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Terms in this set (47)1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? D Physiological Integrity 2. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first? A Physiological Integrity 3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find b. increased vocal fremitus on palpation. B Physiological Integrity 4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to A Physiological Integrity 5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia? C Physiological Integrity 6. A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5°
C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is D Physiological Integrity 7. The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next? B Physiological Integrity 8. Following discharge teaching, the nurse
evaluates that the patient who was admitted with pneumonia understands measures to prevent a reoccurrence of the pneumonia when the patient states, D
Health Promotion and Maintenance 9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to B Safe and Effective Care Environment 10. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? D Physiological Integrity 11. The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant A Physiological Integrity 12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen? C Physiological Integrity 13. A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the disease can be transmitted to others until B Health Promotion and Maintenance 14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB D Health Promotion and Maintenance 15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan? A Physiological Integrity 16. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops A Physiological Integrity 17. An alcoholic and homeless patient is diagnosed with active TB. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? C Physiological Integrity 18. After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). The nurse discusses
the treatment regimen with the patient with the knowledge that A Physiological Integrity 19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the A Health Promotion and Maintenance 20. During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases the patient's tolerance of the drug by D Physiological Integrity 21. The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? C Physiological Integrity 22. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member B Physiological Integrity 23. The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will monitor workers for A Health Promotion and Maintenance 24. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about D Health Promotion and Maintenance 25. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate? B Psychosocial Integrity 26. An hour after a left upper lobectomy, a patient complains of incisional pain at a level 7 out of 10 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 first? C Physiological Integrity 27. A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon, maybe this week." The best response by the nurse is B Psychosocial Integrity 28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard
entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should D Physiological Integrity 29. The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about B Physiological Integrity 30. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about D Physiological Integrity
31. The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if A Physiological Integrity 32. The nurse identifies a nursing diagnosis
of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse's first action should be to B
Physiological Integrity 33. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to C Physiological Integrity 34. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes D Physiological Integrity 35. A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis? B Physiological Integrity 36. The nurse is caring for a
patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? B Physiological Integrity 37. A patient with primary pulmonary hypertension is receiving nifedipine
(Procardia). The nurse will evaluate that the treatment is effective if A Physiological Integrity 38. A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the
procedure, the nurse will plan to A Physiological Integrity 39. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states D Physiological Integrity 40. A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? A Physiological Integrity 41. A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give? A Physiological Integrity 42. All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to the health care provider? B Physiological Integrity 43. In developing a teaching plan for a patient who is being discharged with a warfarin (Coumadin) prescription after having a pulmonary embolus, the nurse will include information about D Physiological Integrity 44. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? C Physiological Integrity 45. All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first? A Physiological Integrity 46. The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first? C Physiological Integrity 47. A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse's first action should be
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Which action should the nurse take when administering and reading the tuberculosis skin test Quizlet
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