Pneumonia Practice Questions & Answers PDF

1\. **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 posit...

1\. **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. Maintain adequate fluid intake. B. Splint the chest when coughing. E. Instruct patient to cough at end of exhalation. 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. 2\. **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. Hyperthermia related to infectious illness 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. 3\. **Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?** A. **Basilar crackles** B. **Respiratory rate of 28** C. **Oxygen saturation of 85%** D. **Presence of greenish sputum:** A. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance. 4\. **Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia?** A. **Hyperresonance on percussion** B. **Vesicular breath sounds in all lobes** C. **Increased vocal fremitus on palpation** D. **Fine crackles in all lobes on auscultation:** C. Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area. 5\. **What is the priority nursing intervention in helping a patient expectorate thick lung secretions?** A. **Humidify the oxygen as able.** B. **Administer cough suppressant q4hr.** C. **Teach patient to splint the affected area.** D. **Increase fluid intake to 3 L/day if tolerated.:** D. Increase fluid intake to 3 L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions. 6\. **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-Guerin (BCG):** A. Pneumococcal 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. 7\. **The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse?** A. **\"I will seek immediate medical treatment for any upper respiratory infec-tions.\"** B. **\"I should continue to do deep-breathing and coughing exercises for at least 12 weeks.\"** C. **\"I will increase my food intake to 2400 calories a day to keep my immune system well.\"** D. **\"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia\'s resolution.\":** D. \"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia\'s resolution.\" The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions. 8\. **After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient?** A. **Orthostatic blood pressures** B. **Sputum culture and sensitivity** C. **Pulmonary function evaluation** D. **Serum laboratory studies ordered for AM:** B. Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics. 9\. **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. Antibiotic 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 episodes with pertussis. 10\. **The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus** b. **Dry, nonproductive cough** c. **Hyperresonance to percussion** d. **A grating sound on auscultation:** ANS: A 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 grating sound is more representative of a pleural friction rub rather than pneumonia. 11\. **The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?** a. **\"I will call the doctor if I still feel tired after a week.\"** b. **\"I will continue to do the deep breathing and coughing exercises at home.\"** c. **\"I will schedule two appointments for the pneumonia and influenza vac-cines.\"** d. **\"I\'ll cancel my chest x-ray appointment if I\'m feeling better in a couple weeks.\":** ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia 12\. **The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?** 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. **Insert nasogastric tube for feedings for patients with swallowing problems.-:** 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. 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. 13. **A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 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 patient\'s white blood cell (WBC) count is 9000/µL.** 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. 14\. **A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider\'s order to discontinue airborne precautions unless which assessment finding is documented? 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 Mycobacterium 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 because the result will not change even with effective treatment. 15\. **The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?** a. **\"I will avoid being outdoors whenever possible.\"** b. **\"My husband will be sleeping in the guest bedroom.\"** c. **\"I will take the bus instead of driving to visit my friends.\"** d. **\"I will keep the windows closed at home to contain the germs.\":** ANS: B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation. 16\. **A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse?** a. **Ask if the patient is experiencing shortness of breath, hives, or itching.** b. **Ask the patient about any visual abnormalities such as red-green color discrimination.** c. **Explain that orange discolored urine and tears are normal while taking this medication.** d. **Advise the patient to stop the drug and report the symptoms to the health care provider.:** ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication. 17\. **An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?** a. **Yellow-tinged skin** b. **Orange-colored sputum** c. **Thickening of the fingernails** d. **Difficulty hearing high-pitched voices:** 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. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. 18\. **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. **Arrange for a friend to administer the medication on schedule.** b. **Give the patient written instructions about how to take the medications.** c. **Teach the patient about the high risk for infecting others unless treatment is followed.** d. **Arrange for a daily noon meal at a community center where the drug will be administered.:** ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help 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 for this patient. 19. **After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?** a. **Teach about treatment for drug-resistant TB treatment.** b. **Ask the patient whether medications have been taken as directed.** c. **Schedule the patient for directly observed therapy three times weekly.** d. **Discuss with the health care provider the need for the patient to use an injectable antibiotic.:** ANS: B 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. