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EAQ final exam
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EAQ final exam EAQ final exam EAQ final exam
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EAQ final examA patient with pneumonia is being treated at home and has reported fatigue to the nurse. What
instructions should the nurse include when teaching the patient about care and recovery at home?
Select all that apply.
Get adequate rest.
Restrict fluid intake.
Avoid alcohol and smoking.
Resume work to build strength.
Take every dose of the prescribed antibiotic - ANS Get adequate rest.
Avoid alcohol and smoking.
Take every dose of the prescribed antibiotic
The nurse determines that additional discharge teaching is needed for a patient with pneumonia
when the patient states what?
"I will take all medications as prescribed."
"Breathing exercises may help prevent future infections."
"I should take antibiotics for all upper respiratory infections."
"I will seek medical attention if I develop a fever or productive cough." - ANS "I should take
antibiotics for all upper respiratory infections."
A patient has been admitted with a suspected lung abscess. During the assessment, the nurse is
aware that the most common manifestation of a lung abscess is which of these?
Fever
Vomiting
Purulent sputum that has a foul odor and taste
Increased breath sounds on auscultation over the involved segment of lung. - ANS Purulent sputum
that has a foul odor and taste
A patient with asthma who has undergone a total hip replacement complains on the third
postoperative day of shortness of breath and slight chest pain and notes that "something is wrong."
Temperature is 98.8° F, blood pressure 168/98 mm Hg, pulse 96, respirations 32, and oxygen
saturation is 89% on room air. What is the priority nursing action?
,Notify the health care provider and document the vital signs.
Apply oxygen and place the patient in a semi-Fowler's position.
Obtain an electrocardiogram (ECG) and administer albuterol nebulizers.
Administer the prescribed antihypertensive medication and reassess in 15 minutes. - ANS Apply
oxygen and place the patient in a semi-Fowler's position.
The nurse is monitoring a patient who is having a thoracentesis for recurrent pleural effusion. Which
of these assessment findings would be of most concern?
Removal of 1000 mL of pleural fluid
Restlessness and sudden complaint of dyspnea
SpO 2 reading of 96% while on 2 L/minute of oxygen
Patient complaint of pressure at the needle insertion site - ANS Restlessness and sudden complaint
of dyspnea
The nurse is caring for a patient who has a nasogastric tube. What actions should the nurse perform
to prevent aspiration in this patient? Select all that apply.
Monitor gastric residual volumes.
Feed the patient in a reclined position.
Lower the head of the bed to 10 degrees.
Elevate the head of the bed 30 to 45 degrees.
Encourage the patient to sit upright for all meals. - ANS Monitor gastric residual volumes.
Elevate the head of the bed 30 to 45 degrees.
Encourage the patient to sit upright for all meals.
A 46-year-old patient who has undergone total left knee arthroplasty complains of shortness of
breath and slight chest pain. Temperature is 98° F, blood pressure 140/86 mmHg, respirations 30,
and oxygen saturation 92% on room air. The nurse suspects that the patient is experiencing which
condition?
Pneumonia
Unstable angina
Pulmonary embolus
Chronic obstructive pulmonary disease (COPD) exacerbation - ANS Pulmonary embolus
,What is the priority nursing intervention in helping a patient expectorate thick lung secretions?
Humidify the oxygen as able.
Administer cough suppressant.
Teach the patient to splint the affected area.
Increase fluid intake to 3 L/day if tolerated. - ANS Increase fluid intake to 3 L/day if tolerated.
When the patient with a persistent cough is diagnosed with pertussis (instead of acute bronchitis),
the nurse knows that treatment will include which type of medication?
Antibiotic
Corticosteroid
Bronchodilator
Cough suppressant - ANS Antibiotic
To ease pleuritic pain caused by pneumonia, what nursing interventions should be performed?
Instructing the patient to splint the chest when coughing
Offering the patient an incentive spirometer every four hours
Instructing the patient in how to perform abdominal breathing
Encouraging the patient use shallow breathing during episodes of pain - ANS Instructing the patient
to splint the chest when coughing
The nurse is reviewing the laboratory reports for the patient receiving cefuroxime. The nurse
determines that the medication is having the intended effect by noting which laboratory result?
Sodium 138 mEq/L
Platelets 175,000 per µL
White blood cell count 4500/mm³
Blood urea nitrogen (BUN) 8 mmol/L - ANS White blood cell count 4500/mm³
When the patient is diagnosed with a lung abscess, what should the nurse teach the patient?
Lobectomy surgery usually is needed to drain the abscess.
Intravenous (IV) antibiotic therapy will be used for a prolonged period of time.
Oral antibiotics will be used when the patient and x-ray show evidence of improvement.
, No further culture and sensitivity tests are needed if the patient takes the medication as prescribed.
- ANS Oral antibiotics will be used when the patient and x-ray show evidence of improvement.
A 70-year-old patient presents to the emergency department with a cough producing yellow
sputum, fever, chills, and shortness of breath. On examination the nurse finds that the patient is
confused, has a respiratory rate of 42/minute, and a blood pressure of 80/50 mm Hg. The nurse
expects that what will be included in the patient's treatment plan?
Admit the patient to intensive care unit.
Admit the patient to a general medical-surgical unit.
Discharge the patient and monitor for signs of worsening infection.
Admit the patient for a 23-hour observation and monitor for pulmonary embolism. - ANS Admit the
patient to intensive care unit.
The health care provider has prescribed intravenous (IV) vancomycin for a patient with pneumonia.
Which action should the nurse perform first?
Obtain a full set of vital signs.
Obtain sputum cultures for sensitivity.
Administer the antibiotic over at least 60 minutes.
Draw a blood specimen to evaluate the white blood cell count. - ANS Obtain sputum cultures for
sensitivity.
The nurse would determine that levofloxacin therapy has not been effective after noting which
indicator?
Temperature 99.7° F
Increased respiratory rate
Adventitious lung sounds
White blood cell count 14,000/mm 3 - ANS White blood cell count 14,000/mm 3
Which factor places a conscious patient at risk for pneumonia?
Difficulty swallowing medication
Lying supine for two consecutive hours
Effective postoperative pain management
Adequate cough and deep breathing exercises - ANS Difficulty swallowing medication
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