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
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?
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?
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
26. A nurse received report on the following clients. Which of these clients should see following report?
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?
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)?
29 Your client has right middle lobe pneumonia. In what position should the nurse place the patient to perform postural drainage?
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?
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.
32. After morning report on a respiratory floor, which of the following patients, should the nurse assess first?
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
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
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.
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?
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?
38. Heparin Infusion Protocol
Standard Drip Mix = 25.000units heparin in 500 mLD W
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
39. The client needs instructions to use the incentive spirometer. The nurse should instruct the client to
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
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.
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