Complex Care Final Exam Practice Questions
The nurse is caring for a patient with pneu monia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic?
a. Teach the patient to cough and deep breathe.
b. Take the temperature, pulse, and respiratory rate.
c. Obtain a sputum specimen for culture and Gram stain.
d. Check the patient's oxygen saturation by pulse oximetry. - /nc. Obtain a sputum specimen for culture and Gram stain.
A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.
The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required?
a. "I will be given amphotericin B to treat the fungus."
b. "I got this fungus because I am immunocompromised."
c. "I need to be isolated from my family and friends so they won't get it."
d. "The effectiveness of my therapy can be monitored with fungal serology titers." - /nc. "I need to be isolated from my family and friends so they won't get it."
The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.
A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis?
a. Lobectomy surgery is usually needed to drain the abscess.
b. IV antibiotic therapy will be used for a 6-month period of time.
c. Oral antibiotics will be used until there is evidence of improvement.
d. Culture and sensitivity tests are needed for 1 year after resolving the abscess - /nc. Oral antibiotics will be used until there is evidence of improvement.
IV antibiotics are used until the patient and radiographs show evidence of improvement.
Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.
The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)?
a. Maintain adequate fluid intake.
b. Maintain a 30-degree elevation.
c. Splint the chest when coughing.
d. Maintain a semi-Fowler's position.
e. Instruct patient to cough at end of exhalation. - /na. Maintain adequate fluid intake.
c. 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.
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 infections."
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." - /nd. "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 examination 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.
The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient?
a. Positioning patient on right side
b. Maintaining adequate fluid intake
c. Positioning patient with "good lung" down
d. Performing postural drainage every 4 hours - /nc. Positioning patient with "good lung"
down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment
warrants follow-up nursing actions?
a. Water-seal chamber has 5 cm of water.
b. No new drainage in collection chamber
c. Chest tube with a loose-fitting dressing
d. Small pneumothorax at CT insertion site - /nc. Chest tube with a loose-fitting dressing
If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive?
a. Pneumococcal
b. Staphylococcus aureus
c. Haemophilus influenzae
d. Bacille-Calmette-Guérin (BCG) - /na. Pneumococcal
The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, 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 is prevalent.
While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate?
a. Continue with ambulation.
b. Obtain a physician's order for arterial blood gas.
c. Obtain a physician's order for supplemental oxygen.
d. Move the oximetry probe from the finger to the earlobe - /nc. Obtain a physician's order for supplemental oxygen.
An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.
The nurse is caring for a group of patients. Which patient is at risk of aspiration?
a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery
b. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia
c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube
d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields - /nc. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube
Conditions that increase the risk of aspiration include decreased level of consciousness,
difficulty swallowing (dysphagia), 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. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.
A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient?
a. Pulmonary infarction
b. Pulmonary hypertension
c. Cytomegalovirus (CMV)
d. Bronchiolitis obliterans (BOS) - /nd. Bronchiolitis obliterans (BOS)
BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough,
wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to
the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.
The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance?
a. Basilar crackles
b. Oxygen saturation of 85%
c. Presence of greenish sputum
d. Respiratory rate of 28 breaths/min - /na. 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
The nurse is caring for a patient with pneu monia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic?
a. Teach the patient to cough and deep breathe.
b. Take the temperature, pulse, and respiratory rate.
c. Obtain a sputum specimen for culture and Gram stain.
d. Check the patient's oxygen saturation by pulse oximetry. - /nc. Obtain a sputum specimen for culture and Gram stain.
A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.
The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required?
a. "I will be given amphotericin B to treat the fungus."
b. "I got this fungus because I am immunocompromised."
c. "I need to be isolated from my family and friends so they won't get it."
d. "The effectiveness of my therapy can be monitored with fungal serology titers." - /nc. "I need to be isolated from my family and friends so they won't get it."
The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.
A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis?
a. Lobectomy surgery is usually needed to drain the abscess.
b. IV antibiotic therapy will be used for a 6-month period of time.
c. Oral antibiotics will be used until there is evidence of improvement.
d. Culture and sensitivity tests are needed for 1 year after resolving the abscess - /nc. Oral antibiotics will be used until there is evidence of improvement.
IV antibiotics are used until the patient and radiographs show evidence of improvement.
Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.
The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)?
a. Maintain adequate fluid intake.
b. Maintain a 30-degree elevation.
c. Splint the chest when coughing.
d. Maintain a semi-Fowler's position.
e. Instruct patient to cough at end of exhalation. - /na. Maintain adequate fluid intake.
c. 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.
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 infections."
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." - /nd. "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 examination 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.
The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient?
a. Positioning patient on right side
b. Maintaining adequate fluid intake
c. Positioning patient with "good lung" down
d. Performing postural drainage every 4 hours - /nc. Positioning patient with "good lung"
down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment
warrants follow-up nursing actions?
a. Water-seal chamber has 5 cm of water.
b. No new drainage in collection chamber
c. Chest tube with a loose-fitting dressing
d. Small pneumothorax at CT insertion site - /nc. Chest tube with a loose-fitting dressing
If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive?
a. Pneumococcal
b. Staphylococcus aureus
c. Haemophilus influenzae
d. Bacille-Calmette-Guérin (BCG) - /na. Pneumococcal
The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, 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 is prevalent.
While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate?
a. Continue with ambulation.
b. Obtain a physician's order for arterial blood gas.
c. Obtain a physician's order for supplemental oxygen.
d. Move the oximetry probe from the finger to the earlobe - /nc. Obtain a physician's order for supplemental oxygen.
An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.
The nurse is caring for a group of patients. Which patient is at risk of aspiration?
a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery
b. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia
c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube
d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields - /nc. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube
Conditions that increase the risk of aspiration include decreased level of consciousness,
difficulty swallowing (dysphagia), 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. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.
A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient?
a. Pulmonary infarction
b. Pulmonary hypertension
c. Cytomegalovirus (CMV)
d. Bronchiolitis obliterans (BOS) - /nd. Bronchiolitis obliterans (BOS)
BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough,
wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to
the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.
The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance?
a. Basilar crackles
b. Oxygen saturation of 85%
c. Presence of greenish sputum
d. Respiratory rate of 28 breaths/min - /na. 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
