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B. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a sidelying 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 oxygen 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. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.
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1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort
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. Azithromycin (Zithromax)
b. Acetaminophen (Tylenol)
c. Guaifenesin (Robitussin)
d. Codeine phosphate
(Codeine)
A
Physiological Integrity
3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
a. hyperresonance on percussion.
b. increased vocal fremitus on palpation.
c. fine crackles in all lobes on auscultation.
d. asymmetric chest expansion on inspection.
B
Physiological Integrity
4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
a. splint the chest when coughing.
b. maintain fluid restrictions.
c. wear the nasal oxygen cannula.
d. try the pursed-lip breathing technique.
A
Physiological Integrity
5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia?
a.
24-year-old patient who has had temperatures ranging from 100.6° to 101° F
b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours
c. 50-year-old patient who has an oxygen saturation of 91% on room air
d. 72-year-old patient with a pulse of 102 and a blood pressure (BP) of 90/56
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
a. hyperthermia related to infectious illness.
b. ineffective airway clearance related to thick secretions.
c. impaired transfer ability related to weakness.
d. impaired gas exchange related to respiratory congestion.
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?
a. Check the patient's pulse rate.
b. Obtain an oxygen saturation.
c. Notify the health care provider.
d. Document the change.
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,
a. "I will increase my food intake to 3000 calories a day."
b. "I will need to use home oxygen therapy for 3 months."
c. "I will seek medical treatment for any upper respiratory infections."
d. "I will do deep-breathing and coughing exercises for the next 6 weeks."
D
Health Promotion and Maintenance
9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to
a. turn and reposition immobile patients at least every 2 hours.
b. position patients with altered consciousness in lateral positions.
c. monitor frequently for respiratory symptoms in patients who are immunosuppressed.
d. provide for continuous subglottic aspiration in patients receiving enteral feedings.
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?
a. Bronchial breath sounds are heard at the right base.
b. Increased vocal fremitus is palpable over the right chest.
c. The patient coughs up small amounts of green
mucous.
d. The patient's white blood cell (WBC) count is 9000/µl.
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. turns the patient over to the right side.
b. splints the patient's chest during coughing.
c. elevates
the patient's head to 45 degrees.
d. assists the patient to get up to the bathroom.
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?
a. After the patient rinses the mouth with mouthwash
b. As soon as the order is received from the health care provider
c.
Right after the patient gets up in the morning
d. After the skin test is administered
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
a. the chest x-ray shows resolution of the tuberculosis.
b. three sputum smears for acid-fast bacilli are negative.
c. TB
medications have been taken for 6 months.
d. sputum cultures on 3 consecutive days are negative.
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
a. demonstrates correct use of a nebulizer.
b. reports daily to the public health department.
c. washes dishes and personal items after
use.
d. covers the mouth and nose when coughing.
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. "Take vitamin B6 daily to prevent peripheral nerve damage."
b. "Read a newspaper daily to check for changes in vision."
c. "Schedule an audiometric
examination to monitor for hearing loss."
d. "Avoid wearing soft contact lenses to avoid orange staining."
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. yellow-tinged skin.
b.
changes in hearing.
c. orange-colored urine.
d. thickening of the nails.
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?
a. Giving the patient written instructions about how to take the medications
b. Teaching the patient about the high risk for
infecting others unless treatment is followed
c. Arranging for a daily noontime meal at a community center and give the medication then
d. Educating the patient about the long-term impact of TB on health
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. directly observed therapy (DOT) will be necessary if the medications have not been taken correctly.
b. the positive sputum smears indicate that the patient is experiencing toxic reactions to the medications.
c. twice-weekly administration may be used to improve compliance with the treatment regimen.
d. a regimen using only INH and rifampin (Rifadin) will be used for the last 4 months of drug therapy.
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. use and side effects of INH.
b. standard four-drug therapy for TB.
c. need for annual repeat TB skin testing.
d. recommendation guidelines for bacille Calmette-Guérin (BCG)
vaccine.
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
a. cooling the solution to 80° F before administration.
b. keeping the patient flat in bed for 1 hour after the infusion is completed.
c. diluting the amphotericin B in 500 ml of sterile water.
d.
giving diphenhydramine (Benadryl) 1 hour before starting the infusion.
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?
a. "How long have you lived in the United States?"
b. "Is there any family history of
TB?"
c. "Have you received the BCG vaccine for TB?"
d. "Do you take any over-the-counter (OTC) medications?"
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
a. washes the hands before entering the patient's room.
b. puts on a surgical
face mask before visiting the patient.
c. brings food from a "fast-food" restaurant to the patient.
d. hands the patient a tissue from the box at the bedside.
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. shortness of breath.
b. chest pain.
c. elevated temperature.
d.
barrel-chest.
