Nokea
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21 , oxygen saturation $93 \%$ on $2 \mathrm{~L}$ nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply:
- A. Keep head-of-the-bed less than 30 degrees at all times.
- B. Collect sputum cultures.
- C. Encourage 3L of fluids a day to keep secretions thin.
- D. Encourage incentive spirometer usage
- E. Provide education about receiving the Pneumovax vaccine annually.
Correct Answer: B,D
Rationale: Sputum cultures identify the causative organism, and incentive spirometer use promotes lung expansion. Head-of-bed <30 degrees increases aspiration risk, 3L fluids may overload heart failure patients, and Pneumovax is not annual.
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When the client asks why the physician chose this particular drug to treat the pneumonia, which response by the nurse is best?
- A. The sensitivity report showed the organism is often killed by penicillin.
- B. Most viral infections respond well when treated with penicillin drugs.
- C. Penicillin is one of the safest yet most effective antibiotics.
- D. All antibiotics are similar; the choice of drug is not that important.
Correct Answer: A
Rationale: Penicillin is chosen based on the sensitivity report, indicating that the pneumococcal bacteria are susceptible to it.
Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment?
- A. Assess the client's bilateral lung sounds.
- B. Obtain an order for a STAT chest x-ray.
- C. Notify the health-care provider as soon as possible.
- D. Document the findings in the client's chart.
Correct Answer: A
Rationale: No tidaling may indicate resolution or obstruction; assessing lung sounds (A) confirms status. CXR (B), notification (C), and documentation (D) follow.
The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply.
- A. The client will be able to speak again after the surgery area has healed.
- B. The client should wear a protective covering over the stoma when showering.
- C. The client should clean the stoma and then apply a petroleum-based ointment.
- D. The client should use a humidifier in the room.
- E. The client can get a special telephone for communication.
Correct Answer: B,D,E
Rationale: Showering protection (B), humidifiers (D), and special phones (E) support tracheostomy care. Speech (A) is lost permanently, and petroleum ointment (C) risks infection.
Select all the medications used to treat pneumonia that are narrowspectrum?
- A. Macrolides
- B. Tamiflu
- C. Fluroquinolones
- D. Penicillins
Correct Answer: A,D
Rationale: Narrow-spectrum antibiotics target specific bacteria. Macrolides and Penicillins are narrow-spectrum, effective against gram-positive bacteria common in pneumonia. Tamiflu is antiviral, and Fluoroquinolones are broad-spectrum.
Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD?
- A. I need to get an influenza vaccine each year, even when there is a shortage.
- B. I need to get a vaccine for pneumonia each year with my influenza shot.
- C. If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing.
- D. I need to restrict my drinking liquids to keep from having so much phlegm.
Correct Answer: A
Rationale: Annual flu vaccines (A) reduce COPD exacerbation risk, even in shortages. Pneumonia vaccines (B) are not yearly, smoking reduction (C) is insufficient, and fluid restriction (D) is incorrect.