NURS 3000 Exam test quiz and
answers graded A+
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, non-productive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85% - ANS✅✅ANS: A
The weak, non-productive 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
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 - ANS✅✅ANS: A
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. A grating
sound is
more representative of a pleural friction rub rather than pneumonia
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's 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 - ANS✅✅ANS: A
,Coughing is less painful and more likely to be effective when the patient splints the chest during
coughing.
Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but
will not
improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with
COPD, but
will not improve airway clearance.
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. Ill cancel my chest x-ray appointment if Im feeling better in a couple week - ANS✅✅ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several
weeks. The
Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a
follow-up
chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia
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 problem - ANS✅✅ANS: B
The risk for aspiration is decreased when patients with a decreased level of consciousness are placed
in a side-
lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but
will not
decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds
and oxygen
saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the
risk for
,aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness
(e.g.,
seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, 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. Other high-risk groups are those who are seriously ill, have poor dentition, or
are
receiving acid-reducing medications
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 - ANS✅✅ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest
that a
change in treatment is needed.
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 - ANS✅✅ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for
M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not
used for tuberculosis testing. A
chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are
important, it is
not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases
can mimic
the appearance of TB.
, 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 - ANS✅✅ANS: D
Negative sputum smears indicate that
Mycobacterium tuberculosis
is not present in the sputum, and the patient
cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether
treatment
has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms
of the
disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be
done because
the result will not change even with effective treatment
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 - ANS✅✅NS: C
Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To
promote gas
exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization
decreases the
risk for postoperative complications such as pneumonia and deep vein thrombosis. In a
pneumonectomy, chest
tubes may or may not be placed in the space from which the lung was removed. If a chest tube is
used, it is
answers graded A+
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, non-productive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85% - ANS✅✅ANS: A
The weak, non-productive 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
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 - ANS✅✅ANS: A
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. A grating
sound is
more representative of a pleural friction rub rather than pneumonia
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's 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 - ANS✅✅ANS: A
,Coughing is less painful and more likely to be effective when the patient splints the chest during
coughing.
Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but
will not
improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with
COPD, but
will not improve airway clearance.
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. Ill cancel my chest x-ray appointment if Im feeling better in a couple week - ANS✅✅ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several
weeks. The
Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a
follow-up
chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia
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 problem - ANS✅✅ANS: B
The risk for aspiration is decreased when patients with a decreased level of consciousness are placed
in a side-
lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but
will not
decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds
and oxygen
saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the
risk for
,aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness
(e.g.,
seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, 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. Other high-risk groups are those who are seriously ill, have poor dentition, or
are
receiving acid-reducing medications
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 - ANS✅✅ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest
that a
change in treatment is needed.
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 - ANS✅✅ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for
M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not
used for tuberculosis testing. A
chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are
important, it is
not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases
can mimic
the appearance of TB.
, 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 - ANS✅✅ANS: D
Negative sputum smears indicate that
Mycobacterium tuberculosis
is not present in the sputum, and the patient
cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether
treatment
has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms
of the
disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be
done because
the result will not change even with effective treatment
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 - ANS✅✅NS: C
Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To
promote gas
exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization
decreases the
risk for postoperative complications such as pneumonia and deep vein thrombosis. In a
pneumonectomy, chest
tubes may or may not be placed in the space from which the lung was removed. If a chest tube is
used, it is