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed. 20\. **Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB** b. **Need for annual repeat TB skin testing** c. **Use and side effects of isoniazid (INH)** d. **Bacille Calmette-Guérin (BCG) vaccine:** ANS: C 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 for TB and would not be helpful for this individual, who already has a TB infection. 21\. **When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse?** a. **The patient is offered a tissue from the box at the bedside.** b. **A surgical face mask is applied before visiting the patient.** c. **A snack is brought to the patient from the unit refrigerator.** d. **Hand washing is performed before entering the patient\'s room.:** ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient\'s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient\'s room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. 22\. **A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher** b. **Blood cultures from two sites** c. **Ciprofloxacin (Cipro) 400 mg IV** d. **Acetaminophen (Tylenol) rectal suppository:** ANS: B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last. 23\. **A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine** b. **Guaifenesin (Robitussin)** c. **Acetaminophen (Tylenol)** d. **Piperacillin/tazobactam (Zosyn):** ANS: D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. 24\. **A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm.** b. **The chest-x-ray showed infiltrates in the lower 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 TB. The other data are expected in a patient with HIV and TB. 25\. **The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?** a. **UAP splint the patient\'s chest during coughing.** b. **UAP assist the patient to ambulate to the bathroom.** c. **UAP help the patient to a bedside chair for meals.** d. **UAP lower the head of the patient\'s bed to 15 degrees.:** ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. 26\. **The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?** a. **A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled** b. **A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath** c. **A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes** 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: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. 27\. **The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. \"Is there any family history of TB?\"** b. **\"How long have you lived in the United States?\"** c. **\"Do you take any over-the-counter (OTC) medications?\"** d. **\"Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?\":** ANS: D 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. 28\. **Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?** a. **Providing supportive care to patients diagnosed with pertussis** b. **Teaching family members about the need for careful hand washing** c. **Teaching patients about the need for adult pertussis immunizations** d. **Encouraging patients to complete the prescribed course of antibiotics:** ANS: C The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made. 29\. **After change-of-shift report, which patient should the nurse assess first?** a. **72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet** b. **28-year-old with a history of a lung transplant and a temperature of 101° F** **(38.3° C)** c. **40-year-old with a pleural effusion who is complaining of severe stabbing chest pain** d. **64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion:** ANS: D The patient\'s history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia. 30\. **Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age** b. **Blood pressure** c. **Respiratory rate** d. **Oxygen saturation** e. **Presence of confusion** f. **Blood urea nitrogen (BUN) level:** ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring. 31. **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 32\. **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 33\. **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 34. **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 vac-cines.\":** 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 35\. **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 36. **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 patient\'s white blood cell (WBC) count is 9000/µl.** 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 37\. **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 38. **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 39. **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 40\. **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 41\. **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 42. **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 43. **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-Guérin (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 44\. **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 patient\'s 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 patient\'s 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 45\. **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 46\. **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 47\. **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 48\. **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 patient\'s 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 49\. **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 patient\'s bed to 10 degrees.** b. **splint the patient\'s 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 50\. **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 51\. **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-Guérin (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 52\. **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. **Administer the PRN morphine.** c. **Have the patient cough forcefully.