MedvSurgvTestvbankv(vRedvHESIvTestvbankvMed-Surgvandvothervresources)
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 - correct answersD. 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 - correct answersB. 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. - correct answersA. 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 - correct answersA. 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 - correct answersA. 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 - correct answersA. 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.vWhichvofvthevfollowingvphysicalvassessmentvfindingsvinvavpatientvwithvpneumoniavbestvsupportsvthevnursingvdiagnosisvofv
ineffectivevairwayvclearance?vA.vOxygenvsaturationvofv85%v
B.vRespiratoryvratevofv28v
C.vPresencevofvgreenishvsputumv
D.vBasilarvcracklesv-
vcorrectvanswersD.vBasilarvcracklesvThevpresencevofvadventitiousvbreathvsoundsvindicatesvthatvtherevisvaccumulationvofvsecret
ionsvinvthevlowervairways.vThisvwouldvbevconsistentvwithvavnursingvdiagnosisvofvineffectivevairwayvclearancevbecausevthevpa
tientvisvretainingvsecretions.
8.vWhichvofvthevfollowingvclinicalvmanifestationsvwouldvthevnursevexpectvtovfindvduringvassessmentvofvavpatientvadmittedvwi
thvpneumococcalvpneumonia?vA.vHyperresonancevonvpercussionv
B.vFinevcracklesvinvallvlobesvonvauscultationv
C.vIncreasedvvocalvfremitusvonvpalpationvD.vVesicularvbreathvsoundsvinvallvlobesv-
vcorrectvanswersC.vIncreasedvvocalvfremitusvonvpalpation.vAvtypicalvphysicalvexaminationvfindingvforvavpatientvwithvpneumo
niavisvincreasedvvocalvfremitusvonvpalpation.vOthervsignsvofvpulmonaryvconsolidationvincludevdullnessvtovpercussion,vbronchia
lvbreathvsounds,vandvcracklesvinvthevaffectedvarea.
9.vWhichvofvthevfollowingvnursingvinterventionsvisvofvthevhighestvpriorityvinvhelpingvavpatientvexpectoratevthickvsecretionsvre
latedvtovpneumonia?v
A.vHumidifyvthevoxygenvasvablev
B.vIncreasevfluidvintakevtov3L/dayvifvtolerated.v
C.vAdministervcoughvsuppressantvq4hr.v
D.vTeachvpatientvtovsplintvthevaffectedvarea.v-
vcorrectvanswersB.vIncreasevfluidvintakevtov3L/dayvifvtolerated.vAlthoughvseveralvinterventionsvmayvhelpvthevpatientvexpector
atevmucus,vthevhighestvpriorityvshouldvbevonvincreasingvfluidvintake,vwhichvwillvliquefyvthevsecretionsvsovthatvthevpatientvca
nvexpectoratevthemvmoreveasily.vHumidifyingvthevoxygenvisvalsovhelpful,vbutvisvnotvthevprimaryvintervention.vTeachingvthevp
atientvtovsplintvthevaffectedvareavmayvalsovbevhelpful,vbutvdoesvnotvliquefyvthevsecretionsvsovthatvtheyvcanvbevremoved.
10.vDuringvdischargevteachingvforvav65-year-
oldvpatientvwithvemphysemavandvpneumonia,vwhichvofvthevfollowingvvaccinesvshouldvthevnursevrecommendvthevpatientvrecei
ve?v
A.vS.vaureusv
B.vH.vinfluenzaev
C.vPneumococcalv
D.vBacillevCalmette-Guérinv(BCG)v-
vcorrectvanswersC.vPneumococcalvThevpneumococcalvvaccinevisvimportantvforvpatientsvwithvavhistoryvofvheartvorvlungvdiseas
e,vrecoveringvfromvavseverevillness,vagev65vorvover,vorvlivingvinvavlong-termvcarevfacility.
11.vThevnursevevaluatesvthatvdischargevteachingvforvavpatientvhospitalizedvwithvpneumoniavhasvbeenvmostveffectivevwhenvthe
vpatientvstatesvwhichvofvthevfollowingvmeasuresvtovpreventvavrelapse?v
A.v"Ivwillvincreasevmyvfoodvintakevtov2400vcaloriesvavdayvtovkeepvmyvimmunevsystemvwell."v
B.v"Ivmustvusevhomevoxygenvtherapyvforv3vmonthsvandvthenvwillvhavevavchestvx-rayvtovreevaluate."v
C.v"Ivwillvseekvimmediatevmedicalvtreatmentvforvanyvuppervrespiratoryvinfections."v
D.v"Ivshouldvcontinuevtovdovdeep-breathingvandvcoughingvexercisesvforvatvleastv6vweeks."v-
vcorrectvanswersD.v"Ivshouldvcontinuevtovdovdeep-
breathingvandvcoughingvexercisesvforvatvleastv6vweeks."vItvisvimportantvforvthevpatientvtovcontinuevwithvcoughingvandvdeepv
breathingvexercisesvforv6vtov8vweeksvuntilvallvofvthevinfectionvhasvclearedvfromvthevlungs.vAvpatientvshouldvseekvmedicalvtr
eatmentvforvuppervrespiratoryvinfectionsvthatvpersistvforvmorevthanv7vdays.vIncreasedvfluidvintake,vnotvcaloricvintake,visvrequi
redvtovliquefyvsecretions.vHomevO2visvnotvavrequirementvunlessvthevpatient'svoxygenationvsaturationvisvbelowvnormal.
