and Answers| Latest Update
A 66yr old male is found to have hospital acquired pneumonia, which of the following
statements made by the nurse indicates the correct understanding of HAP?
1. Occurring after inter-tracheal intubation
2. Occurring 48hrs or longer after admission
3. Onset before hospitalization
4. Occurring from normal entry of secretions into the lower airway 2. Occurring 48hrs or
longer after admission
There is a 48hr window following a patients admission to determine whether a patient came into
the hospital with a condition or infection. After this period, it is determined that it was acquired
while the patient was in the hospital setting.
The nurse obtains the following assessment data for a 76yr old patient who has influenza. Which
information would be most important to indicate to your provider?
1. Diffused crackles in the lungs
2. Fever of 100.4 F
3. A sore throat and frequent cough
4.. Malaise and persistent headache 1. Diffused crackles in the lungs
, Abnormal lung sounds are not expected for a patient who has influenza. While a fever, sore
throat, and headache/malaise are symptoms.
A patient with acute dyspnea is scheduled for a CT scan. Which information obtained by the
nurse is important to tell the healthcare provider before they have a CT?
1. The RR is 22
2. O2 saturation is 93%
3. Apical pulse is 102
4. The patient is allergic to shellfish 4. The patient is allergic to shellfish
An allergy to shellfish usually means the patient will also be allergic to iodine. The healthcare
provider must be made aware before they expose the patient to the iodine solution.
A patient with COPD has a nursing diagnosis of impaired breathing pattern. Which nursing
action would be most important o include in your plan of care?
1. Keep the patient NPO
2. Teach the patient how to effectively use pursed lip breathing
3. Titrate O2 to keep the saturation greater than 96%
4. Discuss a high protein, high carb diet with the patient 2. Teach the patient how to
effectively use pursed lip breathing