** d. **Notify the patient\'s health care provider.:** ANS: A The patient\'s 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 53\. **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 patient\'s 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: Physiolog 54\. **The most important action the nurse should do before and after suctioning a client is:** a. **Placing the client in a supine position** b. **Making sure that suctioning takes only 10-15 seconds** c. **Evaluating for clear breath sounds** d. **Hyperventilating the client with 100% oxygen:** d. Hyperventilating the client with 100% oxygen 55\. **The position of a conscious client during suctioning is: a. Fowler\'s** b. **Supine position** c. **Side-lying** d. **Prone:** a. Fowler\'s Position a conscious person who has a functional gag reflex in the semi fowler\'s position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you. 56\. **Presence of overdistended and non-functional alveoli is a condition called:** a. **Bronchitis** b. **Emphysema** c. **Empyema** d. **Atelectasis:** Answer: B. An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung. 57\. **23. The accumulation of fluids in the pleural space is called: a. Pleural effusion** b. **Hemothorax** c. **Hydrothorax** d. **Pyothorax:** a. Pleural effusion 58\. **2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?** a. **Do nothing, because this is an expected finding.** b. **Immediately clamp the chest tube and notify the physician.** c. **Check for an air leak because the bubbling should be intermittent.** d. **Increase the suction pressure so that bubbling becomes vigorous.:** Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. 59\. **4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:** a. **Call the physician.** b. **Place the tube in a bottle of sterile water.** c. **Immediately replace the chest tube system.** d. **Place the sterile dressing over the disconnection site.:** Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action. 60\. **While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:** a. **Call the physician to reinsert the tube.** b. **Grasp the retention sutures to spread the opening.** c. **Call the respiratory therapy department to reinsert the tracheotomy.** d. **Cover the tracheostomy site with a sterile dressing to prevent infection.:** b. Grasp the retention sutures to spread the opening. 61\. **A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?** a. **Stridor** b. **Occasional pink-tinged sputum** c. **A few basilar lung crackles on the right** d. **Respiratory rate of 24 breaths/min:** Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction 62. **An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?** a. **A low respiratory** b. **Diminished breathe sounds** c. **The presence of a barrel chest** d. **A sucking sound at the site of injury:** Answer B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. 63\. **A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?** a. **Hypocapnia** b. **A hyperinflated chest noted on the chest x-ray** c. **Increase oxygen saturation with exercise** d. **A widened diaphragm noted on the chest x-ray:** Answer B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, - hypercapnia, - dyspnea on exertion and at rest - oxygen desaturation with exercise - and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. 64\. **A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:** a. **Dyspnea** b. **Chest pain** c. **A bloody, productive cough** d. **A cough with the expectoration of mucoid sputum:** Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement. 65\. **A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:** a. **1 L/min** b. **2 L/min** c. **6 L/min** d. **10 L/min:** Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. 66\. **A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:** a. **Promote oxygen intake.** b. **Strengthen the diaphragm.** c. **Strengthen the intercostal muscles.** d. **Promote carbon dioxide elimination.:** Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing. 67\. **Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids** b. **Having the clients take three deep breaths** c. **Asking the client to split into the collection container** d. **Asking the client to obtain the specimen after eating:** Answer B. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning 68\. **A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians?** a. **Dry cough** b. **Hematuria** c. **Bronchospasm** d. **Blood-streaked sputum:** Answer C. If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. 69\. **A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute** b. **5 seconds** c. **10 seconds** d. **30 seconds:** Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds. 70\. **A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention?** a. **Continue to suction.** b. **Notify the physician immediately.** c. **Stop the procedure and reoxygenate the client.** d. **Ensure that the suction is limited to 15 seconds.:** Answer C. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated. 71\. **An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of:** a. **Metabolic acidosis** b. **Respiratory acidosis** c. **Overcompensated respiratory acidosis** d. **Combined respiratory and metabolic acidosis:** Answer A. In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect. 72\. **A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?** a. **Dyspnea** b. **Bradypnea** c. **Bradycardia** d. **Decreased respiratory:** Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain 73\. **A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching?** a. **Inhales the mist and quickly exhales** b. **Removes the cap and shakes the inhaler well before use** c. **Presses the canister down with the finger as he breathes in** d. **Waits 1 to 2 minutes between puffs if more than one puff has been pre-scribed:** Answer A. The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options B, C, and D are accurate instructions regarding the use of the inhaler. 74\. **A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?** a. **Administering atropine intravenously** b. **Administering small doses of midazolam (Versed)** c. **Encouraging additional fluids for the next 24 hours** d. **Ensuring the return of the gag reflex before offering food or fluids:** Answer D. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after. 75\. **A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations** b. **Rapid deep respirations** c. **Paradoxical respirations** d. **Pain, especially with inspiration:** Answer D. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and Sx include - pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation - shallow respirations - splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. 76\. **A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:** a. **Right pneumothorax** b. **Pulmonary embolism** c. **Displaced endotracheal tube** d. **Acute respiratory distress syndrome:** Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. 