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answers
A nurse is monitoring a group of clients for increased risk of
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developing pneumonia. Which of the following would be at risk? |\ |\ |\ |\ |\ |\ |\ |\ |\
A. pt with dysphagia
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B. pt with AIDS
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C. pt who was vaccinated 6m ago for flu and pneumonia
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D. Pt who is postop & had local anesthesia
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E. pt who has a closed head injury and is receiving mechanical
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ventilation
F. Pt who has myasthenia gravis - CORRECT ANSWERS ✔✔A: at
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risk for aspiration |\ |\
B: immunocompromised
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E: at risk for ventilator-associated pneumonia
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F: pt w/MG has weakness and can have difficulty clearing airway
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A nurse is caring for a pt who upon awakening, was disoriented
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x3. Pt reports chills and chest pain that is worse upon inspiration.
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Which of the following actions is the nursing priority?
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A. Obtain baseline vitals & O2 sat
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B. Obtain sputum culture
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C. Obtain a complete history
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D. provide pneumococcal vaccine - CORRECT ANSWERS ✔✔A:
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assess pt & determine next intervention to provide safe/effective
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pt care |\
,A nurse is caring for a pt who has pneumonia. Assessment
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findings include: |\ |\
Temp: 100 F, RR 30/min, BP 130/76, HR 100/min, O2 91% ORA.
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Prioritize the following interventions: |\ |\ |\ |\
A. Administer Abx
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B. Administer O2 therapy
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C. Perform a sputum culture
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D. Instruct the pt to obtain yearly flu vax - CORRECT ANSWERS
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✔✔B: ABCs always first. |\ |\ |\ |\
C: needed in order to determine best abx
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A: abx to treat condition
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D: reduces risk of flu which can lead to pneumonia
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A nurse in a clinic is assessing a pt who has sinusitis. Which of
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the following techniques should the nurse use to identify
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manifestations of this disorder? |\ |\ |\
A. percuss posterior lobes of lung
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B. Auscultation of trachea
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C. Inspection of the conjuctiva
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D. Palpation of the orbital areas - CORRECT ANSWERS ✔✔D. there
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will be tenderness at orbital, frontal, and facial areas on
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palpation
A nurse is teaching a group of pts about influenza. Which of the
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following statements indicates an understanding?
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, A. "I should wash my hands after blowing my nose to prevent
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spreading the virus." |\ |\
B. "I need to avoid drinking fluids if I develop symptoms."
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C. "I need a flu shot every 2 years bc of the different flu strains."
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D. "I should cover my mouth with my hand when I sneeze." -
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CORRECT ANSWERS ✔✔A: hand hygiene helps prevent spread
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A nurse in the ED is caring for a pt who is experiencing an acute
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asthma attack. Which of the following assessments indicates that
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the respiratory status is declining? SATA
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A. SaO2 95%
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B. Wheezing
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C. Retraction of sternal muscles
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D. Pink mucous membranes
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E. Tachycardia - CORRECT ANSWERS ✔✔B: wheezing indicates
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narrowing of airways |\ |\ |\
C: indicates increased work of breathing
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E: Tachycardia can be a manifestation of decreased oxygenation
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A nurse is caring for a pt 2 hrs after admission. The pt has a
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SaO2 of 91%, exhibits audible wheezes, and is using accessory
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muscles when breathing. Which of the following classes of
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medications should the nurse expect to administer? |\ |\ |\ |\ |\ |\
A. Antibiotics
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B. Beta-Blocker
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C. Antiviral
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