Test 2 Flashcards
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%
a. Weak, nonproductive cough effort
The weak, nonproductive cough indicates that the client is unable to clear the airway effectively.
- 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
b. Increased tactile fremitus
Increased tactile fremitus over the area of pulmonary consolidation is expected with
bacterial pneumonias.
- 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.
a. Assist the client to splint the chest when coughing.
Coughing is less painful and more likely to be effective when the client splints the chest during coughing.
- The nurse is providing teaching to a client with pneumonia. Which of the following client statements indicates 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.”
c. “I will continue to do the deep-breathing and coughing exercises at home.”
Clients should continue to cough and deep breathe after discharge for up to 6–8 weeks.
- 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.
b. Place clients with altered consciousness in side-lying positions.
The risk for aspiration is decreased when clients with a decreased level of consciousness
are placed in a side-lying or upright position.
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 (4.5 to 11.0 × 109/L).
d. Increased tactile fremitus is palpable over the right chest.
c. The client’s white blood cell (WBC) count is (4.5 to 11.0 × 109/L).
The normal WBC count indicates that the antibiotics have been effective.
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.
c. Obtain consecutive sputum specimens from the client for 3 days.
Three consecutive sputum specimens are obtained on different days for bacteriological testing for M. tuberculosis
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.
d. Three sputum smears for acid-fast bacilli are negative.
Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the client cannot transmit the bacteria by the airborne route
. The nurse is providing teaching to a client with pulmonary tuberculosis(TB) regarding the transmission of TB. Which of the following client actions indicates 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
c. Covers the mouth and nose when coughing
Covering the mouth and nose will help decrease airborne transmission of TB.
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.”
a. “Your urine, sweat, and tears will be orange coloured.”
Orange-coloured body secretions are an adverse effect of rifampin
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
a. Yellow-tinged skin
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and clients who develop hepatotoxicity will need to use other medications
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 community center and giving the medication then
d. Arranging for a daily noontime meal at community center and giving the medication then
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the client is available to receive the medication.
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.
a. Ask the client whether medications have been taken as directed.
The first action should be to determine whether the client 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.
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
c. Puts on a surgical face mask before visiting the client
A high-efficiency particulate air (HEPA) mask, rather than a standard surgical mask, should be used when entering the client’s room because the HEPA mask can filter out 100% ofsmall
airborne particles
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.
d. Require the use of protective equipment.
Prevention of lung disease requires the use of appropriate protective equipment such as masks