77\. **A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly** b. **Inhale through the nose** c. **Hold the breath after inhalation** d. **Take two inhalations during one breath:** Answer C. Instructions for using a metered-dose inhaler include - shaking the canister, - holding it right side up, - inhaling slowly and evenly through the mouth, - delivering one spray per breath, - and holding the breath after inhalation. 78\. **A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?** a. **Bilateral wheezing** b. **Inspiratory crackles** c. **Intercostal retractions** d. **Increased respiratory rate:** Answer D. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. T his is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. 79\. **A nurse is assessing a male client with chronic airflow limitations and notes that the client has a \"barrel chest.\" The nurse interprets that this client has which of the following forms of chronic airflow limitations?** a. **Emphysema** b. **Bronchial asthma** c. **Chronic obstructive bronchitis** d. **Bronchial asthma and bronchitis:** Answer A. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as \"barrel chest.\" The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. 80\. **A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem?** a. **Cough** b. **High-grade fever** c. **Chills and night sweats** d. **Anorexia and weight loss:** Answer B. The client with tuberculosis USUALLY experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever How often should a nurse assess the skin and nares of the patient with a nasal cannula? The nurse should assess the client\'s nares and ears for skin breakdown every 6 hours. What does central cyanosis indicate? Hypoexmia 81. **Describe the clinical signs of RIGHT sided heart failure.:** weight gain distended neck veins hepatomegaly and splenomegaly dependent peripheral edema 82. **A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax** b. **Pulmonary embolism** c. **Displaced endotracheal tube** d. **Acute respiratory distress syndrome:** Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. 83\. **The nurse is caring for a patient diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in patients with renal failure?** 1. **The patient breathes rapidly to eliminate carbon dioxide** 2. **The patient will maintain bicarbonate in excess of normal** 3. **The pH will decrease from present value** 4. **The patient\'s oxygen saturation will improve:** Answer 1 because in metabolic acidosis compensation is accomplished through increased ventilation to raise the pH. :) 84\. **A client presents to and emergency department following a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client\'s chest and torso, crepitus, and tachypnea. Based on this assessment, the nurse should:** **1) Assist in the placement of a cervical collar 2) Anticipate the need to intubate the client 3) Provide chest compressions.** **4) Tape the chest wall.:** 2, the assessment data implies a client with multiple broken ribs and potentially flail chest. In the case of flail chest, more invasive interventions are generally required, including management of the client\'s airway with intubation. The client would most likely already have a cervical collar on, and this is not the intervention that would address the assessment data. There is no evidence to suggest that chest compressions are warranted. Taping the chest wall is and intervention for broken ribs that has proven to not be as effective as once believed. (Ohman, 2010, p. 451) Works Cited Ohman, K. A. (2010). Davis\'s Q & A fot the NCLEX-RN examination. Philadelphia, PA: F.A. Davis Company. 85\. **A physician orders arterial blood gases (ABGs) on a 5-year-old client admitted with severe asthma. Which signs and symptoms noted during a nurse\'s assessment of the child are consistent with the blood gas findings of pH = 7.30, PaCO2 = 49 mm HG, and HCO3 = 24 mEQ/L?** 1. **Diaphoresis, headache, tachycardia, confusion, restlessness, apprehension, and flushed face** 2. **Rapid and deep respirations, paresthesia, light-headedness, twitching, anxiety, and fear** 3. **Rapid and deep breathing, fruity breath, fatigue, headache, lethargy, drowsiness, nausea, vomiting, and abdominal pain** 4. **Slow and shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, and seizures:** Answer: 1 Diaphoresis, headache, tachycardia, confusion, restlessness, apprehension, and flushed face are all signs and symptoms of respiratory acidosis without compensation. These occur because of the lack of oxygen and trapping of carbon dioxide in the lower airway from the narrowed airway passages. Rapid and deep respirations, paresthesia, light-headedness, twitching, anxiety, and fear are signs and symptoms of respiratory alkalosis. Respiratory alkalosis may occur in asthma is excess artificial ventilation is used in treatment. Rapid and deep breathing, fruity breath, fatigue, headache, lethargy, drowsiness, nausea, vomiting, and abdominal pain are signs and symptoms of metabolic acidosis. Slow and shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, and seizures are signs and symptoms of metabolic alkalosis. Metabolic acidosis and alkalosis are not associated with asthma, but may occur from other complications. 86\. **A nurse is completing a health history for a child with CF. Which statement from a parent is consistent with the diagnosis?** 1. **\"When I bathe my baby, my baby\'s skin feels oily.\"** 2. **\"When I kiss my baby, my baby\'s skin tastes salty.\"** 3. **\"When I change my baby\'s diapers, the baby\'s stools are ribbon-like.\" 4. \"When I wipe my baby\'s mouth, my baby has a lot of saliva and thin mucous.\":** Answer: 2 - the level of chloride to sodium is increased two to five times in the sweat of children with CF, so the skin may taste salty. 87\. **Client experienced smoke inhalation and developed pulmonary edema. The nurse auscultates the client\'s breath sounds and anticipates hearing which of the following?** 1. **Crackles** 2. **Decreased breath sounds** 3. **Inspiratory and expiratory wheezing** 4. **Upper airway rhonchi:** 1. In pulmonary edema, the most frequently heard sounds are crackles. Decreased breath sounds and inspiratory and expiratory wheezing are associated with asthma, and rhonchi are heard when there\'s sputum in the airways. From NCLEX RN Review Made Incredibly Easy 88\. **The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?** 1. **During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.