MSN 377 Exam 3 - Ch 27, 65, 67 QUESTIONS WITH COMPLETE SOLUTIONS

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% correct answer: a. Weak, nonproductive cough effort 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. correct answer: b. increased tactile fremitus. 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 patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate 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. correct answer: a. Assist the patient to splint the chest when coughing. 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. Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. I will call the doctor if I still feel tired after a week. b. I will need to use home oxygen therapy for 3 months. c. I will continue to do the deep breathing and coughing exercises at home. d. I will schedule two appointments for the pneumonia and influenza vaccines. correct answer: c. I will continue to do the deep breathing and coughing exercises at home. Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time. Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? 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. Provide for continuous subglottic aspiration in patients receiving enteral feedings. correct answer: b. Place patients with altered consciousness in side-lying positions. 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. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. After a patient with right lower-lobe pneu