Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
A) Weak, nonproductive cough effort
B) Large amounts of greenish sputum
C) Respiratory rate of 28 breaths/minute
D) Resting pulse oximetry (SpO2) of 85%
Answer: A
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
Answer: A
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance?
A) Assist the patient to splint the chest when coughing.
B) Teach the patient about the need for fluid restrictions.
C) Encourage the patient to wear the nasal oxygen cannula.
D) Instruct the patient on the pursed lip breathing technique.
Answer: A
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 vaccines.
D) I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks
Answer: B
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
Answer: B
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 patients white blood cell (WBC) count is 9000/L.
D) Increased tactile fremitus is palpable over the right chest.
Answer: C
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
A) Teach about the reason for the blood tests.
B) Schedule an appointment for a chest x-ray.
C) Teach about the need to get sputum specimens for 2 to 3 consecutive days.
D) Instruct the patient to expectorate three specimens as soon as possible
Answer: C
A patient is admitted with active tuberculosis (TB). The nurse should question a health care providers 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.
Answer: D
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.
Answer: B
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.
Answer: C
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
Answer: A
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.
Answer: D
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
Answer: B
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-Gurin (BCG) vaccine
Answer: C
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 patients room.
Answer: B
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?
A) Treat workers with pulmonary fibrosis.
B) Teach about symptoms of lung disease.
C) Require the use of protective equipment.
D) Monitor workers for coughing and wheezing.
Answer: C
The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include?
A) Options for smoking cessation
B) Reasons for annual sputum cytology testing
C) Erlotinib (Tarceva) therapy to prevent tumor risk
D) Computed tomography (CT) screening for lung cancer
Answer: A
A lobectomy is scheduled for a patient with stage I nonsmall cell lung cancer. The patient tells the nurse, I would rather have chemotherapy than surgery. Which response by the nurse is most appropriate?
A) Are you afraid that the surgery will be very painful?
B) Did you have bad experiences with previous surgeries?
C) Surgery is the treatment of choice for stage I lung cancer.
D) Tell me what you know about the various treatments available.
Answer: D
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?
A) Milk the chest tube gently to remove any clots.
B) Clamp the chest tube momentarily to check for the origin of the air leak.
C) Assist the patient to deep breathe, cough, and use the incentive spirometer.
D) Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
Answer: D
A patient with newly diagnosed lung cancer tells the nurse, I don't think I'm going to live to see my next birthday. Which response by the nurse is best?
A) Would you like to talk to the hospital chaplain about your feelings?
B) Can you tell me what it is that makes you think you will die so soon?
C) Are you afraid that the treatment for your cancer will not be effective?
D) Do you think that taking an antidepressant medication would be helpful?
Answer: B
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
A) A large air leak in the water-seal chamber
B) 400 mL of blood in the collection chamber
C) Complaint of pain with each deep inspiration
D) Subcutaneous emphysema at the insertion site
Answer: B
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
A) Paradoxic chest movement
B) Complaint of chest wall pain
C) Heart rate of 110 beats/minute
D) Large bruised area on the chest
Answer: A
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
A) Emergency pericardiocentesis
B) Stabilization of the chest wall with tape
C) Administration of an inhaled bronchodilator
D) Insertion of a chest tube with a chest drainage system
Answer: D
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction control chamber of the collection device. Which action by the nurse is most appropriate?
A) Document the presence of a large air leak.
B) Notify the surgeon of a possible pneumothorax.
C) Take no further action with the collection device.
D) Adjust the dial on the wall regulator to decrease suction
Answer: C
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patients postoperative care?
A) Positioning on the right side
B) Bed rest for the first 24 hours
C) Frequent use of an incentive spirometer
D) Chest tube placement with continuous drainage
Answer: C
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?
A) Observe for distended neck veins.
B) Auscultate for crackles in the lungs.
C) Palpate for heaves or thrills over the heart.
D) Review hemoglobin and hematocrit values.
Answer: A
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patients condition is improving?
A) Blood pressure (BP) is less than 140/90 mm Hg.
B) Patient reports decreased exertional dyspnea.
C) Heart rate is between 60 and 100 beats/minute.
D) Patients chest x-ray indicates clear lung fields.
Answer: B
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
A) Start a peripheral IV line to administer the necessary sedative drugs.
B) Position the patient sitting upright on the edge of the bed and leaning forward.
C) Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time.
D) Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
Answer: B
The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?
A) I will make an appointment to see the doctor every year.
B) I will stop taking the prednisone if I experience a dry cough.
C) I will not worry if I feel a little short of breath with exercise.
D) I will call the health care provider right away if I develop a fever.
Answer: D
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
Answer: B
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
A) Oxygen saturation is 88%.
B) Blood pressure is 145/90 mm Hg.
C) Respiratory rate is 22 breaths/minute when lying flat.
D) Pain level is 5 (on 0 to 10 scale) with a deep breath.
Answer: A
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)
Answer: D
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.
Answer: C
A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
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
Answer: D
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 patients 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 patients bed to 15 degrees.
Answer: D
A patient with a possible pulmonary embolism complains of chest pain
and difficulty breathing. The nurse finds a heart rate of 142
beats/minute, blood pressure of 100/60 mmHg, and respirations of 42
breaths/minute.
Which action should the nurse take first?
A) Administer anticoagulant drug therapy.
B) Notify the patients health care provider.
C) Prepare patient for a spiral computed tomography (CT).
D) Elevate the head of the bed to a semi-Fowlers position.
Answer: D
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)
Answer: B
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-Gurin (BCG) vaccine for TB?
Answer: D
A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?
A) Position the patient so that the left chest is dependent.
B) Tape a nonporous dressing on three sides over the chest wound.
C) Cover the sucking chest wound firmly with an occlusive dressing.
D) Keep the head of the patients bed at no more than 30 degrees elevation.
Answer: B
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?
A) Assist the patient to sit upright in a chair.
B) Splint the patients chest during coughing.
C) Medicate the patient with prescribed morphine.
D) Observe the patient use the incentive spirometer.
Answer: C
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
A) The oxygen saturation is 94%.
B) The blood pressure is 98/56 mm Hg.
C) The patients central IV line is disconnected.
D) The international normalized ratio (INR) is prolonged.
Answer: C
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) whenever I take a deep breath. Which action will the nurse take next?
A) Auscultate breath sounds.
B) Administer the PRN morphine.
C) Have the patient cough forcefully.
D) Notify the patients health care provider.
Answer: A
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
A) Purpose of antibiotic therapy
B) Ways to limit oral fluid intake
C) Appropriate use of cough suppressants
D) Safety concerns with home oxygen therapy
Answer: C
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
Answer: C
An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?
A) Listening to the patients lung sounds several times during the shift
B) Placing the patient on droplet precautions and in a private hospital room
C) Increasing the oxygen flow rate to keep the oxygen saturation above 90%
D) Monitoring patient serology results to identify the specific infecting organism
Answer: B
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?
A) Teach the patient to avoid the use of over-the-counter expectorants.
B) Assist the patient with chest physiotherapy and postural drainage.
C) Notify the health care provider immediately about any bloody or foul-smelling sputum.
D) Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
Answer: D
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
A) I am going to buy a rib binder to wear during the day.
B) I can take shallow breaths to prevent my chest from hurting.
C) I should plan on taking the pain pills only at bedtime so I can sleep.
D) I will use the incentive spirometer every hour or two during the day.
Answer: D
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
A) Document the amount of drainage every eight hours.
B) Obtain samples of drainage for culture from the system.
C) Assess patient pain level associated with the chest tube.
D) Check the water-seal chamber for the correct fluid level.
Answer: A
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
Answer: D