Chapter 28: Nursing Management: Lower Respiratory Problems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 28: Nursing Management: Lower Respiratory Problems

Test Bank

MULTIPLE CHOICE

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.

Weak, nonproductive cough effort

b.

Large amounts of greenish sputum

c.

Respiratory rate of 28 breaths/minute

d.

Resting pulse oximetry (SpO2) of 85%

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.

DIF: Cognitive Level: Application REF: 551-552 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

2. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find

a.

vesicular breath sounds.

b.

increased tactile fremitus.

c.

dry, nonproductive cough.

d.

hyperresonance to percussion.

ANS: B

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.

DIF: Cognitive Level: Application REF: 549

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance?

a.

Assist the patient to splint the chest when coughing.

b.

Educate 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.

ANS: 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.

DIF: Cognitive Level: Application REF: 552-553

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. Which statement by a patient who has been hospitalized for pneumonia 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.

ANS: C

Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time.

DIF: Cognitive Level: Application REF: 552 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

5. Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk?

a.

Turn and reposition immobile patients at least every 2 hours.

b.

Place patients with altered consciousness in side-lying positions.

c.

Monitor for respiratory symptoms in patients who are immunosuppressed.

d.

Provide for continuous subglottic aspiration in patients receiving enteral feedings.

ANS: B

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 oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.

DIF: Cognitive Level: Application REF: 551

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. 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.

The patient coughs up small amounts of green mucus.

c.

The patients white blood cell (WBC) count is 9000/l.

d.

Increased tactile fremitus is palpable over the right chest.

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.

DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

7. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will 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 patient for 3 days.

d.

Instruct the patient to expectorate three specimens as soon as possible.

ANS: C

Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated.

DIF: Cognitive Level: Application REF: 555

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. Which information about a patient 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.

ANS: D

Negative sputum smears indicate that M. 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 since it will not change even with effective treatment.

DIF: Cognitive Level: Application REF: 557

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB

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.

ANS: C

Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.

DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Evaluation

MSC: NCLEX: Health Promotion and Maintenance

10. Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis?

a.

Your urine, sweat, and tears will be orange colored.

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.

ANS: A

Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications.

DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

11. When teaching the patient who is receiving standard multidrug therapy for tuberculosis (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 sputum.

d.

thickening of the fingernails.

ANS: A

Noninfectious hepatitis is a toxic effect of isoniazid (INH), 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. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

DIF: Cognitive Level: Application REF: 555 | 556

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

a.

Educating the patient about the long-term impact of TB on health

b.

Giving the patient written instructions about how to take the medications

c.

Teaching the patient about the high risk for infecting others unless treatment is followed

d.

Arranging for a daily noontime meal at a community center and giving the medication then

ANS: D

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 patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.

DIF: Cognitive Level: Application REF: 556

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

a.

Ask the patient whether medications have been taken as directed.

b.

Discuss the need to use some different medications to treat the TB.

c.

Schedule the patient for directly observed therapy three times weekly.

d.

Educate about using a 2-drug regimen for the last 4 months of treatment.

ANS: A

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. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB.

DIF: Cognitive Level: Application REF: 556-557

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. A staff nurse has a tuberculosis (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 isoniazid (INH).

b.

standard four-drug therapy for TB.

c.

need for annual repeat TB skin testing.

d.

bacille Calmette-Gurin (BCG) vaccine.

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. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.

DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

15. When caring for a patient who is hospitalized with active tuberculosis (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 patients room.

b.

hands the patient a tissue from the box at the bedside.

c.

puts on a surgical face mask before visiting the patient.

d.

brings food from a fast-food restaurant to the patient.

ANS: C

A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patients room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

DIF: Cognitive Level: Application REF: 557

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be 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.

ANS: D

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.

DIF: Cognitive Level: Application REF: 560-561

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

17. 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.

computed tomography (CT) screening for lung cancer.

b.

options for smoking cessation.

c.

reasons for annual sputum cytology testing.

d.

erlotinib (Tarceva) therapy to prevent tumor risk.

ANS: B

Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors.

DIF: Cognitive Level: Application REF: 563 | 565 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

18. A lobectomy is scheduled for a patient with stage I nonsmall 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.

Did you have bad experiences with previous surgeries?

c.

Surgery is the treatment of choice for stage I lung cancer.

d.

Tell me what you know about the various treatments available.

ANS: D

More assessment of the patients 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 patients reasons for not wanting surgery.

DIF: Cognitive Level: Application REF: 565

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

19. An hour after a thoracotomy, 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 is best for the nurse to take next?

a.

Administer the prescribed PRN morphine.

b.

Assist the patient to deep breathe and cough.

c.

Milk the chest tube gently to remove any clots.

d.

Tape the area around the insertion site of the chest tube.

ANS: A

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 and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.

DIF: Cognitive Level: Application REF: 573-574

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. A patient with newly diagnosed lung cancer tells the nurse, I think I am going to die pretty soon. Which response by the nurse is best?

a.

Would you like to talk to the hospital chaplain about your feelings?

b.

Can you tell me what it is that makes you think you will die so soon?

c.

Are you afraid that the treatment for your cancer will not be effective?

d.

Do you think that taking an antidepressant medication would be helpful?

ANS: B

The nurses initial response should be to collect more assessment data about the patients 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 answer beginning, Are you afraid implies that the patient thinks that the cancer will be immediately fatal, although the patients statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

DIF: Cognitive Level: Application REF: 565

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

21. The health care provider inserts a chest tube 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.

complaint of pain with each deep inspiration.

d.

subcutaneous emphysema at the insertion site.

ANS: B

The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. 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.