** 2. **It is necessary for the client to wear a mask at all times to prevent transmission of the disease.** 3. **The family should support the client to help reduce feeling of low self-esteem and isolation.** 4. **The client will be required to take prescribed medication for a duration of 6-9 months.:** 4 The client will be required to take prescribed medication for a duration of 6-9 months. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) on respiratory precautions for 2-4 weeks after beginning treatment; can send home with family because they are already exposed \(2) not required (3) important, but not as important as taking medication (4) correct-necessary to take medication for 6-9 months 89\. **A nurse is developing a discharge teaching plan for a client hospitalized following an acute exacerbation of reactive airway disease. When teaching the client how to prevent acute asthma attacks, what should the nurse plan to discuss first?** A. **Triggers that can precipitate an attack and how to eliminate them from the client\'s environment** B. **The client\'s perception of the disease process and what may have triggered the current attack** C. **The client\'s medication regimen, including the proper use of metered-dose inhalers** D. **Manifestation of respiratory infections and the importance of avoiding people who have infections:** Answer: B The client\'s perception of the disease process and what may have triggered the current attack Rationale: According to teaching/learning theory, the nurse must first assess the learner. This step gives the nurse valuable information about the client\'s knowledge and misconceptions about asthma and potential environmental triggers. TEST TAKING STRATEGY: This question requires prioritizing several choices that all seem correct. Since the question is about teaching the client, use teaching/learning theory to help prioritize the steps. (ATItesting.com/respiratory) 90\. **10. Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?** **A. A positive reaction indicates that the client has active tuberculosis (TB). B. A positive reaction indicates that the client has been exposed to the disease.** C. **A negative reaction always excludes the diagnosis of TB** D. **The PPD can be read within 12 hours after the injection:** Answer B Exposure 91. **A client with chronic obstructive pulmonary disease is in the third postoperative day following right-sided thoracotomy. During the day shift, the client has required 10 L oxygen by mask to keep his or her oxygen saturations greater than 88%. Based on this information, which action should be taken by the evening shift nurse?** 1. **work to wean oxygen therapy down to 3L by mask** 2. **call respiratory therapy for a nebulizer treatment** 3. **check respiratory rate and notify the physician** 4. **administer dose of ordered pain medications:** 3) check respiratory rate and notify the physician Rationale: The night shift nurse should check the client\'s respiratory rate and report abnormal findings to the physician. Although uncommon, clients with COPD on high flow oxygen can lose their respiratory drive. Tip: An option that includes an assessment is often the correct answer because the nursing process is driven by the information collected in an assessment. Ohman, K. (2010). Davis\'s Q&A for the NCLEX-RN examination. Philadelphia, PA: F.A. Davis. 92\. **While assessing the client the nurse notices that the clients chest tube has become dislodged. Which of the following actions should the nurse take first? A. Place the tubing into sterile water to restore the water seal.** B. **Apply sterile gauze to the site.** C. **Clamp all connections and call physician.** D. **Assess the clients respiratory status.:** Answer: B (Should be A) 93\. **A nurse assigned to care for multiple clients is reviewing the laboratory reports. Based on the information provided, which clients should the nurse assess first? Prioritize the order in which the nurse should plan to assess the clients.** 1. **A client diagnosed with renal insufficiency whose serum potassium level is 5.2 mEq/L** 2. **A client diagnosed with hyperemesis whose serum sodium level is 122 mEq/L** 3. **A client recovering following head trauma whose serum osmolality is 290 mOsm/kg** 4. **A client diagnosed with diabetes mellitus whose artierial blood gas results are pH=7.22, PCO2= 35 mm Hg, HCO3=15 mEq/L:** ANSWER: 4213 The first client to be assessed should be the client diagnosed with diabetes mellitus because the artierial blood gas results indicate metabolic acidosis. A compensatory mechanism will include Kussmaul respirations to eliminate excess acid. Airway assessment is priority, and further assessment is needed to determine the underlying cause for the metabolic acidosis. The client with hyperemesis is experiencing severe hyopnatremia with serum sodium below the normal range or 135 to 145 mEq/L and is at risk for seizures. Safety is the second priority. The client diagnosed with renal insufficiency, whose serum potassium level is 5.3 mEq/L, is the third client to be assessed. The serum potassium level is slightly above normal of 3.5 to 5.0 mEq/L. The client recovering following head trauma, whose serum osmolality is 290 mOsm/kg and has normal serum osmolality level, can be assessed last. This client is the most stable. 94\. **Which information given by an asthmatic patient during the admission assessment will be of most concern to the nurse?** a. **The patient says that the asthma symptoms are worse every spring.** b. **The patient\'s only asthma medications are albuterol (Proventil) and salme-terol (Serevent).** c. **The patient uses cromolyn (Intal) before any aerobic exercise.** d. **The patient\'s heart rate increases after using the albuterol (Proventil) in-haler.:** B Rationale: Long\--agonists should be used only in patients who are also using another medication for long-term control (typically an inhaled corticosteroid). Salmeterol should not be used as the first-line therapy for long-term control. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma. 95\. **A 2-year-old child is brought to the emergency department in respiratory distress. The child is drooling, sitting upright and leaning forward with chin thrust out, mouth open, and tongue protruding, which nursing intervention is most appropriate?** 1. **Check the child\'s gag reflex with a tongue blade.** 2. **Allow the child to cry to keep lungs expanded.