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21. A client who was admitted with pneumonia was complaining of abdominal pain from frequent non-...

21. A client who was admitted with pneumonia was complaining of abdominal pain from frequent non- productive coughing. When he does produce sputum, it is watery and yellowish-green. Which of the following are appropriate nursing interventions at this time? Select all that apply

  1. Give him a pillow for splinting
  2. Administer antitussive syrup, 30mg ordered prn.
  3. Place him in appropriate positions for postural drainage
  4. Encourage him to increase his oral fluid intake
  5. Request an order for increasing flow rate.

22. A priority nursing diagnosis for the newly admitted client who is diagnosed with pneumonia is: Inadequate Ventilation R / T Exhaustion. Which of the following nursing interventions appropriate for the client?

  1. Place client in appropriate postural drainage positions
  2. Administer antibiotics q 4 hours as ordered
  3. Encourage deep breathing 2-3 times each half hour
  4. Insure that the ordered is delivered cannula

23. A nurse is discharging a client with TB (Tuberculosis) who has been on medications for 1 week. Which statement by the client indicates that additional teaching is needed?

  1. “I need to be sure to include foods that have a lot of calories”.
  2. “I will wear a surgical mask on my taxi ride home”.
  3. All the people I work with need to be tested for TB”
  4. My meds can be stopped in 9 weeks when sputum tests are negative”.

24. A client is admitted to the unit with pneumonia. Oxygen is started at 4L/minute via nasal cannula. Two days later, which of the following changes would indicate to the nurse that the client was developing oxygen toxicity?

A. Vesicular sounds at apices

B. Alert & oriented to name only

C. Intermittent periods of apnea

D. Respiratory rate of 12 per min.

25. Which of the following nursing interventions are important to include in the care of a patient admitted with bilateral bl -basilar pneumonia? Select all that apply

  1. Teach the Huff method of coughing
  2. Restrict oral fluid intake during meals
  3. Maintain a high Fowlers position.
  4. Schedule IPPB treatments after meals
  5. Administer ordered mucolytic via nebulizer

26. A nurse received report on the following clients. Which of these clients should see following report?

  1. 70 yo female with bilateral pneumonia, respiratory rate is 11 bpm & shallow
  2. 26 yo female 1-daypost bariatric surgery whose resp. rate decreased from 32 to 22/min
  3. 31 yo male admitted with bronchitis 24 hours ago, c/o chest pain with deep inspirations
  4. 43 male who has TB and is scheduled for a chest x-ray in downstairs lab

27. Which of the following clients is most at risk for developing oxygen toxicity when using nasal cannula at a flow rate of 5 liters /minute?

  1. 55 yr male, weighing 170 pounds, recovering from knee surgery
  2. 34 yr male, weighing 110 pounds, post op colostomy placement
  3. 47 yr female weighing 150 pounds, who has a fractured femur
  4. 18 yr female, weighing 175 pounds, during the delivery of a baby

28. Which of the following nursing actions should be included in the care of the client who is receiving oxygen via Venturi face mask (yellow device – 28%/4Liters)?

  1. Change the mask every 24 hours.
  2. Perform oral care q 2-4 hours.
  3. Monitor for signs of oxygen toxicity.
  4. Check the flow rate q 24 hours.

29 Your client has right middle lobe pneumonia. In what position should the nurse place the patient to perform postural drainage?

  1. Prone with head and chest elevated on pillows
  2. Head down lying on right side
  3. Semi Fowlers
  4. Head down lying on left side

30. A 35 year old client has been admitted with a diagnosis of pneumonia. The client's current respiratory rate is 24 and pulse rate is 132. Which of the following additional findings should be addressed FIRST by the nurse?

  1. Pleuritic chest pain of 8 (scale 0-10)
  2. Blood pressure of 92/56
  3. Tympanic temperature of 101.6
  4. Pulse oximetry reading of 95

31. A 34 yo female was admitted to the hospital with a diagnosis of bacterial pneumonia. Admission vital signs are: B/P 115/72, pulse 119, respiratory rate 32, temperature of 101.8. MD orders include “diet as tolerated”. Which of the following menu items would be best for the nurse to suggest for this client.

  1. Broiled chicken and steamed broccoli
  2. Saltine crackers and cheese slices
  3. Baked salmon, rice and milkshake
  4. Apple juice and some containers of jello.