DIF: Cognitive Level: Application REF: 572

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. 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.

paradoxic chest movement.

b.

the complaint of chest wall pain.

c.

a heart rate of 110 beats/minute.

d.

a large bruised area on the chest.

ANS: A

Paradoxic 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.

DIF: Cognitive Level: Application REF: 567 | 569

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

23. When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for

a.

emergency pericardiocentesis.

b.

stabilization of the chest wall with tape.

c.

administration of an inhaled bronchodilator.

d.

insertion of a chest tube with a chest drainage system.

ANS: D

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

DIF: Cognitive Level: Application REF: 567 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

24. 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 surgeon of a possible pneumothorax.

d.

take no further action with the collection device.

ANS: D

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. A new collection device is needed when the collection chamber is filled.

DIF: Cognitive Level: Application REF: 572

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. 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.

bed rest for the first 24 hours.

c.

frequent use of an incentive spirometer.

d.

chest tubes to water-seal chest drainage.

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. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis.

DIF: Cognitive Level: Application REF: 573 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

26. To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make?

a.

Lung sounds

b.

Heart sounds

c.

Blood pressure

d.

Peripheral edema

ANS: D

Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale.

DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

27. A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if

a.

the BP is less than 140/90 mm Hg.

b.

the patient reports decreased exertional dyspnea.

c.

the heart rate is between 60 and 100 beats/minute.

d.

the patients chest x-ray indicates clear lung fields.

ANS: B

Since a major symptom of PPH 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 effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

28. A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to

a.

start a peripheral intravenous line to administer the necessary sedative drugs.

b.

position the patient sitting upright on the edge of the bed and leaning forward.

c.

remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

d.

instruct the patient about the importance of incentive spirometer use after the procedure.

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 lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. 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.

DIF: Cognitive Level: Application REF: 576 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

29. 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 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.

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 oxygen use is not an expectation after lung transplant. Shortness of breath should be reported.

DIF: Cognitive Level: Application REF: 583 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

30. Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis?

a.

Administer aspirin suppository.

b.

Send to radiology for chest x-ray.

c.

Give ciprofloxacin (Cipro) 400 mg IV.

d.

Obtain blood cultures from two sites.

ANS: D

Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last.

DIF: Cognitive Level: Application REF: 549

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

31. 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 mm Hg.

b.

Oxygen saturation is 89%.

c.

Pain level is 5/10 with a deep breath.

d.

Respiratory rate is 24 when lying flat.

ANS: B

Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% 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 oxygen saturation is the priority.

DIF: Cognitive Level: Application REF: 576

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

32. A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first?

a.

guaifenesin (Robitussin)

b.

acetaminophen (Tylenol)

c.

azithromycin (Zithromax)

d.

codeine phosphate (Codeine)

ANS: C

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

DIF: Cognitive Level: Application REF: 549

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

The Mantoux test had an induration of only 8 mm.

b.

The chest-x-ray showed infiltrates in the upper lobes.

c.

The patient is being treated with antiretrovirals for HIV infection.

d.

The patient has a cough that is productive of blood-tinged mucus.

ANS: C

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

DIF: Cognitive Level: Application REF: 556

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

34. A 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.

impaired transfer ability related to weakness.

c.

ineffective airway clearance related to thick secretions.

d.

impaired gas exchange related to respiratory congestion.

ANS: 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.

DIF: Cognitive Level: Application REF: 552-553

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

35. The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP

a.

lower the head of the patients bed to 10 degrees.

b.

splint the patients chest during coughing.

c.

help the patient to ambulate to the bathroom.

d.

assist the patient to a bedside chair for meals.

ANS: A

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

DIF: Cognitive Level: Application REF: 552-553

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

36. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurses first action should be to

a.

elevate the head of the bed to 45 to 60 degrees.

b.

administer the ordered pain medication.

c.

notify the patients health care provider.

d.

offer emotional support and reassurance.

ANS: A

The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

DIF: Cognitive Level: Application REF: 580

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

37. After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first?

a.

A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes

b.

A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled

c.

A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath.

d.

A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

ANS: C

Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

DIF: Cognitive Level: Application REF: 577-578

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

38. The nurse is performing tuberculosis (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.

Is there any family history of TB?

b.

Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?

c.

How long have you lived in the United States?

d.

Do you take any over-the-counter (OTC) medications?

ANS: B

Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a 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.

DIF: Cognitive Level: Application REF: 557

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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

a.

Position the patient so that the right chest is dependent.

b.

Keep the head of the patients bed at no more than 30 degrees elevation.

c.

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

d.

Cover the sucking chest wound firmly with an occlusive dressing.

ANS: C

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 right 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.

DIF: Cognitive Level: Application REF: 567

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

Assist the patient to sit up at the bedside.

b.

Splint the patients chest during coughing.

c.

Medicate the patient with the prescribed morphine.

d.

Have the patient use the prescribed incentive spirometer.

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.

DIF: Cognitive Level: Application REF: 574

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

41. 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 BP is 98/56 mm Hg.

b.

The oxygen saturation is 94%.

c.

The patients central intravenous line is disconnected.

d.

The international normalized ratio (INR) is prolonged.

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.

DIF: Cognitive Level: Application REF: 581

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

42. 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 patients lungs.

b.

Administer the PRN morphine.

c.

Have the patient cough forcefully.

d.

Notify the patients health care provider.

ANS: A

The patients 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.

DIF: Cognitive Level: Application REF: 576

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. 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. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. Obtain the oxygen saturation.

b. Check the patients pulse rate.

c. Document the change in status.

d. Notify the health care provider.

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.

DIF: Cognitive Level: Analysis REF: 549 | 551

OBJ: Special Questions: Alternate Item Format, Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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