Chapter 30: Nursing Management: Lower Respiratory Problems Lewis et al.: Medical-Surgical Nursing in Canada, 3rd Edition exam 1 Already Passed!!

1. Following assessment of a patient with pneumonia, the nurse documents a nursing diagnosis of ineffective airway clearance. On which of the following data would the nurse base this nursing diagnosis? a. SpO2 of 85% b. Respiratory rate of 28 breaths/min c. Presence of greenish sputum d. Weak, nonproductive cough - ANS: D The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. PTS: 1 DIF: Cognitive Level: Application REF: page 667, Nursing Care Plan 30-1 OBJ: 2 TOP: Nursing Process: Diagnosis MSC: CRNE: CH-15 2. A 56-year-old normally healthy patient at the clinic is diagnosed with community-acquired pneumonia. The nurse anticipates that empirical treatment of the patient could include the administration of which of the following medications? a. Ciprofloxacin (Cipro) b. Azithromycin (Zithromax) c. Trimethoprim-sulfamethoxazole (Bactrim) d. A second- or third-generation cephalosporin - ANS: B Early initiation of appropriate antibiotic therapy has been demonstrated to reduce mortality. The treatment of choice is a macrolide (erythromycin, azithromycin, or clarithromycin). PTS: 1 DIF: Cognitive Level: Comprehension REF: page 665 OBJ: 1 TOP: Nursing Process: Planning MSC: CRNE: CH-443. During assessment of the chest in a patient with pneumococcal pneumonia, what would the nurse expect to find? a. Hyperresonance on percussion b. Increased tactile fremitus on palpation c. Fine crackles in all lobes on auscultation d. Asymmetrical chest expansion on inspection - ANS: B