** 3. **Check the airway for a foreign body obstruction** 4. **Support the child in an upright position.:** Answer: 4. the classic signs of epiglottitis are drooling, sitting upright, and leaning forward with chin thrust outward, mouth open, and tongue protruding. The child with epigolttits should be kept in an upright position to ease the work of breathing and to avoid aspiration of secretionss and obstruction of the airway by the swollen epiglottis. Placing the child on the lap of the parent may help reduce the child\'s anxiety. The gag reflex of a child with epiglottits should never be checked unless emergency personnel and equipment are immediately availabel to perform a tracheotomy if the airway should become obstructed by the swollen epiglottis. Likewise, crying and inspecting the airway for a foreign body may also cause entrapment of the epiglottis and obstruction of the airway. 96\. **The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should:** 1. **Apply a 100% non-rebreather mask.** 2. **Assess the vital signs.** 3. **Reposition the client.** 4. **Prepare for intubation.:** 2. Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation. 97\. **A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented?** 1. **seizure** 2. **infection** 3. **neutropenic** 4. **high-risk fall:** Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included. Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia. Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia. Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia. 98\. **A client presents to the ER following a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client\'s chest and torso, crepitus, and tachypnea.** **Based on this assessment, the nurse should?** A. **Assist with the placement of a cervical collar.** B. **Anticipate the need to intubate the client.** C. **Provide chest compressions.** D. **tapes the chest wall.:** Answer B. 99\. **An 80 year old client is living in an independent living facility with home health nursing support. The client is diagnosed with pneumonia and started on an oral antibiotic. Which nursing diagnosis would be most appropriate for this client?** 1. **Risk for imbalanced nutrition** 2. **Risk for fluid volume deficit** 3. **Fluid volume deficit** 4. **Fluid volume excess:** Answer: 2\-\--The diagnosis of pneumonia may result in fever or increased respiratory rate that increases amount of fluid lost. Additionally, older adults have a decreased sensation of thirst. 100\. **Which of the following physical assessment findings in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?** A. **Basilar crackles** B. **Respiratory rate of 28** C. **Oxygen Saturation 85%** D. **Presence of green sputum:** Answer: A. The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. 101\. **On the third post-burn day, the nurse finds that the client\'s hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:** A. **Decrease the rate of the intravenous infusion.** B. **Change the type of intravenous fluid being administered.** C. **Change the urinary catheter.** D. **Increase the rate of the intravenous infusion:** Correct answer D: Urine output should be between 30-50ml\'s per hour IV flow rate should be increased to try to increase the urine output per hour. 102\. **A nurse caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect?** a. **pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L** b. **pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3- 23 mEq/L** c. **pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3- 18 mEq/L** d. **pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L:** a. pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3- 24 mEq/L 103\. **A patient with COPD asks why the heart is affected by the respiratory disease. The nurse\'s response to the patient is based on the knowledge that cor pulmonale is characterized by** a. **pulmonary congestion secondary to left ventricular failure.** b. **excess serous fluid collection in the alveoli caused by retained respiratory secretions.** c. **right ventricular hypertrophy secondary to increased pulmonary vascular resistance.** d. **right ventricular failure secondary to compression of the heart by hyper inflated lungs.:** Correct Answer: C 104. **A nurse is caring for a patient who has pneumonia and has a perscription for prednisone. The nurse should monitor the client for which of the following?** **(Select all that apply) fluid retention tremors hyperglycemia fever black, tarry stools:** Answer: Fluid retention, hyperglycemia, fever, and black, tarry stools. Fluid retention and hyperglycemia are adverse effects of prednisone. The immunosuppresive action of prednisone places the client at risk for infection which can be signaled by the presence of fever. Prednisone can cause a peptic ulcer which may cause tarry stools. Tremors are side effects of theophylline (Theo-Dur), but not prednisone. 105. **24. A patient has been admitted to the medical floor with dry skin and mucous membranes, is weak, has orthostatic blood pressure changes, and has decreased urine output. The patients serum osmolality however is normal. Which of the following IV fluids would the nurse anticipate being prescribed for this patient?** **a. Lactated Ringers** **b.3% NaCl** c. **10% dextrose in water** d. **0.45% NaCl:** a. Lactated Ringers 106\. **A nurse is planning care for a child that has severe diarrhea. Which of the following is the priority nursing action? a. Introduce a regular diet** b. **Rehydrate** c. **Maintain fluid therapy** d. **Assess fluid balance:** d. Assess fluid balance 107\. **26. A nurse is providing discharge instructions for a client with a history of heart failure. Until a scale is obtained, which of the following instructions would be most helpful if the client does not have a scale at home to weigh on? a. Wear a name band alternating wrists and ankles to see if it gets tighter.** b. **Wear a ball cap every day to determine whether there is an increase in head circumference.** c. **Wear the same belt in the same location around the waist and alert the physician if the belt becomes tighter.** d. **Discuss taking extra medication if the client feels there is weight gain.:** c. Wear the same belt in the same location around the waist and alert the physician if the belt becomes tighter. 108\. **A patient who was found unconscious in a burning bedroom and has burns to the lower legs has been assessed by the nurse in the emergency department. The nurse notes that the patient\'s face is bright red. Which of these actions should the nurse take first? a. Elevate the legs on pillows.