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NSG320 Topic 3 Chapter 28 NCLEX
A,B,D.
Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental
carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the
development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the
geographic area where the patient has lived for some time may be a risk, but not necessarily where
the patient was born. - ✔✔During admission of a patient diagnosed with non-small cell lung
carcinoma, the nurse questions the patient related to a history of which risk factors for this type of
cancer (select all that apply)?
A. Asbestos exposure
B. Exposure to uranium
C. Chronic interstitial fibrosis
D. History of cigarette smoking
E. Geographic area in which he was born
A,B,E.
Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse
should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for
%
a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The
patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed. -
✔✔To promote airway clearance in a patient with pneumonia, what should the nurse instruct the
patient to do (select all that apply)?
A. Maintain adequate fluid intake.
B. Splint the chest when coughing.
C. Maintain a 30-degree elevation.
D. Maintain a semi-Fowler's position.
E. Instruct patient to cough at end of exhalation.*
A,C,D,E.
An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette
smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein
thrombosis, immobilization, surgery within the last 3 months, oral contraceptives and hormone
therapy, heart failure, pregnancy, and clotting disorders. - ✔✔When admitting a 45-year-old female
with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors
(select all that apply)?
A. Obesity
B. Pneumonia
C. Malignancy
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D. Cigarette smoking
E. Prolonged air travel
A.
Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing
diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her
breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective
airway clearance from the information given because the patient is expectorating sputum. - ✔✔The
nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse
notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20.
Which nursing diagnosis is most appropriate based upon this assessment?
A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
A.
Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which
must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing
symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing
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episodes with pertussis. - ✔✔When the patient with a persisting cough is diagnosed with pertussis
(instead of acute bronchitis), the nurse knows that treatment will include which type of medication?
A. Antibiotic
B. Corticosteroid
C. Bronchodilator
D. Cough suppressant
A.
The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering
from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus
vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would
not be recommended as adults do not need it unless they are immunocompromised. The BCG
vaccine is for infants in parts of the world where tuberculosis (TB) is prevalent. - ✔✔During
discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and
pneumonia, which vaccine should the nurse recommend that this patient receive?
A. Pneumococcal
B. Staphylococcus aureus
C. Haemophilus influenzae
D. Bacille-Calmette-Guérin (BCG)
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