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
a. reasons for annual sputum cytology testing.
b. CT screening for lung cancer.
c. erlotinib (Tarceva) therapy to prevent tumor risk.
d. options for smoking cessation.
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?
a. "Are you afraid that the surgery will be very painful?"
b. "Tell me what you know about the various treatments available."
c. "Surgery is the treatment of choice for
stage I lung cancer."
d. "Did you have bad experiences with previous surgeries?"
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?
a. Assist the patient to
deep breathe and cough.
b. Milk the chest tube gently to remove any clots.
c. Medicate the patient with the ordered morphine.
d. Notify the surgeon about the large air leak.
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
a. "Are you afraid that the treatment
for your cancer will not be effective?"
b. "Can you tell me what it is that makes you think you will die so soon?"
c. "Would you like to talk to the hospital chaplain about your feelings?"
d. "Do you think that taking an antidepressant medication would be helpful?"
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
a. position the patient so that the right chest is dependent.
b. administer high-flow oxygen using a non-rebreathing mask.
c. cover the sucking chest wound with an occlusive dressing.
d. tape a nonporous dressing on three sides over the chest wound.
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
a. a large air leak in the water-seal chamber.
b. 400 ml of blood in the collection chamber.
c. severe pain with each deep patient inspiration.
d. subcutaneous emphysema at the insertion site.
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
a. complaints of severe pain.
b. heart rate of 110 beats/min.
c. a large bruised area on the chest.
d. paradoxic chest movement.
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. the breath sounds on one side are decreased.
b. there are wheezes audible throughout both lungs.
c. there is a sucking sound with each patient breath.
d. paradoxic movement of the chest is noted.
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
a. have the patient use the incentive spirometer.
b. medicate the patient with the ordered morphine.
c. splint the patient's chest during coughing.
d. assist the patient to sit up at the bedside.
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
a. document the presence of a large air leak.
b. obtain and attach a new collection device.
c. notify the health care provider of a possible pneumothorax.
d. take no further action with the collection device.
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
a. positioning on the right side.
b. chest tubes to water-seal chest drainage.
c. bedrest for the first 24 hours.
d. frequent use of an incentive spirometer.
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?
a. Audible crackles at both lung bases
b. 3+ edema in the lower extremities
c. Loud murmur at the mitral area
d. High systemic BP
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?
a. The international normalized ratio (INR) is prolonged.
b. The central line is disconnected.
c. The oxygen saturation is 90%.
d. The BP is 88/56.
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. the patient reports decreased exertional dyspnea.
b. the blood pressure is less than 140/90 mm Hg.
c. the heart rate is between 60 and 100 beats/minute.
d. the patient's chest x-ray indicates clear lung fields.
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. position the patient sitting upright on the edge of the bed and leaning forward.
b. instruct the patient about the importance of incentive spirometer use after the procedure.
c. start a peripheral intravenous line to administer the necessary sedative drugs.
d. remove the water pitcher and remind the patient not to eat or drink anything for 8 hours.
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
a. "I will make an appointment to see the doctor every year."
b. "I will not turn the home oxygen up higher than 2 L/minute."
c. "I will be careful to use sterile technique with my central line."
d. "I will write down my medications and spirometry in a journal."
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. Listen to the patient's lungs.
b. Check the patient's O2 saturation.
c. Have the patient cough forcefully.
d. Notify the patient's health care provider.
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. The skin test will determine if you have a tuberculosis infection.
b. The skin test will indicate whether you have active tuberculosis.
c. The skin test is used to decide which antibiotic therapy will work best.
d. The skin test is done prior to notification of the public health
department.
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?
a. The patient has many abdominal bruises.
b. The patient's BP is 90/46.
c. The activated partial thromboplastin
time is 2 times the patient baseline.
d. The patient's stool is dark green and liquid.
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
a. where to schedule activated partial thromboplastin time testing.
b. avoidance of a high protein
diet.
c. how to obtain enteric-coated aspirin.
d. foods that are high in vitamin K.
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?
a. BP is 150/90.
b. Pain level is 5/10 with a deep breath.
c. Oxygen saturation is 89%.
d. Respiratory
rate is 24 when lying flat.
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. Obtain blood cultures from two sites.
b. Give ciprofloxin (Cipro) 400 mg IV.
c. Send to radiology for chest radiograph.
d. Administer aspirin suppository.
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?
a. A 23-year-year-old patient with cystic fibrosis who has pulmonary function testing scheduled in 30 minutes
b. A 35-year-old patient who was admitted the previous day with bacterial pneumonia and has a temperature of 100.2° F
c. A 46-year-old patient who is
complaining of dyspnea after having a thoracentesis an hour previously
d. A 77-year-old patient with TB who has four antitubercular medications due in 15 minutes
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
to
a. elevate the head of the bed.
b. administer the ordered pain medication.
c. notify the patient's health care provider.
d. offer emotional support and reassurance.
A
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