** b. **Place the patient on 100% oxygen using a non-breather mask.** c. **Assess for singed nasal hair and dark oral mucous membranes.** d. **Insert 2 large-bore IV lines.:** b. Place the patient on 100% oxygen using a non-breather mask. 109\. **28. A patient with severe burns has fluid replacement ordered using the Parkland formula. The initial rate of administration is 1050 ml/hr. The nurse would expect that 18 hours after the burn occurred, the rate of the fluid administration should be \_\_\_\_\_ ml/hr a. 263** b. **350** c. **525** d. **1050:** c. 525 110\. **After the dressing change, the client needs to be positioned in bed. Which of the following nursing interventions would the nurse identify as inappropriate nursing care for reducing contractures?** a. **Placing a pillow under the knee of a client with burns on the posterior legs.** b. **Splinting the affected extremity in a functional position.** c. **Daily physical therapy and range-of-motion exercises.** d. **Hyperextending the neck of a client with burns of the anterior chest and neck.:** a. Placing a pillow under the knee of a client with burns on the posterior legs. 111. **An elderly patient tells the nurse that she does not drink many fluids because he/she is on a water pill and does not want to harm what the water pill is supposed to do. Which of the following is the nurses best response to this patient?** a. **Limiting fluids will ensure that you will not be overhydrated.** b. **Just make sure you drink the things that you like, such as coffee and juice.** c. **It is not necessary for you to drink water throughout the day?** d. **Taking a water pill does not mean you should not drink fluids. You can become dehydrated.:** d. Taking a water pill does not mean you should not drink fluids. You can become dehydrated. 112\. **. During the acute period of burn care, the focus of care is to promote healing of full-thickness burn wounds. In order for this to occur, the wound must:** a. **Have decreased tissue perfusion.** b. **Be free of eschar.** c. **Have the edema decreased with diuretics.** d. **Be pain free.:** b. Be free of eschar. 113\. **The nurse anticipates that which of the following treatments would be used for a client who has a magnesium level of 2.8 mEq/L? a. Magnesium oxide (MagOx)** b. **Furosemide (Lasix).** c. **Milk of Magnesia** d. **Fluid restriction:** b. Furosemide (Lasix). 114\. **The home health nurse assesses an elderly client for a routine visit. As part of the assessment, the nurse will be evaluating skin turgor. The nurse remembers** a. **the skin will tent caused by overhydration.** b. **the skin will appear edematous and spongy caused by dehydration.** c. **The skin may be inelastic and is a normal part of aging.** d. **The skin will appear moist and boggy.:** c. The skin may be inelastic and is a normal part of aging. 115\. **The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when a. white blood cell levels decrease.** b. **blisters and edema have subsided.** c. **the patient has been hospitalized for 48 hours.** d. **the patient has large quantities of pale urine.:** d. the patient has large quantities of pale urine. 116\. **The nurse is caring for a client who has postoperative vomiting. Arterial blood gas results are: pH 7.47, pCO2 40, HCO3 33, pO2 84. Which of the following interventions should the nurse include in the plan of care to restore acid base balance?** a. **Administer an antibiotic for infection** b. **Administer an antiemetic agent** c. **Encourage the patient to use an incentive spirometer** d. **Administer oxygen at 2 liters by nasal cannula:** b. Administer an antiemetic agent 117\. **Which serum potassium level would the nurse anticipate seeing in an elderly patient with a three day history of vomiting and ileostomy drainage? a. 3.4 mEq/L** b. **3.0 mEq/L** c. **5.8 mEq/L** d. **6.0 mEq/L:** b. 3.0 mEq/L 118\. **The nurse is planning the care of a patient diagnosed with hyperkalemia.** **Which of the following should be included in this patients plan of care? a. Providing oral Kayexalate as prescribed** b. **Dietary consult to select foods low in calcium** c. **Dietary consult to select foods high in sodium** d. **Maintain fluid restriction:** a. Providing oral Kayexalate as prescribed 119\. **The nurse is providing fluid replacement for a client with burns on 50% of his total body surface area. It has been 16 hours since the time the burn occurred. The clients blood pressure is 82/58 mm Hg, pulse is 130 beats/minute, urine output is 25 ml during the past hour. What orders should the nurse expect to receive from the physician?** a. **Maintain the IV fluids at the current rate and continue with ongoing assess-ment including vital signs and urine output for the next 8 hours.** b. **Decrease the IV fluids rate and continue with ongoing assessment including vital signs and urine output for the next 8 hours.** c. **Administer pain medication and continue with ongoing assessment includ-ing vital signs and urine output for the next 8 hours.** d. **Increase the IV fluids and continue with ongoing assessment including vital signs and urine output hourly for the next 8 hours:** d. Increase the IV fluids and continue with ongoing assessment including vital signs and urine output hourly for the next 8 hours 120\. **The nurse reviews the patients arterial blood gas (ABG) and interprets it as uncompensated, respiratory alkalosis. Which of the following ABG readings supports the nurses interpretation?** a. **pH 7.55, Hco3- of 26mEq/L, Pco2 of 50 mmHg** b. **pH 7.50, HCo3- of 25mEq/L, Pco2 of 30 mm Hg** c. **pH 7.45, Hco3- of 21 mEq/L, Pco2 of 30 mm Hg** d. **pH 7.47, Hc03- of 35 mEq/L, Pco2- of 47 mm Hg:** b. pH 7.50, HCo3- of 25mEq/L, Pco2 of 30 mm Hg 121\. **. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as a. full-thickness skin destruction.** b. **deep full-thickness skin destruction.** c. **deep partial-thickness skin destruction.** d. **superficial partial-thickness skin destruction:** c. deep partial-thickness skin destruction. 122\. **Which complication of burn injuries is common to all three periods of burn management for a client with a major injury? a. Wound infection** **b.Psychological problems.** c. **Contractures** d. **Stress ulcers:** b.Psychological problems. 123\. **A client who is having burn debridement states, \"You are the worst nurse I have ever seen. All you do is hurt me\". Which of the following responses by the nurse is appropriate?