NURS 219 – Exam 1, Nursing Course, Study Guide and Foundational Concepts
Review
A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient? - ANS ✔✔Perform a respiratory system
assessment and ask specific questions about this episode of respiratory distress.
When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the
nurse position the patient? - ANS ✔✔Sitting upright with the arms supported on an over bed
table.
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the
nurse would expect the patient to have? - ANS ✔✔Kussmaul respirations.
On auscultation of a patient's lungs, the nurse hears short, high-pitched sounds during
exhalation in the lower 1/3 of both lungs. The nurse records this finding as? - ANS
✔✔Expiratory wheezes in both lungs.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of
ineffective airway clearance. Which information best supports this diagnosis? - ANS ✔✔Weak,
nonproductive cough effort.
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would
expect to find? - ANS ✔✔increased tactile fremitus.
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse
use to promote airway clearance? - ANS ✔✔Assist the patient to splint the chest when
coughing.
,Which statement by a patient who has been hospitalized for pneumonia indicates a good
understanding of the discharge instructions given by the nurse? - ANS ✔✔"I will continue to do
the deep breathing and coughing exercises at home."
Which nursing action will be most effective in preventing aspiration pneumonia in patients who
are at risk? - ANS ✔✔Place patients with altered consciousness in side-lying positions.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV)
antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment
has been effective? - ANS ✔✔The patient's white blood cell (WBC) count is 9000/µl.
The health care provider writes an order for bacteriologic testing for a patient who has a
positive tuberculosis skin test. Which action will the nurse take? - ANS ✔✔Obtain consecutive
sputum specimens from the patient for 3 days.
Which information about a patient who has a recent history of tuberculosis (TB) indicates that
the nurse can discontinue airborne isolation precautions? - ANS ✔✔Three sputum smears for
acid-fast bacilli are negative.
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary
tuberculosis (TB) have been met when the patient with TB: - ANS ✔✔covers the mouth and
nose when coughing.
Which information will the nurse include in the patient teaching plan for a patient who is
receiving rifampin (Rifadin) for treatment of tuberculosis? - ANS ✔✔"Your urine, sweat, and
tears will be orange colored."
When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB)
about possible toxic effects of the antitubercular medications, the nurse will give instructions to
notify the health care provider if the patient develops: - ANS ✔✔yellow-tinged skin.
, An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which
intervention by the nurse will be most effective in ensuring adherence with the treatment
regimen? - ANS ✔✔Arranging for a daily noontime meal at a community center and giving the
medication then.
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient
continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the
nurse take next? - ANS ✔✔Ask the patient whether medications have been taken as directed.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is
negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on
teaching the staff nurse about the: - ANS ✔✔use and side effects of isoniazid (INH).
Which action by the occupational health nurse at a manufacturing plant where there is
potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? -
ANS ✔✔Require the use of protective equipment.
When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking,
it will be most important for the nurse to include information about: - ANS ✔✔options for
smoking cessation.
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells
the nurse, "I would rather have radiation than surgery." Which response by the nurse is most
appropriate? - ANS ✔✔"Tell me what you know about the various treatments available."
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has
decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage
and a large air leak. Which action is best for the nurse to take next? - ANS ✔✔Administer the
prescribed PRN morphine.
Review
A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient? - ANS ✔✔Perform a respiratory system
assessment and ask specific questions about this episode of respiratory distress.
When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the
nurse position the patient? - ANS ✔✔Sitting upright with the arms supported on an over bed
table.
A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the
nurse would expect the patient to have? - ANS ✔✔Kussmaul respirations.
On auscultation of a patient's lungs, the nurse hears short, high-pitched sounds during
exhalation in the lower 1/3 of both lungs. The nurse records this finding as? - ANS
✔✔Expiratory wheezes in both lungs.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of
ineffective airway clearance. Which information best supports this diagnosis? - ANS ✔✔Weak,
nonproductive cough effort.
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would
expect to find? - ANS ✔✔increased tactile fremitus.
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse
use to promote airway clearance? - ANS ✔✔Assist the patient to splint the chest when
coughing.
,Which statement by a patient who has been hospitalized for pneumonia indicates a good
understanding of the discharge instructions given by the nurse? - ANS ✔✔"I will continue to do
the deep breathing and coughing exercises at home."
Which nursing action will be most effective in preventing aspiration pneumonia in patients who
are at risk? - ANS ✔✔Place patients with altered consciousness in side-lying positions.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV)
antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment
has been effective? - ANS ✔✔The patient's white blood cell (WBC) count is 9000/µl.
The health care provider writes an order for bacteriologic testing for a patient who has a
positive tuberculosis skin test. Which action will the nurse take? - ANS ✔✔Obtain consecutive
sputum specimens from the patient for 3 days.
Which information about a patient who has a recent history of tuberculosis (TB) indicates that
the nurse can discontinue airborne isolation precautions? - ANS ✔✔Three sputum smears for
acid-fast bacilli are negative.
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary
tuberculosis (TB) have been met when the patient with TB: - ANS ✔✔covers the mouth and
nose when coughing.
Which information will the nurse include in the patient teaching plan for a patient who is
receiving rifampin (Rifadin) for treatment of tuberculosis? - ANS ✔✔"Your urine, sweat, and
tears will be orange colored."
When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB)
about possible toxic effects of the antitubercular medications, the nurse will give instructions to
notify the health care provider if the patient develops: - ANS ✔✔yellow-tinged skin.
, An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which
intervention by the nurse will be most effective in ensuring adherence with the treatment
regimen? - ANS ✔✔Arranging for a daily noontime meal at a community center and giving the
medication then.
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient
continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the
nurse take next? - ANS ✔✔Ask the patient whether medications have been taken as directed.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is
negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on
teaching the staff nurse about the: - ANS ✔✔use and side effects of isoniazid (INH).
Which action by the occupational health nurse at a manufacturing plant where there is
potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? -
ANS ✔✔Require the use of protective equipment.
When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking,
it will be most important for the nurse to include information about: - ANS ✔✔options for
smoking cessation.
A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells
the nurse, "I would rather have radiation than surgery." Which response by the nurse is most
appropriate? - ANS ✔✔"Tell me what you know about the various treatments available."
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has
decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage
and a large air leak. Which action is best for the nurse to take next? - ANS ✔✔Administer the
prescribed PRN morphine.