12.vAftervadmittingvavpatientvtovthevmedicalvunitvwithvavdiagnosisvofvpneumonia,vthevnursevwillvverifyvthatvwhichvofvthevfol
lowingvphysicianvordersvhavevbeenvcompletedvbeforevadministeringvavdosevofvcefotetanv(Cefotan)vtovthevpatient?v
A.vSerumvlaboratoryvstudiesvorderedvforvAMv
B.vPulmonaryvfunctionvevaluationv
C.vOrthostaticvbloodvpressuresv
D.vSputumvculturevandvsensitivityv-
vcorrectvanswersD.vSputumvculturevandvsensitivityThevnursevshouldvensurevthatvthevsputumvforvculturevandvsensitivityvwasvse
ntvtovthevlaboratoryvbeforevadministeringvthevcefotetan.vItvisvimportantvthatvthevorganismsvarevcorrectlyvidentifiedv(byvthevcul
ture)vbeforevtheirvnumbersvarevaffectedvbyvthevantibiotic;vthevtestvwillvalsovdeterminevwhethervthevpropervantibioticvhasvbeen
vorderedv(sensitivityvtesting).vAlthoughvantibioticvadministrationvshouldvnotvbevundulyvdelayedvwhilevwaitingvforvthevpatientvt
ovexpectoratevsputum,vallvofvthevothervoptionsvwillvnotvbevaffectedvbyvthevadministrationvofvantibiotics.
,13.vWhichvofvthevfollowingvnursingvinterventionsvisvmostvappropriatevtovenhancevoxygenationvinvavpatientvwithvunilateralvma
lignantvlungvdisease?v
A.vPositioningvpatientvonvrightvside.v
B.vMaintainingvadequatevfluidvintakev
C.vPerformingvposturalvdrainageveveryv4vhoursv
D.vPositioningvpatientvwithv"goodvlungvdown"v-
vcorrectvanswersD.vPositioningvpatientvwithv"goodvlungvdown"vTherapeuticvpositioningvidentifiesvthevbestvpositionvforvthevpat
ientvassuringvstablevoxygenationvstatus.vResearchvindicatesvthatvpositioningvthevpatientvwithvthevunaffectedvlungv(goodvlung)v
dependentvbestvpromotesvoxygenationvinvpatientsvwithvunilateralvlungvdisease.vForvbilateralvlungvdisease,vthevrightvlungvdown
vhasvbestvventilationvandvperfusion.vIncreasingvfluidvintakevandvperformingvposturalvdrainagevwillvfacilitatevairwayvclearance,v
butvpositioningvisvmostvappropriatevtovenhancevoxygenation.
14.vAv71-year-
oldvpatientvisvadmittedvwithvacutevrespiratoryvdistressvrelatedvtovcorvpulmonale.vWhichvofvthevfollowingvnursingvinterventions
visvmostvappropriatevduringvadmissionvofvthisvpatient?v
A.vDelayvanyvphysicalvassessmentvofvthevpatientvandvreviewvwithvthevfamilyvthevpatient'svhistoryvofvrespiratoryvproblems.vB.
vPerformvavcomprehensivevhealthvhistoryvwithvthevpatientvtovreviewvpriorvrespiratoryvproblems.v
C.vPerformvavphysicalvassessmentvofvthevrespiratoryvsystemvandvaskvspecificvquestionsvrelatedvtovthisvepisodevofvrespiratoryv
distress.v
D.vCompletevavfullvphysicalvexaminationvtovdeterminevtheveffectvofvthevrespiratoryvdistressvonvothervbodyvfunctions.v-
vcorrectvanswersC.vPerformvavphysicalvassessmentvofvthevrespiratoryvsystemvandvaskvspecificvquestionsvrelatedvtovthisvepisod
evofvrespiratoryvdistress.Becausevthevpatientvisvhavingvrespiratoryvdifficulty,vthevnursevshouldvaskvspecificvquestionsvaboutvthi
svepisodevandvperformvavphysicalvassessmentvofvthisvsystem.vFurthervhistoryvtakingvandvphysicalvexaminationvofvothervbodyv
systemsvcanvproceedvoncevthevpatient'svacutevrespiratoryvdistressvisvbeingvmanaged.
