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Chapter 27: Lower Respiratory Problems Lewis: After 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 cough effort b. Profuse green

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Chapter 27: Lower Respiratory Problems Lewis: After 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 cough effort b. Profuse green sputum c. Respiratory rate of 28breaths/minute d. Resting pulse oximetry (SpO2) of 85% 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. DIF: Cognitive Level: Analyze (analysis)

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Chapter 27: Lower Respiratory Problems Lewis: Afte
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Chapter 27: Lower Respiratory Problems Lewis: Afte

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February 19, 2025
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Chapter 27:
Lower
Respiratory
Problems
Lewis:

,Medical-Surgical Nursing, 10th Edition
exam preparation questions and
answers. Terms in this set (51)




After assessment of a ANS: A
patient with The weak, nonproductive cough indicates that the
pneumonia, the nurse patient is unable to clear the airway effectively. The
identifies a nursing other data would be used to support diagnoses such
diagnosis of ineffective as impaired gas exchange and ineffective breathing
airway clearance. pattern.
Which assessment data
best supports this DIF: Cognitive Level: Analyze (analysis)

diagnosis? a. Weak
cough effort
b. Profuse green
sputum

c. Respiratory rate
of 28breaths/minute
d. Resting pulse
oximetry

(SpO2) of 85%

,The nurse assesses the ANS: A
chest of a patient with Increased tactile fremitus over the area of pulmonary
pneumococcal consolidation is expected with bacterial pneumonias.
pneumonia. Which Dullness to percussion would be expected.
finding would the nurse
Pneumococcal pneumonia typically presents with
expect? a. Increased
a loose, productive cough. Adventitious breath
tactile fremitus
sounds such as crackles and wheezes are typical.
b. Dry,
A grating sound is more representative of a
nonproductivecough
pleural friction rub rather than pneumonia.
c. Hyperresonance
topercussion DIF: Cognitive Level: Apply (application)
d. A grating sound
onauscultation

A patient with bacterial ANS: C
pneumonia has coarse Coughing is less painful and more likely to be
crackles and thick effective when the patient splints the chest during
sputum. Which action coughing. Fluids should be encouraged to help
should the nurse plan to liquefy secretions. Nasal O2 will improve gas
promote airway exchange, but will not improve airway clearance.
clearance? Pursed-lip breathing is used to improve gas
a. Restrict oral exchange in patients with chronic obstructive
fluidsduring the day. pulmonary disease but will not improve airway
b. Teach pursed- clearance.
lipbreathing technique.
c. Assist the patient DIF: Cognitive Level: Apply (application)

tosplint the chest when

, coughing.
d. Encourage the
patientto wear the
nasal O2 cannula.



The nurse provides ANS: B
discharge instructions to Patients should continue to cough and deep breathe
a patient who was after discharge. Fatigue is expected for several
hospitalized for weeks. The pneumococcal and influenza vaccines
pneumonia. Which can be given at the same time in different arms. A
statement, if made by follow-up chest x-ray needs to be done in 6 to 8
the patient, indicates a weeks to evaluate resolution of pneumonia.
good understanding of
the instructions? DIF: Cognitive Level: Apply (application)

a. "I will call my
healthcare provider if I
still feel tired after a
week."
b. "I will continue to
dodeep breathing and
coughing exercises at
home."
c. "I will schedule
twoappointments for
the pneumonia and
influenza vaccines."
d. "I will cancel my

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