ANSWERS 2024-2025 LATEST VERSION//ALREADY GRADED A+
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for
increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for
discharge, which action by the nurse will be most effective in improving compliance with discharge
teaching?
A. Have the patient repeat the instructions immediately after teaching
B. Accomplish the patient teaching just before the scheduled discharge C. Arrange for the
patient's caregiver to be present during the teaching
D. Start giving the patient discharge teaching during the admission process - CORRECT ANSWER-C.
Arrange for the patient's caregiver to be present during the teaching
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which
assessment findings should the nurse report to the healthcare provider before the patient goes for the
CT? Select all that apply.
A. Allergy to shellfish
B. Patient reports claustrophobia
C. Elevated serum creatinine level
D. Recent bronchodilator inhaler use
E. Inability to remove a wedding band - CORRECT ANSWER-A. Allergy to shellfish C. Elevated serum
creatinine level
A patient arrives in the ear, nose and throat clinic complaining of a piece of tissue being "stuck up my
nose" and which foul-smelling nasal drainage from the right nare. Which action should the nurse take
first?
A. Notify the clinic health care provider
B. Obtain aerobic culture specimens of the drainage
C. Ask the patient about how the cotton got into the nose
D. Have the patient occlude the left nare and blow the nose - CORRECT ANSWER-D. Have the patient
occlude the left nare and blow the nose
,A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The
nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mmHg, and respirations of 42
breaths/min. Which action should the nurse take first?
A. Administer anticoagulant drug therapy
B. Notify the patient's health care provider
C. Pressure patient for a spiral computed tomography (CT)
D. Elevate the head of the bed to a semi-Fowler's position - CORRECT ANSWER-D. Elevate the head
of the bed to a semi-Fowler's position
The emergency department nurse is evaluating the effective of therapy for a patient who has received
treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has
been effective?
A. No wheezes are audible
B. O2 saturation is >90%
C. Accessory muscle use has decreased
D. Respiratory rate is 16 breaths/minute - CORRECT ANSWER-B. O2 saturation is >90%
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse
position the patient?
A. Supine with the head of the bed elevated 30 degrees
B. In a high-Fowler's position with the left arm extended
C. On the right side with the left arm extended above the head
D. Sitting upright with the arms supported on an over bed table - CORRECT ANSWER-D. Sitting
upright with the arms supported on an over bed table
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, 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
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?
A. Ask the patient to lie down to complete a full physical assessment.
B. Briefly ask specific questions about this episode of respiratory distress.
C. Complete the admission database to check for allergies before treatment.
D. Delay the physical assessment to first complete pulmonary function tests. - CORRECT ANSWER-B.
Briefly ask specific questions about this episode of respiratory distress.
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse
include in the teaching plan?
A. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions.
B. Identifying and avoiding environmental triggers are the best way to prevent symptoms.
C. Frequent hand washing is the primary way to prevent spreading the condition to others.
D. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. - CORRECT
ANSWER-B. Identifying and avoiding environmental triggers are the best way to prevent
symptoms.
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 (pneumonia is typically productive)
C. Hyperresonance to percussion
D. Grating sound on auscultation - CORRECT ANSWER-A. Increased tactile fremitus
, The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would
expect which finding?
A. Barrel-shaped chest
B. Paradoxical respirations
C. Hyperresonance on percussion
D. Localized decreased breath sounds - CORRECT ANSWER-D. Localized decreased breath sounds
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse
plan to promote airway clearance?
A. Restrict oral fluids during the day
B. Teach pursed-lip breathing technique
C. Assist the patient to splint the chest when coughing
D. Encourage the patient to wear the nasal O2 cannula - CORRECT ANSWER-C. Assist the patient to
splint the chest when coughing
A 56-year-old normally healthy patient at the clinic is diagnosed with bacterial community-acquired
pneumonia. Before treatment is prescribed, the nurse asks the patient about an allergy to
A. Amoxicillin
B. Erythromycin
C. Sulfonamides
D. Cephalosporins - CORRECT ANSWER-B. Erythromycin
The nurse would interpret an induration of 5 mm resulting from the tuberculin skin testing as a positive
finding in which patient?
A. A patient with a history of illegal IV drug use
B. A patient with diabetes and end-stage kidney disease