15.vWhenvplanningvappropriatevnursingvinterventionsvforvavpatientvwithvmetastaticvlungvcancervandvav60-pack-
yearvhistoryvofvcigarettevsmoking,vthevnursevrecognizesvthatvthevsmokingvhasvmostvlikelyvdecreasedvthevpatient'svunderlyingvr
espiratoryvdefensesvbecausevofvimpairmentvofvwhichvofvthevfollowing?v
A.vReflexvbronchoconstrictionv
B.vAbilityvtovfiltervparticlesvfromvthevairv
C.vCoughvreflexv
D.vMucociliaryvclearancev-
vcorrectvanswersD.vMucociliaryvclearancevSmokingvdecreasesvthevciliaryvactionvinvthevtracheobronchialvtree,vresultingvinvimpa
iredvclearancevofvrespiratoryvsecretions,vchronicvcough,vandvfrequentvrespiratoryvinfections.
16.vWhilevambulatingvavpatientvwithvmetastaticvlungvcancer,vthevnursevobservesvavdropvinvoxygenvsaturationvfromv93%vtov8
6%.vWhichvofvthevfollowingvnursingvinterventionsvisvmostvappropriatevbasedvuponvthesevfindings?v
A.vContinuevwithvambulationvasvthisvisvavnormalvresponsevtovactivity.v
B.vMovevthevoximetryvprobevfromvthevfingervtovthevearlobevforvmorevaccuratevmonitoringvduringvactivity.v
C.vObtainvavphysician'svordervforvsupplementalvoxygenvtovbevusedvduringvambulationvandvothervactivity.v
D.vObtainvavphysician'svordervforvarterialvbloodvgasvdeterminationsvtovverifyvthevoxygenvsaturation.v-
vcorrectvanswersC.vObtainvavphysician'svordervforvsupplementalvoxygenvtovbevusedvduringvambulationvandvothervactivity.vAn
voxygenvsaturationvlevelvthatvdropsvbelowv90%vwithvactivityvindicatesvthatvthevpatientvisvnotvtoleratingvthevexercisevandvnee
dsvtovhavevsupplementalvoxygenvapplied.
17.vThevnursevisvcaringvforvav73-year-
oldvpatientvwhovunderwentvavleftvtotalvkneevarthroplasty.vOnvthevthirdvpostoperativevday,vthevpatientvcomplainsvofvshortnessv
ofvbreath,vslightvchestvpain,vandvthatv"somethingvisvwrong."vTemperaturevisv98.4ovF,vbloodvpressurev130/88,vrespirationsv36,v
andvoxygenvsaturationv91%vonvroomvair.vWhichvofvthevfollowingvshouldvthevnursevfirstvsuspectvasvthevetiologyvofvthisvepiso
de?v
A.vSepticvembolusvfromvthevkneevjointv
B.vPulmonaryvembolusvfromvdeepvveinvthrombosisv
C.vNewvonsetvofvanginavpectorisv
D.vPleuralveffusionvrelatedvtovpositioningvinvthevoperatingvroomv-
vcorrectvanswersB.vPulmonaryvembolusvfromvdeepvveinvthrombosisvThevpatientvpresentsvthevclassicvsymptomsvofvpulmonaryv
embolus:vacutevonsetvofvsymptoms,vtachypnea,vshortnessvofvbreath,vandvchestvpain.
18.vInvthevcasevofvpulmonaryvembolusvfromvdeepvveinvthrombosis,vwhichvofvthevfollowingvactionsvshouldvthevnursevtakevfirs
t?v
A.vNotifyvthevphysician.v
B.vAdministervavnitroglycerinvtabletvsublingually.v
C.vConductvavthoroughvassessmentvofvthevchestvpain.v
,D.vSitvthevpatientvupvinvbedvasvtoleratedvandvapplyvoxygen.v-
vcorrectvanswersD.vSitvthevpatientvupvinvbedvasvtoleratedvandvapplyvoxygen.Thevpatient'svclinicalvpicturevisvconsistentvwithvp
ulmonaryvembolus,vandvthevfirstvactionvthevnursevtakesvshouldvbevtovassistvthevpatient.vForvthisvreason,vthevnursevshouldvsitv
thevpatientvupvasvtoleratedvandvapplyvoxygenvbeforevnotifyingvthevphysician.
