Nursing Management: Lower Respiratory Problems
Questions With Complete Solutions
1. Following assessment of a patient with pneumonia, the nurse
identifies a nursing diagnosis of ineffective airway clearance.
Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort Correct Answers D
Rationale: 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.
Cognitive Level: Application Text Reference: p. 568
Nursing Process: Diagnosis
Health Promotion and Maintenance
14. The nurse recognizes that the goals of teaching regarding
the transmission of TB have been met when the patient with TB
a. demonstrates correct use of a nebulizer.
b. reports daily to the public health department.
c. washes dishes and personal items after use.
d. covers the mouth and nose when coughing. Correct Answers
D
Rationale: Covering the mouth and nose will help decrease
airborne transmission of TB. The other actions will not be
effective in decreasing the spread of TB.
,Cognitive Level: Application Text Reference: p. 574
Nursing Process: Evaluation
Health Promotion and Maintenance
15. A patient is receiving isoniazid (INH) after having a
positive tuberculin skin test. Which information will the nurse
include in the patient teaching plan?
a. "Take vitamin B6 daily to prevent peripheral nerve damage."
b. "Read a newspaper daily to check for changes in vision."
c. "Schedule an audiometric examination to monitor for hearing
loss."
d. "Avoid wearing soft contact lenses to avoid orange staining."
Correct Answers A
Rationale: Peripheral neurotoxicity associated can be prevented
by taking vitamin B6 when being treated with INH. Visual
changes, hearing problems, and orange staining are adverse
effects of other TB medications.
Cognitive Level: Application Text Reference: p. 573
Nursing Process: Planning
Health Promotion and Maintenance
20. During IV administration of amphotericin B ordered for
treatment of coccidioidomycosis, the nurse increases the
patient's tolerance of the drug by
a. cooling the solution to 80° F before administration.
,b. keeping the patient flat in bed for 1 hour after the infusion is
completed.
c. diluting the amphotericin B in 500 ml of sterile water.
d. giving diphenhydramine (Benadryl) 1 hour before starting the
infusion. Correct Answers D
Rationale: Administration of an antihistamine before giving the
amphotericin B will reduce the incidence of hypersensitivity
reactions. Cooling the solution and keeping the patient flat after
infusion are not indicated. Amphotericin B does not need to be
diluted in 500 ml of fluid, although the nurse should ensure
adequate hydration in the patient receiving this drug.
Cognitive Level: Application Text Reference: p. 575
Nursing Process: Implementation
Health Promotion and Maintenance
24. When developing a teaching plan for a patient with a 42
pack-year history of cigarette smoking, it will be most important
for the nurse to include information about
a. reasons for annual sputum cytology testing.
b. CT screening for lung cancer.
c. erlotinib (Tarceva) therapy to prevent tumor risk.
d. options for smoking cessation. Correct Answers D
Rationale: Because smoking is the major cause of lung cancer,
the most important role for the nurse is educating patients about
the benefits of and means of smoking cessation. Early screening
of at-risk patients using sputum cytology, chest x-ray, or CT
scanning has not been effective in reducing mortality. Tarceva
, may be used to in patients who have lung cancer, but not to
reduce risk for developing tumors.
Cognitive Level: Application Text Reference: pp. 582, 584
Nursing Process: Planning
Health Promotion and Maintenance
25. A lobectomy is scheduled for a patient with stage I non-
small cell lung cancer. The patient tells the nurse, "I would
rather have radiation than surgery." Which response by the nurse
is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Tell me what you know about the various treatments
available."
c. "Surgery is the treatment of choice for stage I lung cancer."
d. "Did you have bad experiences with previous surgeries?"
Correct Answers B
Rationale: More assessment of the patient's concerns about
surgery is indicated; an open-ended response will elicit the most
information from the patient. The answer beginning, "Surgery is
the treatment of choice" is accurate, but it discourages the
patient from sharing concerns about surgery. The remaining two
answers indicate that the nurse has jumped to conclusions about
the patient's reasons for not wanting surgery.