** a. **\"Do I cause more pain than the other nurses\"?** b. **\"Tell me more about that\".** c. **\"Let me get you more pain medication\".** d. **\"You have the right to your judgments\".:** b. \"Tell me more about that\". 124\. **A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client\'s total body surface area (TBSA)? a. 9 percent** b. **18 percent** c. **36 percent** d. **54 percent:** d. 54 percent 125\. **What is the nurse\'s primary concern regarding fluid & electrolytes when caring for an elderly patient who is intermittently confused?** a. **risk of dehydration** b. **risk of kidney damage** c. **risk of stroke** d. **risk of bleeding:** a. risk of dehydration 126\. **The nurse is planning care for a patient with severe burns. Which of the following is this patient at risk for developing?** a. **intracellular fluid deficit** b. **intracellular fluid overload** c. **extracellular fluid deficit** d. **interstitial fluid deficit:** a. intracellular fluid deficit 127\. **A patient, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following?** a. **the body\'s natural compensatory mechanisms.** b. **pharmacological effects of a diuretic.** c. **effects of rapidly infused intravenous fluids** d. **cardiac failure.:** a. the body\'s natural compensatory mechanisms. -The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. 128\. **A pregnant patient is admitted with excessive thirst, increased urination, and has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate?** a. **Risk for Imbalanced Fluid Volume** b. **Excess Fluid Volume** c. **Imbalanced Nutrition** d. **Ineffective Tissue Perfursion:** a. Risk for Imbalanced Fluid Volume -The patient with excessive thirst, increased urination and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the patient\'s excess volume loss that can increase the serum levels of sodium. 129\. **A patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patient\'s primary HCP with which of the following 24-hour urine output volumes?** a. **600 mL** b. **750 mL** c. **1000 mL** d. **1200 mL:** a. 600 mL 130\. **A patient is receiving IV fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? a. fluid volume excess** b. **fluid volume deficit** c. **seizure activity** d. **liver failure:** a. fluid volume excess 131\. **A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will most likely need which of the following precautions implemented? a. seizure** b. **infection** c. **neutropenic** d. **high-risk fall:** a. seizure -Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, and having an oral airway at the bedside would be included. 132\. **A patient is diagnosed with hypokalemia. After reviewing the patient\'s current medication, which of the following might have contributed to the patient\'s health problem?** a. **corticosteroid** b. **thiazide diuretic** c. **narcotic** d. **muscle relaxer:** a. corticosteroid -excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, and large doses of some antibiotics. 133\. **A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which of the following?** a. **hyperkalemia** b. **hypokalemia** c. **hypercalcemia** d. **hypocalcemia:** a. hyperkalemia -Hyperkalemia is serum potassium lever greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness and ECG changes. 134. **The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which of the following should be included in this patient\'s plan of care?** a. **Restrict fluids** b. **Administer IV fluids** c. **Provide Kayexalate** d. **Administer IV NS with furosemide:** a. Restrict fluids -The nursing care for a patient with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution. 135\. **When caring for a patient diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the patient?** a. **other electrolyte disturbances** b. **hypertension** c. **visual disturbances** d. **drug toxicity:** a. other electrolyte disturbances -The patient diagnosed with hypocalcemia may also have a high phosphorus or decreased magnesium levels. 136\. **A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this patient\'s plan of care?** a. **Request a dietitian consult for selecting foods high in phosphorous.** b. **Provide aluminum hydroxide antacids as prescribed.** c. **Instruct patient to avoid poultry, peanuts, and seeds.** d. **Instruct to avoid the intake of sodium phosphate.:** a. Request a dietitian consult for selecting foods high in phosphorous. -Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds and whole grains. 137\. **When analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms?** a. **The kidneys retain bicarbonate.** b. **The kidneys excrete bicarbonate.** c. **The lungs will retain carbon dioxide.** d. **The lunch will excrete carbon dioxide.:** a. The kidneys retain bicarbonate. -The kidneys will compensate for a reparatory disorder by retaining bicarbonate. 138. **The nurse is caring for a patient diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in patients with renal failure?** a. **The patient breathes rapidly to eliminate carbon dioxide.** b. **The patient will retain bicarbonate in excess of normal.** c. **The pH will decrease from the present value.** d. **The patient\'s oxygen saturation level will improve.:** a. The patient breathes rapidly to eliminate carbon dioxide. -In metabolic acidosis compensation is accomplished through increased ventilation or \"blowing off\" CO2. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis. 139\. **When caring for a group of patients, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis? a. bulimia** b. **dialysis** c. **venous stasis ulcer** d. **COPD:** a. bulimia -Metabolic alkalosis is caused by vomiting, diuretic therapy or nasogastric suction, among others. A patient with bulimia may engage in vomiting or indiscriminate use of diuretics. 140\. **The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. The nurse would anticipate which initial intervention to correct this problem?** a. **Encourage the patient to breathe in and out slowly into a paper bag.** b. **Immediately administer oxygen via a mask and monitor oxygen saturation.** c. **Prepare to start an IV fluid bolus using isotonic fluids.** d. **Anticipate the administration of IV sodium bicarbonate.:** a. Encourage the patient to breathe in and out slowly into a paper bag. -The patient is exhibiting signs of hyperventilation that is confirmed with