19.vThevnursevisvcaringvforvavpostoperativevpatientvwithvsuddenvonsetvofvrespiratoryvdistress.vThevphysicianvordersvavSTATv
ventilation-
perfusionvscan.vWhichvofvthevfollowingvexplanationsvshouldvthevnursevprovidevtovthevpatientvaboutvthevprocedure?v
A.vThisvtestvinvolvesvinjectionvofvavradioisotopevtovoutlinevthevbloodvvesselsvinvthevlungs,vfollowedvbyvinhalationvofvavradio
isotopevgas.v
B.vThisvtestvwillvusevspecialvtechnologyvtovexaminevcrossvsectionsvofvthevchestvwithvusevofvavcontrastvdye.v
C.vThisvtestvwillvusevmagneticvfieldsvtovproducevimagesvofvthevlungsvandvchest.vD.vThisvtestvinvolvesvinjectingvcontrastvdye
vintovavbloodvvesselvtovoutlinevthevbloodvvesselsvofvthevlungs.v-
vcorrectvanswersA.vThisvtestvinvolvesvinjectionvofvavradioisotopevtovoutlinevthevbloodvvesselsvinvthevlungs,vfollowedvbyvinhal
ationvofvavradioisotopevgas.Avventilation-
perfusionvscanvhasvtwovparts.vInvthevperfusionvportion,vavradioisotopevisvinjectedvintovthevbloodvandvthevpulmonaryvvasculatu
revisvoutlined.vInvthevventilationvpart,vthevpatientvinhalesvavradioactivevgasvthatvoutlinesvthevalveoli.
20.vDuringvassessmentvofvav45-year-
oldvpatientvwithvasthma,vthevnursevnotesvwheezingvandvdyspnea.vThevnursevinterpretsvthatvthesevsymptomsvarevrelatedvtovwhi
chvofvthevfollowingvpathophysiologicvchanges?vA.vLaryngospasmvB.vOverdistentionvofvthevalveolivC.vNarrowingvofvthevairwa
yvD.vPulmonaryvedemav-
vcorrectvanswersC.vNarrowingvofvthevairwayNarrowingvofvthevairwayvleadsvtovreducedvairflow,vmakingvitvdifficultvforvthevpa
tientvtovbreathevandvproducingvthevcharacteristicvwheezing.
21.vAv45-year-
oldvmanvwithvasthmavisvbroughtvtovthevemergencyvdepartmentvbyvautomobile.vHevisvshortvofvbreathvandvappearsvfrightened.v
Duringvthevinitialvnursingvassessment,vwhichvofvthevfollowingvclinicalvmanifestationsvmightvbevpresentvasvanvearlyvsymptomv
duringvanvexacerbationvofvasthma?v
A.vAnxietyv
B.vCyanosisv
C.vHypercapniav
D.vBradycardiav-
vcorrectvanswersA.vAnxietyvAnvearlyvsymptomvduringvanvasthmavattackvisvanxietyvbecausevhevisvacutelyvawarevofvthevinabil
ityvtovgetvsufficientvairvtovbreathe.vHevwillvbevhypoxicvearlyvonvwithvdecreasedvPaCO2vandvincreasedvpHvasvhevisvhyperven
tilating.
22.vThevnursevisvassignedvtovcarevforvavpatientvwhovhasvanxietyvandvanvexacerbationvofvasthma.vWhichvofvthevfollowingvisv
thevprimaryvreasonvforvthevnursevtovcarefullyvinspectvthevchestvwallvofvthisvpatient?v
A.vObservevforvsignsvofvdiaphoresisv
B.vAllowvtimevtovcalmvthevpatientv
C.vMonitorvthevpatientvforvbilateralvchestvexpansionv
D.vEvaluatevthevusevofvintercostalvmusclesv-
vcorrectvanswersD.vEvaluatevthevusevofvintercostalvmusclesvThevnursevphysicallyvinspectsvthevchestvwallvtovevaluatevthevusev
ofvintercostalv(accessory)vmuscles,vwhichvgivesvanvindicationvofvthevdegreevofvrespiratoryvdistressvexperiencedvbyvthevpatient.
23.vWhichvofvthevfollowingvpositionsvisvmostvappropriatevforvthevnursevtovplacevavpatientvexperiencingvanvasthmavexacerbati
on?v
A.vSupinev
B.vLithotomyv
C.vHigh-Fowler'sv
D.vReversevTrendelenburgv-vcorrectvanswersC.vHigh-
Fowler'sThevpatientvexperiencingvanvasthmavattackvshouldvbevplacedvinvhigh-
Fowler'svpositionvtovallowvforvoptimalvchestvexpansionvandvenlistvthevaidvofvgravityvduringvinspiration.
