MSN 377 Exam 3 - Ch 27, 65, 67 Questions & Answers 2024
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 gree...
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% - ANSWER-a. Weak, nonproductive cough effort
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.
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. - ANSWER-b. increased tactile fremitus.
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 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. - ANSWER-a. Assist the patient to splint the
chest when coughing.
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.
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. - ANSWER-c. I will
continue to do the deep breathing and coughing exercises at home.
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.
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. - ANSWER-b. Place
patients with altered consciousness in side-lying positions.
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.
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. - ANSWER-c. The patients white blood cell
(WBC) count is 9000/l.
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that
a change in treatment is needed.
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.
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