainage every 8 hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.

Answer 48

a. Document the amount of drainage every 8 hours.

ANS: A
UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

Question 49

After change-of-shift report, which patient should the nurse assess first?

a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C)
c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain
d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

Answer 49

d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D
The patient’s history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

Question 50

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?

a. Age
b. Blood pressure
c. Respiratory rate
d. O2 saturation
e. Presence of confusion
f. Blood urea nitrogen (BUN) level

Answer 50

a. Age
b. Blood pressure
c. Respiratory rate
e. Presence of confusion
f. Blood urea nitrogen (BUN) level

ANS: A, B, C, E, F
Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess, but are not used for CURB-65 scoring.

Question 51

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].)

a. Obtain the O2 saturation.
b. Check the patient’s pulse rate.
c. Document the change in status.
d. Notify the health care provider.

Answer 51

a. Obtain the O2 saturation.
b. Check the patient’s pulse rate.
d. Notify the health care provider.
c. Document the change in status.

ANS:
A, B, D, C

Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.