32. After morning report on a respiratory floor, which of the following patients, should the nurse assess first?

  1. 21-year- old female, with tuberculosis, whose IV of Normal Saline has 45 remaining
  2. 49year-old female, with pneumonia, who's tympanic temperature is still 101.2
  3. 70-year-old male, with pneumonia who now thinks the hospital is a hotel on Long Island
  4. 36year -old male, with a flail chest complaining of pain on inspiration (7 on scale of 0- 10)

33. A patient comes to the clinic requesting a Mantoux Tuberculin Skin Test for employment. The nurse administers 0.1 ml of tuberculin purified protein derivative (PPD) into the intradermal on the ventral surface of the forearm and charted the location. The nurse’s next action should be to instruct the patient to

  1. Keep the area dry and covered.
  2. Apply a thin film of corticosteroid cream
  3. Return to have it interpreted in 1 week
  4. Avoid scratching the application site.

34. A patient who has a severe case of community acquired pneumonia had a physician's order for activity as tolerated". The best nursing response for the patient should be to

  1. assist the patient to sit in a chair three times a day
  2. check pulse before allowing him to stand urinate.
  3. ask the patient what activities he would like to do
  4. keep patient on strict bedrest for the first 24 hours

35. A client who was admitted with pneumonia was complaining of abdominal pain from frequent non-productive coughing. When he does produce sputum, it is watery and yellowish-green. Which of the following are appropriate nursing interventions at this time? Select all that apply.

  1. Give him a pillow for splinting
  2. Request an order for increasing IV flow rate
  3. Place him in appropriate positions for postural drainage.
  4. Encourage him to increase his oral fluid intake.
  5. Administer antitussive syrup, 30mg ordered prn.

36. Nursing care of a patient who has a diagnosed DVT and is being treated with IV heparin therapy will include which of the following?

  1. Elevating affected LE with pillows
  2. Measuring LE diameters daily
  3. Monitoring INR levels morning
  4. Insuring that diet includes only 5-10% protein

37. A client was admitted for observation following smoke inhalation. To ensure that the client had 100% oxygen delivered, the nurse should choose which of the following devices?

  1. Venturi mask with highest % device inserted
  2. Nasal Cannula
  3. Partial-rebreather mask
  4. Non-rebreather mask

38. Heparin Infusion Protocol

Standard Drip Mix = 25.000units heparin in 500 mLD W

  • If aPTT is less than 30 notify MD
  • If aPTT is between 30 - 40 , increase the rate by 120 units/hour
  • If aPTT is between 41 – 70 maintain the current rate
  • If aPTT is between 71 - 80 decrease the rate by 120 units/hour
  • If aPTT is greater than stop the infusion and call MD

The client's heparin was infusing at 20mL / hour. This morning, the client's activated Partial Thromboplastin Time (aPTT) was 71. Use the heparin protocol above to determine the appropriate nursing intervention

  1. Stop the infusion immediately
  2. Decrease the drip rate by 2.6 ml per hour.
  3. Call the doctor to clarify the orders
  4. Set the heparin drip rate at 17.6 ml/hr

39. The client needs instructions to use the incentive spirometer. The nurse should instruct the client to

  1. Inhale deeply and then blow gently into the device.
  2. Maintain the mask’s vents in the open position when inhaling.
  3. Use the spirometer whenever the patient feels short of breath.
  4. Practice using it at least q hour for about 8-10 breaths each time.

40. When a client is discharged with an order for Coumadin (sodium warfarin), the nurse should teach the client

which the following ? Select all that apply

  1. INR values prior to discharge must between 1-2
  2. A rectal every week is needed to assess for bleeding
  3. Dark green vegetables should always be avoided
  4. Blood sample must be drawn periodically while taking Coumadin
  5. Tooth brushes purchased should be “soft”.

Homework Answers

Answer #1

21.D.Encourage him to increase oral fluid intake to help to dilute the sputum for easy splitting.

22.B.administration of antibiotics will be the priority nursing intervention for pneumonia.

23.D.my medicines can be stopped after sputum test if it comes negative. This is a wring statement as it shows patient need more education. TB medicines cannot be stopped after few weeks. It should be continued at least for 6 months as per order.

24. A. Vesicular sound at apices indicates that patient has oxygen toxicity.

25.

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