Nokea
An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care?
- A. Nasogastric intubation
- B. Administration of probiotic supplements
- C. Bedrest
- D. Cautious hydration
Correct Answer: D
Rationale: Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the patient.
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A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?
- A. Increase oral fluids unless contraindicated
- B. Call the nurse for oral suctioning, as needed
- C. Lie in a low Fowlers or supine position
- D. Increase activity
Correct Answer: A
Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.
The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment?
- A. Lately, I have this cough that just never seems to go away
- B. I find that I dont have nearly the stamina that I used to
- C. I seem to get nearly every cold and flu that goes around my workplace
- D. I never used to have any allergies, but now I think Im developing allergies to dust and pet hair
Correct Answer: A
Rationale: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections, and fatigue are not characteristic early signs of lung cancer.
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action?
- A. Smoking decreases the amount of mucus production
- B. Smoke particles compete for binding sites on hemoglobin
- C. Smoking causes atrophy of the alveoli
- D. Smoking damages the ciliary cleansing mechanism
Correct Answer: D
Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication?
- A. Acute respiratory distress syndrome (ARDS)
- B. Atelectasis
- C. Aspiration
- D. Pulmonary embolism
Correct Answer: B
Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.
A patient who was involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care?
- A. Facilitation of long-term intubation
- B. Restoration of adequate gas exchange
- C. Attainment of effective coping
- D. Self-management of oxygen therapy
Correct Answer: B
Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.