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The nurse is caring for a patient with pneumonia who has symptoms of a sharp pain 'whenever I take a deep breath.' Which of the following actions should the nurse take next?
- A. Listen to the patient's lungs.
- B. Administer the PRN morphine.
- C. Have the patient cough forcefully.
- D. Notify the patient's health care provider.
Correct Answer: A
Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
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The nurse is caring for a patient with pneumonia has a fever of 38.4 C (101.1 F). Which of the following orders should the nurse implement first?
- A. Administer acetaminophen 650 mg.
- B. Obtain blood and sputum cultures.
- C. Administer ceftriaxone 1 g IV.
- D. Give patient cool compresses.
Correct Answer: B
Rationale: Obtaining cultures before antibiotic administration is critical to identify the causative organism and ensure appropriate treatment. Administering acetaminophen and ceftriaxone are important but should follow culture collection to avoid altering results. Cool compresses are a supportive measure but not the priority.
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.
The nurse is caring for a patient with primary pulmonary hypertension (PPH) who is receiving nifedipine. Which of the following findings indicate that the treatment is effective?
- A. BP is less than 140/90 mm Hg
- B. Patient reports decreased exertional dyspnea.
- C. Heart rate is between 60 and 100 beats/minute.
- D. Patient's chest x-ray indicates clear lung fields.
Correct Answer: B
Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.
The nurse notes new onset confusion in an older-adult patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions?
- A. Obtain the oxygen saturation.
- B. Check the patient's pulse rate.
- C. Document the change in status.
- D. Notify the health care provider.
Correct Answer: A,B,D,C
Rationale: Assessment for physiological causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.
The nurse is providing teaching to a patient with pulmonary tuberculosis (TB) regarding the transmission of TB. Which of the following patient actions indicate that the teaching has been effective?
- A. Demonstrates correct use of a nebulizer
- B. Washes dishes and personal items after use.
- C. Covers the mouth and nose when coughing.
- D. Reports daily to the public health department.
Correct Answer: C
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.