NUR 372 - EXAM 2 PRACTICE QUESTIONS AND
ANSWERS
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% - Answer -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.
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. - Answer -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.
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. - Answer -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.
The nurse is assessing a client diagnosed with cellulitis of the upper left arm. Which
manifestation should the nurse anticipate finding with this client? (Select all that apply.)
A. Deep, firm, painful nodule
, B. Swollen lymph glands
C. Fever and chills
D. Pustules with surrounding erythema
E. Erythema - Answer -B,C,E
B. Swollen lymph glands
C. Fever and chills
E. Erythema
Cellulitis may present with systemic symptoms, such as swollen lymph glands, which
signal an attempt to eliminate excessive localized fluid through the lymphatic system.
Fever and chills, which are a physiological attempt to eliminate the responsible
pathogen from the body, may also be present. Erythema is characteristic of cellulitis.
Pustules with surrounding erythema represent folliculitis, not cellulitis. Deep, firm,
painful nodules describe furuncles.
The nurse is performing a health history for a new client in the clinic. Which should the
nurse identify as a risk factor for cellulitis in an adult? (Select all that apply.)
A. Obesity
B. Peripheral vascular disease
C. Diabetes mellitus
D. Hypertension
E. Impetigo - Answer -A,B,C
A. Obesity
B. Peripheral vascular disease
C. Diabetes mellitus
Diabetes, peripheral vascular disease, and obesity are all risk factors for cellulitis in the
adult. Impetigo is a risk factor for cellulitis in children, not adults. Hypertension is not a
risk factor.
The nurse is performing a health history on a client with cellulitis that developed from a
hand wound. Which factor will help determine the organism responsible for the
cellulitis? (Select all that apply.)
A. History of diabetes
B. Cause of wound
C. Wound exposure to contaminated water
D. Current medications
E. History of cellulitis - Answer -B,C
B. Cause of wound
C. Wound exposure to contaminated water
The cause of the wound (for example, bite, cut, surgery, other injury) and wound
exposure to contaminated water will help determine the causative organism and choice
of antibiotic. A history of cellulitis or diabetes and current medications will help guide
treatment but will not help determine the causative organism.
The nurse examines a wound on a client with a history of cellulitis. Which manifestation
suggests cellulitis?
A. Intact skin with nonblanchable redness and elevated borders
ANSWERS
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% - Answer -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.
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. - Answer -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.
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. - Answer -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.
The nurse is assessing a client diagnosed with cellulitis of the upper left arm. Which
manifestation should the nurse anticipate finding with this client? (Select all that apply.)
A. Deep, firm, painful nodule
, B. Swollen lymph glands
C. Fever and chills
D. Pustules with surrounding erythema
E. Erythema - Answer -B,C,E
B. Swollen lymph glands
C. Fever and chills
E. Erythema
Cellulitis may present with systemic symptoms, such as swollen lymph glands, which
signal an attempt to eliminate excessive localized fluid through the lymphatic system.
Fever and chills, which are a physiological attempt to eliminate the responsible
pathogen from the body, may also be present. Erythema is characteristic of cellulitis.
Pustules with surrounding erythema represent folliculitis, not cellulitis. Deep, firm,
painful nodules describe furuncles.
The nurse is performing a health history for a new client in the clinic. Which should the
nurse identify as a risk factor for cellulitis in an adult? (Select all that apply.)
A. Obesity
B. Peripheral vascular disease
C. Diabetes mellitus
D. Hypertension
E. Impetigo - Answer -A,B,C
A. Obesity
B. Peripheral vascular disease
C. Diabetes mellitus
Diabetes, peripheral vascular disease, and obesity are all risk factors for cellulitis in the
adult. Impetigo is a risk factor for cellulitis in children, not adults. Hypertension is not a
risk factor.
The nurse is performing a health history on a client with cellulitis that developed from a
hand wound. Which factor will help determine the organism responsible for the
cellulitis? (Select all that apply.)
A. History of diabetes
B. Cause of wound
C. Wound exposure to contaminated water
D. Current medications
E. History of cellulitis - Answer -B,C
B. Cause of wound
C. Wound exposure to contaminated water
The cause of the wound (for example, bite, cut, surgery, other injury) and wound
exposure to contaminated water will help determine the causative organism and choice
of antibiotic. A history of cellulitis or diabetes and current medications will help guide
treatment but will not help determine the causative organism.
The nurse examines a wound on a client with a history of cellulitis. Which manifestation
suggests cellulitis?
A. Intact skin with nonblanchable redness and elevated borders