24.vThevnursevisvcaringvforvavpatientvwithvanvacutevexacerbationvofvasthma.vFollowingvinitialvtreatment,vwhichvofvthevfollow
ingvfindingsvindicatesvtovthevnursevthatvthevpatient'svrespiratoryvstatusvisvimproving?v
A.vWheezingvbecomesvlouderv
B.vVesicularvbreathvsoundsvdecreasev
C.vAerosolvbronchodilatorsvstimulatevcoughingv
D.vThevcoughvremainsvnonproductivev-
vcorrectvanswersA.vWheezingvbecomesvloudervThevprimaryvproblemvduringvanvexacerbationvofvasthmavisvnarrowingvofvthevai
rwayvandvsubsequentvdiminishedvairvexchange.vAsvthevairwaysvbeginvtovdilate,vwheezingvgetsvloudervbecausevofvbettervairvex
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 - correct answersD. 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 - correct answersB. 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. - correct answersA. 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 - correct answersA. 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 - correct answersA. 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 - correct answersA. 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.vWhichvofvthevfollowingvphysicalvassessmentvfindingsvinvavpatientvwithvpneumoniavbestvsupportsvthevnursingvdiagnosisvofv
ineffectivevairwayvclearance?vA.vOxygenvsaturationvofv85%v
B.vRespiratoryvratevofv28v
C.vPresencevofvgreenishvsputumv
D.vBasilarvcracklesv-
vcorrectvanswersD.vBasilarvcracklesvThevpresencevofvadventitiousvbreathvsoundsvindicatesvthatvtherevisvaccumulationvofvsecret
ionsvinvthevlowervairways.vThisvwouldvbevconsistentvwithvavnursingvdiagnosisvofvineffectivevairwayvclearancevbecausevthevpa
tientvisvretainingvsecretions.
8.vWhichvofvthevfollowingvclinicalvmanifestationsvwouldvthevnursevexpectvtovfindvduringvassessmentvofvavpatientvadmittedvwi
thvpneumococcalvpneumonia?vA.vHyperresonancevonvpercussionv
B.vFinevcracklesvinvallvlobesvonvauscultationv
C.vIncreasedvvocalvfremitusvonvpalpationvD.vVesicularvbreathvsoundsvinvallvlobesv-
vcorrectvanswersC.vIncreasedvvocalvfremitusvonvpalpation.vAvtypicalvphysicalvexaminationvfindingvforvavpatientvwithvpneumo
niavisvincreasedvvocalvfremitusvonvpalpation.vOthervsignsvofvpulmonaryvconsolidationvincludevdullnessvtovpercussion,vbronchia
lvbreathvsounds,vandvcracklesvinvthevaffectedvarea.
9.vWhichvofvthevfollowingvnursingvinterventionsvisvofvthevhighestvpriorityvinvhelpingvavpatientvexpectoratevthickvsecretionsvre
latedvtovpneumonia?v
A.vHumidifyvthevoxygenvasvablev
B.vIncreasevfluidvintakevtov3L/dayvifvtolerated.v
C.vAdministervcoughvsuppressantvq4hr.v
D.vTeachvpatientvtovsplintvthevaffectedvarea.v-
vcorrectvanswersB.vIncreasevfluidvintakevtov3L/dayvifvtolerated.vAlthoughvseveralvinterventionsvmayvhelpvthevpatientvexpector
atevmucus,vthevhighestvpriorityvshouldvbevonvincreasingvfluidvintake,vwhichvwillvliquefyvthevsecretionsvsovthatvthevpatientvca
nvexpectoratevthemvmoreveasily.vHumidifyingvthevoxygenvisvalsovhelpful,vbutvisvnotvthevprimaryvintervention.vTeachingvthevp
atientvtovsplintvthevaffectedvareavmayvalsovbevhelpful,vbutvdoesvnotvliquefyvthevsecretionsvsovthatvtheyvcanvbevremoved.
10.vDuringvdischargevteachingvforvav65-year-
oldvpatientvwithvemphysemavandvpneumonia,vwhichvofvthevfollowingvvaccinesvshouldvthevnursevrecommendvthevpatientvrecei
ve?v
A.vS.vaureusv
B.vH.vinfluenzaev
C.vPneumococcalv
D.vBacillevCalmette-Guérinv(BCG)v-
vcorrectvanswersC.vPneumococcalvThevpneumococcalvvaccinevisvimportantvforvpatientsvwithvavhistoryvofvheartvorvlungvdiseas
e,vrecoveringvfromvavseverevillness,vagev65vorvover,vorvlivingvinvavlong-termvcarevfacility.
11.vThevnursevevaluatesvthatvdischargevteachingvforvavpatientvhospitalizedvwithvpneumoniavhasvbeenvmostveffectivevwhenvthe
vpatientvstatesvwhichvofvthevfollowingvmeasuresvtovpreventvavrelapse?v
A.v"Ivwillvincreasevmyvfoodvintakevtov2400vcaloriesvavdayvtovkeepvmyvimmunevsystemvwell."v
B.v"Ivmustvusevhomevoxygenvtherapyvforv3vmonthsvandvthenvwillvhavevavchestvx-rayvtovreevaluate."v
C.v"Ivwillvseekvimmediatevmedicalvtreatmentvforvanyvuppervrespiratoryvinfections."v
D.v"Ivshouldvcontinuevtovdovdeep-breathingvandvcoughingvexercisesvforvatvleastv6vweeks."v-
vcorrectvanswersD.v"Ivshouldvcontinuevtovdovdeep-
breathingvandvcoughingvexercisesvforvatvleastv6vweeks."vItvisvimportantvforvthevpatientvtovcontinuevwithvcoughingvandvdeepv
breathingvexercisesvforv6vtov8vweeksvuntilvallvofvthevinfectionvhasvclearedvfromvthevlungs.vAvpatientvshouldvseekvmedicalvtr
eatmentvforvuppervrespiratoryvinfectionsvthatvpersistvforvmorevthanv7vdays.vIncreasedvfluidvintake,vnotvcaloricvintake,visvrequi
redvtovliquefyvsecretions.vHomevO2visvnotvavrequirementvunlessvthevpatient'svoxygenationvsaturationvisvbelowvnormal.
