Nokea
A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 ' $F$. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia?
- A. Aspiration pneumonia
- B. Ventilator acquired pneumonia
- C. Hospital-acquired pneumonia
- D. Community-acquired pneumonia
Correct Answer: C
Rationale: Hospital-acquired pneumonia (HAP) develops 48 hours or more after hospital admission, as seen in this patient. Aspiration pneumonia is linked to inhaling foreign material, ventilator-acquired pneumonia requires mechanical ventilation, and community-acquired pneumonia occurs outside healthcare settings.
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Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD?
- A. Clubbing of the client's fingers.
- B. Infrequent respiratory infections.
- C. Chronic sputum production.
- D. Nonproductive hacking cough.
Correct Answer: C
Rationale: Chronic sputum production (C) is a hallmark of COPD (chronic bronchitis). Clubbing (A) is late-stage, infections (B) are frequent, and nonproductive cough (D) is atypical.
Which assessment finding indicates that the client has most likely developed pleurisy as a result of the pneumonia?
- A. Productive cough
- B. Pain when breathing
- C. Cyanotic nail beds
- D. Rapid heart rate
Correct Answer: B
Rationale: Pleurisy causes sharp chest pain during breathing due to inflammation of the pleural membranes.
A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in so the results can be interpreted?
- A. 24-48 hours
- B. 12-24 hours
- C. 48-72 hours
- D. 24-72 hours
Correct Answer: C
Rationale: The PPD skin test (Mantoux) is read 48-72 hours after administration to assess for induration, as this is the standard timeframe for an accurate immune response to be visible.
Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching?
- A. If I lose weight I may not need treatment for sleep apnea.
- B. The CPAP machine holds my airway open with pressure.
- C. The CPAP will help me stay awake during the day while I am at work.
- D. It is all right to have a couple of beers because I have this CPAP machine.
Correct Answer: D
Rationale: Alcohol (D) worsens sleep apnea by relaxing airway muscles, contradicting effective CPAP use. Weight loss (A) can reduce sleep apnea severity. CPAP maintaining airway patency (B) and improving daytime alertness (C) are correct.
When caring for a client with allergies, which nursing assessment finding is an early indication that the client is developing anaphylaxis?
- A. Breathing difficulty
- B. Headache
- C. Sore throat
- D. Cool, pale skin
Correct Answer: A
Rationale: Breathing difficulty is an early sign of anaphylaxis, indicating airway constriction or swelling, which requires immediate intervention.