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Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which of the following information best supports this diagnosis?
- A. Weak, nonproductive cough effort
- B. Large amounts of greenish sputum
- C. Respiratory rate of 28 breaths/minute
- D. Resting pulse oximetry (SPO2) of 85%
Correct Answer: A
Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
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Which of the following prescriptions should the nurse implement first for a patient who has just been admitted with probable bacterial pneumonia and sepsis?
- A. Administer Aspirin suppository.
- B. Send to radiology for chest x-ray.
- C. Give ciprofloxacin 400 mg IV.
- D. Obtain blood cultures from two sites.
Correct Answer: D
Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and Aspirin administration can be done last.
The nurse is caring for a patient with a pleural effusion who is scheduled for a thoracentesis. Which of the following actions should the nurse implement prior to the procedure?
- A. Start a peripheral intravenous line to administer the necessary sedative drugs.
- B. Position the patient sitting upright on the edge of the bed and leaning forward.
- C. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
- D. Instruct the patient about the importance of incentive spirometer use after the procedure.
Correct Answer: B
Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed. Incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious.
The health care provider inserts a chest tube in a patient with a hemo-pneumothorax. When monitoring the patient after the chest tube placement, which of the following findings is of greatest concern?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct Answer: B
Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care provider. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.
The nurse is caring for a patient who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?
- A. Paradoxical chest movement
- B. The complaint of chest wall pain
- C. A heart rate of 110 beats/minute
- D. A large bruised area on the chest
Correct Answer: A
Rationale: Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
A patient with newly diagnosed lung cancer tells the nurse, 'I think I am going to die pretty soon.' Which of the following responses by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.