1. A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take
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a. Provide chest physiotherapy
b. Perform oropharyngeal suction
c. Encourage deep-breathing and coughing
d. Assist the client with ambulation
- C. Encourage deep-breathing and coughing--- The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway.
2. A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
a. "If I do this often, I won't experience muscle wasting."
b. "If I do this often, I won't get pneumonia."
c. "If I do this often, I won't get constipated."
d. "If I do this often, I won't have a fast heartbeat."
- B. "If I do this often, I won't get pneumonia."--- Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal.
3. Which patients have the greatest risk for aspiration pneumonia? (select all that apply)
a. Patient with seizures
b. Patient with head injury
c. Patient who had thoracic surgery
d. Patient who had a myocardial infarction
e. Patient who is receiving nasogastric tube feeding
- a. Patient with seizures
b. Patient with head injury
e. Patient who is receiving nasogastric tube feeding
4. An appropriate nursing intervention to assist a patient with pneumonia manage thick secretions and fatigue would be to
a. perform postural drainage every hour.
b. provide analgesics as ordered to promote patient comfort.
c. administer O2 as prescribed to maintain optimal O2 levels.
d. teach the patient how to cough effectively and expectorate secretions - d. teach the patient how to cough effectively and expectorate secretions
5. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity. - c. Administer the PRN supplemental O2.
6. 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. 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.
7. 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 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.
8. 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. 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 oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
9. 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 I'm feeling better in a couple weeks. - B. Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
10. 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. Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
11. 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. 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.
12. 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. All these nursing diagnoses are appropriate for the patient, but the patients oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved
13. 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. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.
14. 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 patient's health care provider. - 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/or 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.
15. A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client?
a. Lying flat on the affected side
b. Prone with the arms raised over the head
c. Supine with the head of the bed elevated
d. Sitting while leaning forward over the bedside table - D. Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air. [Show Less]