12.vAftervadmittingvavpatientvtovthevmedicalvunitvwithvavdiagnosisvofvpneumonia,vthevnursevwillvverifyvthatvwhichvofvthevfol
lowingvphysicianvordersvhavevbeenvcompletedvbeforevadministeringvavdosevofvcefotetanv(Cefotan)vtovthevpatient?v
A.vSerumvlaboratoryvstudiesvorderedvforvAMv
B.vPulmonaryvfunctionvevaluationv
C.vOrthostaticvbloodvpressuresv
D.vSputumvculturevandvsensitivityv-
vcorrectvanswersD.vSputumvculturevandvsensitivityThevnursevshouldvensurevthatvthevsputumvforvculturevandvsensitivityvwasvse
ntvtovthevlaboratoryvbeforevadministeringvthevcefotetan.vItvisvimportantvthatvthevorganismsvarevcorrectlyvidentifiedv(byvthevcul
ture)vbeforevtheirvnumbersvarevaffectedvbyvthevantibiotic;vthevtestvwillvalsovdeterminevwhethervthevpropervantibioticvhasvbeen
vorderedv(sensitivityvtesting).vAlthoughvantibioticvadministrationvshouldvnotvbevundulyvdelayedvwhilevwaitingvforvthevpatientvt
ovexpectoratevsputum,vallvofvthevothervoptionsvwillvnotvbevaffectedvbyvthevadministrationvofvantibiotics.
,13.vWhichvofvthevfollowingvnursingvinterventionsvisvmostvappropriatevtovenhancevoxygenationvinvavpatientvwithvunilateralvma
lignantvlungvdisease?v
A.vPositioningvpatientvonvrightvside.v
B.vMaintainingvadequatevfluidvintakev
C.vPerformingvposturalvdrainageveveryv4vhoursv
D.vPositioningvpatientvwithv"goodvlungvdown"v-
vcorrectvanswersD.vPositioningvpatientvwithv"goodvlungvdown"vTherapeuticvpositioningvidentifiesvthevbestvpositionvforvthevpat
ientvassuringvstablevoxygenationvstatus.vResearchvindicatesvthatvpositioningvthevpatientvwithvthevunaffectedvlungv(goodvlung)v
dependentvbestvpromotesvoxygenationvinvpatientsvwithvunilateralvlungvdisease.vForvbilateralvlungvdisease,vthevrightvlungvdown
vhasvbestvventilationvandvperfusion.vIncreasingvfluidvintakevandvperformingvposturalvdrainagevwillvfacilitatevairwayvclearance,v
butvpositioningvisvmostvappropriatevtovenhancevoxygenation.
14.vAv71-year-
oldvpatientvisvadmittedvwithvacutevrespiratoryvdistressvrelatedvtovcorvpulmonale.vWhichvofvthevfollowingvnursingvinterventions
visvmostvappropriatevduringvadmissionvofvthisvpatient?v
A.vDelayvanyvphysicalvassessmentvofvthevpatientvandvreviewvwithvthevfamilyvthevpatient'svhistoryvofvrespiratoryvproblems.vB.
vPerformvavcomprehensivevhealthvhistoryvwithvthevpatientvtovreviewvpriorvrespiratoryvproblems.v
C.vPerformvavphysicalvassessmentvofvthevrespiratoryvsystemvandvaskvspecificvquestionsvrelatedvtovthisvepisodevofvrespiratoryv
distress.v
D.vCompletevavfullvphysicalvexaminationvtovdeterminevtheveffectvofvthevrespiratoryvdistressvonvothervbodyvfunctions.v-
vcorrectvanswersC.vPerformvavphysicalvassessmentvofvthevrespiratoryvsystemvandvaskvspecificvquestionsvrelatedvtovthisvepisod
evofvrespiratoryvdistress.Becausevthevpatientvisvhavingvrespiratoryvdifficulty,vthevnursevshouldvaskvspecificvquestionsvaboutvthi
svepisodevandvperformvavphysicalvassessmentvofvthisvsystem.vFurthervhistoryvtakingvandvphysicalvexaminationvofvothervbodyv
systemsvcanvproceedvoncevthevpatient'svacutevrespiratoryvdistressvisvbeingvmanaged.