Cognitive Level: Application Text Reference: pp. 583-584
Nursing Process: Implementation
Health Promotion and Maintenance
Questions With Complete Solutions
1. Following assessment of a patient with pneumonia, the nurse
identifies a nursing diagnosis of ineffective airway clearance.
Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort Correct Answers D
Rationale: 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.
Cognitive Level: Application Text Reference: p. 568
Nursing Process: Diagnosis
Health Promotion and Maintenance
14. The nurse recognizes that the goals of teaching regarding
the transmission of TB have been met when the patient with TB
a. demonstrates correct use of a nebulizer.
b. reports daily to the public health department.
c. washes dishes and personal items after use.
d. covers the mouth and nose when coughing. Correct Answers
D
Rationale: Covering the mouth and nose will help decrease
airborne transmission of TB. The other actions will not be
effective in decreasing the spread of TB.
,Cognitive Level: Application Text Reference: p. 574
Nursing Process: Evaluation
Health Promotion and Maintenance
15. A patient is receiving isoniazid (INH) after having a
positive tuberculin skin test. Which information will the nurse
include in the patient teaching plan?
a. "Take vitamin B6 daily to prevent peripheral nerve damage."
b. "Read a newspaper daily to check for changes in vision."
c. "Schedule an audiometric examination to monitor for hearing
loss."
d. "Avoid wearing soft contact lenses to avoid orange staining."
Correct Answers A
Rationale: Peripheral neurotoxicity associated can be prevented
by taking vitamin B6 when being treated with INH. Visual
changes, hearing problems, and orange staining are adverse
effects of other TB medications.
Cognitive Level: Application Text Reference: p. 573
Nursing Process: Planning
Health Promotion and Maintenance
20. During IV administration of amphotericin B ordered for
treatment of coccidioidomycosis, the nurse increases the
patient's tolerance of the drug by
a. cooling the solution to 80° F before administration.
,b. keeping the patient flat in bed for 1 hour after the infusion is
completed.
c. diluting the amphotericin B in 500 ml of sterile water.
d. giving diphenhydramine (Benadryl) 1 hour before starting the
infusion. Correct Answers D
Rationale: Administration of an antihistamine before giving the
amphotericin B will reduce the incidence of hypersensitivity
reactions. Cooling the solution and keeping the patient flat after
infusion are not indicated. Amphotericin B does not need to be
diluted in 500 ml of fluid, although the nurse should ensure
adequate hydration in the patient receiving this drug.
Cognitive Level: Application Text Reference: p. 575
Nursing Process: Implementation
Health Promotion and Maintenance
24. When developing a teaching plan for a patient with a 42
pack-year history of cigarette smoking, it will be most important
for the nurse to include information about
a. reasons for annual sputum cytology testing.
b. CT screening for lung cancer.
c. erlotinib (Tarceva) therapy to prevent tumor risk.
d. options for smoking cessation. Correct Answers D
Rationale: Because smoking is the major cause of lung cancer,
the most important role for the nurse is educating patients about
the benefits of and means of smoking cessation. Early screening
of at-risk patients using sputum cytology, chest x-ray, or CT
scanning has not been effective in reducing mortality. Tarceva
, may be used to in patients who have lung cancer, but not to
reduce risk for developing tumors.
Cognitive Level: Application Text Reference: pp. 582, 584
Nursing Process: Planning
Health Promotion and Maintenance
25. A lobectomy is scheduled for a patient with stage I non-
small cell lung cancer. The patient tells the nurse, "I would
rather have radiation than surgery." Which response by the nurse
is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Tell me what you know about the various treatments
available."
c. "Surgery is the treatment of choice for stage I lung cancer."
d. "Did you have bad experiences with previous surgeries?"
Correct Answers B
Rationale: More assessment of the patient's concerns about
surgery is indicated; an open-ended response will elicit the most
information from the patient. The answer beginning, "Surgery is
the treatment of choice" is accurate, but it discourages the
patient from sharing concerns about surgery. The remaining two
answers indicate that the nurse has jumped to conclusions about
the patient's reasons for not wanting surgery.
Cognitive Level: Application Text Reference: pp. 583-584
Nursing Process: Implementation
Health Promotion and Maintenance
