1. The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base –
answerD. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an
increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually
accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases
to be drawn. Which of the following is the minimum length of time the nurse should plan to hold
pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes –
answerB. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the
puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic
vessel under higher pressure than veins, and significant blood loss or hematoma formation could occur
if the time is insufficient.
3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a
nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal. - answerA. test the drainage for the presence
of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be
tested for the presence of glucose, which would indicate the presence of CSF.
4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
,A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate - answerA. Airway patency Remember ABCs with prioritization. Airway
patency is always the highest priority and is essential for a patient undergoing surgery surrounding the
upper respiratory system.
5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, with
which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice - answerA. ColaWhen learning the supraglottic swallow, it may be helpful to start
with carbonated beverages because the effervescence provides clues about the liquid's position. Thin,
watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration.
Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated
beverages are the better choice to start with.
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the
nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of
20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A.
Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions - answerA. Hyperthermia related to infectious
illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical
nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her
breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective
airway clearance from the information given because the patient is expectorating sputum.
7. Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
,D. Basilar crackles - answerD. Basilar crackles The presence of adventitious breath sounds indicates that
there is accumulation of secretions in the lower airways. This would be consistent with a nursing
diagnosis of ineffective airway clearance because the patient is retaining secretions.
8. Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - answerC. Increased
vocal fremitus on palpation. A typical physical examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to
percussion, bronchial breath sounds, and crackles in the affected area.
9. Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area. - answerB. Increase fluid intake to 3L/day if tolerated.
Although several interventions may help the patient expectorate mucus, the highest priority should be
on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them
more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the
patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they
can be removed.
10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the
following vaccines should the nurse recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - answerC. Pneumococcal The pneumococcal vaccine is important for
patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living
in a long-term care facility.
, 11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been
most effective when the patient states which of the following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." - answerD. "I
should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important for
the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the
infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory
infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below
normal.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
which of the following physician orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - answerD. Sputum culture and sensitivityThe nurse should ensure that
the sputum for culture and sensitivity was sent to the laboratory before administering the cefotetan. It
is important that the organisms are correctly identified (by the culture) before their numbers are
affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered
(sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for
the patient to expectorate sputum, all of the other options will not be affected by the administration of
antibiotics.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down" - answerD. Positioning patient with "good lung down"
Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status.
Research indicates that positioning the patient with the unaffected lung (good lung) dependent best
inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base –
answerD. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an
increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually
accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases
to be drawn. Which of the following is the minimum length of time the nurse should plan to hold
pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes –
answerB. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the
puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic
vessel under higher pressure than veins, and significant blood loss or hematoma formation could occur
if the time is insufficient.
3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a
nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal. - answerA. test the drainage for the presence
of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be
tested for the presence of glucose, which would indicate the presence of CSF.
4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
,A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate - answerA. Airway patency Remember ABCs with prioritization. Airway
patency is always the highest priority and is essential for a patient undergoing surgery surrounding the
upper respiratory system.
5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, with
which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice - answerA. ColaWhen learning the supraglottic swallow, it may be helpful to start
with carbonated beverages because the effervescence provides clues about the liquid's position. Thin,
watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration.
Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated
beverages are the better choice to start with.
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the
nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of
20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A.
Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions - answerA. Hyperthermia related to infectious
illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical
nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her
breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective
airway clearance from the information given because the patient is expectorating sputum.
7. Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
,D. Basilar crackles - answerD. Basilar crackles The presence of adventitious breath sounds indicates that
there is accumulation of secretions in the lower airways. This would be consistent with a nursing
diagnosis of ineffective airway clearance because the patient is retaining secretions.
8. Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - answerC. Increased
vocal fremitus on palpation. A typical physical examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to
percussion, bronchial breath sounds, and crackles in the affected area.
9. Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area. - answerB. Increase fluid intake to 3L/day if tolerated.
Although several interventions may help the patient expectorate mucus, the highest priority should be
on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them
more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the
patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they
can be removed.
10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the
following vaccines should the nurse recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - answerC. Pneumococcal The pneumococcal vaccine is important for
patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living
in a long-term care facility.
, 11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been
most effective when the patient states which of the following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." - answerD. "I
should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important for
the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the
infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory
infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below
normal.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
which of the following physician orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - answerD. Sputum culture and sensitivityThe nurse should ensure that
the sputum for culture and sensitivity was sent to the laboratory before administering the cefotetan. It
is important that the organisms are correctly identified (by the culture) before their numbers are
affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered
(sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for
the patient to expectorate sputum, all of the other options will not be affected by the administration of
antibiotics.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down" - answerD. Positioning patient with "good lung down"
Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status.
Research indicates that positioning the patient with the unaffected lung (good lung) dependent best