15.vWhenvplanningvappropriatevnursingvinterventionsvforvavpatientvwithvmetastaticvlungvcancervandvav60-pack-
yearvhistoryvofvcigarettevsmoking,vthevnursevrecognizesvthatvthevsmokingvhasvmostvlikelyvdecreasedvthevpatient'svunderlyingvr
espiratoryvdefensesvbecausevofvimpairmentvofvwhichvofvthevfollowing?v
A.vReflexvbronchoconstrictionv
B.vAbilityvtovfiltervparticlesvfromvthevairv
C.vCoughvreflexv
D.vMucociliaryvclearancev-
vcorrectvanswersD.vMucociliaryvclearancevSmokingvdecreasesvthevciliaryvactionvinvthevtracheobronchialvtree,vresultingvinvimpa
iredvclearancevofvrespiratoryvsecretions,vchronicvcough,vandvfrequentvrespiratoryvinfections.
16.vWhilevambulatingvavpatientvwithvmetastaticvlungvcancer,vthevnursevobservesvavdropvinvoxygenvsaturationvfromv93%vtov8
6%.vWhichvofvthevfollowingvnursingvinterventionsvisvmostvappropriatevbasedvuponvthesevfindings?v
A.vContinuevwithvambulationvasvthisvisvavnormalvresponsevtovactivity.v
B.vMovevthevoximetryvprobevfromvthevfingervtovthevearlobevforvmorevaccuratevmonitoringvduringvactivity.v
C.vObtainvavphysician'svordervforvsupplementalvoxygenvtovbevusedvduringvambulationvandvothervactivity.v
D.vObtainvavphysician'svordervforvarterialvbloodvgasvdeterminationsvtovverifyvthevoxygenvsaturation.v-
vcorrectvanswersC.vObtainvavphysician'svordervforvsupplementalvoxygenvtovbevusedvduringvambulationvandvothervactivity.vAn
voxygenvsaturationvlevelvthatvdropsvbelowv90%vwithvactivityvindicatesvthatvthevpatientvisvnotvtoleratingvthevexercisevandvnee
dsvtovhavevsupplementalvoxygenvapplied.
17.vThevnursevisvcaringvforvav73-year-
oldvpatientvwhovunderwentvavleftvtotalvkneevarthroplasty.vOnvthevthirdvpostoperativevday,vthevpatientvcomplainsvofvshortnessv
ofvbreath,vslightvchestvpain,vandvthatv"somethingvisvwrong."vTemperaturevisv98.4ovF,vbloodvpressurev130/88,vrespirationsv36,v
andvoxygenvsaturationv91%vonvroomvair.vWhichvofvthevfollowingvshouldvthevnursevfirstvsuspectvasvthevetiologyvofvthisvepiso
de?v
A.vSepticvembolusvfromvthevkneevjointv
B.vPulmonaryvembolusvfromvdeepvveinvthrombosisv
C.vNewvonsetvofvanginavpectorisv
D.vPleuralveffusionvrelatedvtovpositioningvinvthevoperatingvroomv-
vcorrectvanswersB.vPulmonaryvembolusvfromvdeepvveinvthrombosisvThevpatientvpresentsvthevclassicvsymptomsvofvpulmonaryv
embolus:vacutevonsetvofvsymptoms,vtachypnea,vshortnessvofvbreath,vandvchestvpain.
18.vInvthevcasevofvpulmonaryvembolusvfromvdeepvveinvthrombosis,vwhichvofvthevfollowingvactionsvshouldvthevnursevtakevfirs
t?v
A.vNotifyvthevphysician.v
B.vAdministervavnitroglycerinvtabletvsublingually.v
C.vConductvavthoroughvassessmentvofvthevchestvpain.v
,D.vSitvthevpatientvupvinvbedvasvtoleratedvandvapplyvoxygen.v-
vcorrectvanswersD.vSitvthevpatientvupvinvbedvasvtoleratedvandvapplyvoxygen.Thevpatient'svclinicalvpicturevisvconsistentvwithvp
ulmonaryvembolus,vandvthevfirstvactionvthevnursevtakesvshouldvbevtovassistvthevpatient.vForvthisvreason,vthevnursevshouldvsitv
thevpatientvupvasvtoleratedvandvapplyvoxygenvbeforevnotifyingvthevphysician.
19.vThevnursevisvcaringvforvavpostoperativevpatientvwithvsuddenvonsetvofvrespiratoryvdistress.vThevphysicianvordersvavSTATv
ventilation-
perfusionvscan.vWhichvofvthevfollowingvexplanationsvshouldvthevnursevprovidevtovthevpatientvaboutvthevprocedure?v
A.vThisvtestvinvolvesvinjectionvofvavradioisotopevtovoutlinevthevbloodvvesselsvinvthevlungs,vfollowedvbyvinhalationvofvavradio
isotopevgas.v
B.vThisvtestvwillvusevspecialvtechnologyvtovexaminevcrossvsectionsvofvthevchestvwithvusevofvavcontrastvdye.v
C.vThisvtestvwillvusevmagneticvfieldsvtovproducevimagesvofvthevlungsvandvchest.vD.vThisvtestvinvolvesvinjectingvcontrastvdye
vintovavbloodvvesselvtovoutlinevthevbloodvvesselsvofvthevlungs.v-
vcorrectvanswersA.vThisvtestvinvolvesvinjectionvofvavradioisotopevtovoutlinevthevbloodvvesselsvinvthevlungs,vfollowedvbyvinhal
ationvofvavradioisotopevgas.Avventilation-
perfusionvscanvhasvtwovparts.vInvthevperfusionvportion,vavradioisotopevisvinjectedvintovthevbloodvandvthevpulmonaryvvasculatu
revisvoutlined.vInvthevventilationvpart,vthevpatientvinhalesvavradioactivevgasvthatvoutlinesvthevalveoli.
20.vDuringvassessmentvofvav45-year-
oldvpatientvwithvasthma,vthevnursevnotesvwheezingvandvdyspnea.vThevnursevinterpretsvthatvthesevsymptomsvarevrelatedvtovwhi
chvofvthevfollowingvpathophysiologicvchanges?vA.vLaryngospasmvB.vOverdistentionvofvthevalveolivC.vNarrowingvofvthevairwa
yvD.vPulmonaryvedemav-
vcorrectvanswersC.vNarrowingvofvthevairwayNarrowingvofvthevairwayvleadsvtovreducedvairflow,vmakingvitvdifficultvforvthevpa
tientvtovbreathevandvproducingvthevcharacteristicvwheezing.
21.vAv45-year-
oldvmanvwithvasthmavisvbroughtvtovthevemergencyvdepartmentvbyvautomobile.vHevisvshortvofvbreathvandvappearsvfrightened.v
Duringvthevinitialvnursingvassessment,vwhichvofvthevfollowingvclinicalvmanifestationsvmightvbevpresentvasvanvearlyvsymptomv
duringvanvexacerbationvofvasthma?v
A.vAnxietyv
B.vCyanosisv
C.vHypercapniav
D.vBradycardiav-
vcorrectvanswersA.vAnxietyvAnvearlyvsymptomvduringvanvasthmavattackvisvanxietyvbecausevhevisvacutelyvawarevofvthevinabil
ityvtovgetvsufficientvairvtovbreathe.vHevwillvbevhypoxicvearlyvonvwithvdecreasedvPaCO2vandvincreasedvpHvasvhevisvhyperven
tilating.
22.vThevnursevisvassignedvtovcarevforvavpatientvwhovhasvanxietyvandvanvexacerbationvofvasthma.vWhichvofvthevfollowingvisv
thevprimaryvreasonvforvthevnursevtovcarefullyvinspectvthevchestvwallvofvthisvpatient?v
A.vObservevforvsignsvofvdiaphoresisv
B.vAllowvtimevtovcalmvthevpatientv
C.vMonitorvthevpatientvforvbilateralvchestvexpansionv
D.vEvaluatevthevusevofvintercostalvmusclesv-
vcorrectvanswersD.vEvaluatevthevusevofvintercostalvmusclesvThevnursevphysicallyvinspectsvthevchestvwallvtovevaluatevthevusev
ofvintercostalv(accessory)vmuscles,vwhichvgivesvanvindicationvofvthevdegreevofvrespiratoryvdistressvexperiencedvbyvthevpatient.
23.vWhichvofvthevfollowingvpositionsvisvmostvappropriatevforvthevnursevtovplacevavpatientvexperiencingvanvasthmavexacerbati
on?v
A.vSupinev
B.vLithotomyv
C.vHigh-Fowler'sv
D.vReversevTrendelenburgv-vcorrectvanswersC.vHigh-
Fowler'sThevpatientvexperiencingvanvasthmavattackvshouldvbevplacedvinvhigh-
Fowler'svpositionvtovallowvforvoptimalvchestvexpansionvandvenlistvthevaidvofvgravityvduringvinspiration.
24.vThevnursevisvcaringvforvavpatientvwithvanvacutevexacerbationvofvasthma.vFollowingvinitialvtreatment,vwhichvofvthevfollow
ingvfindingsvindicatesvtovthevnursevthatvthevpatient'svrespiratoryvstatusvisvimproving?v
A.vWheezingvbecomesvlouderv
B.vVesicularvbreathvsoundsvdecreasev
C.vAerosolvbronchodilatorsvstimulatevcoughingv
D.vThevcoughvremainsvnonproductivev-
vcorrectvanswersA.vWheezingvbecomesvloudervThevprimaryvproblemvduringvanvexacerbationvofvasthmavisvnarrowingvofvthevai
rwayvandvsubsequentvdiminishedvairvexchange.vAsvthevairwaysvbeginvtovdilate,vwheezingvgetsvloudervbecausevofvbettervairvex
