Nokea
The nurse is caring for a patient with right lower-lobe pneumonia who has been treated with intravenous (IV) antibiotics for 2 days. Which of the following assessment data obtained by the nurse indicates that the treatment has been effective?
- A. Bronchial breath sounds are heard at the right base.
- B. The patient coughs up small amounts of green mucus.
- C. The patient's white blood cell (WBC) count is 9 x 10^9/L.
- D. Increased tactile fremitus is palpable over the right chest.
Correct Answer: C
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
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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.
The nurse has completed discharge teaching for a patient who has had a lung transplant. Which of the following patient statements indicate that the teaching was effective?
- A. I will make an appointment to see the doctor every year.
- B. I will not turn the home oxygen up higher than 2 L/minute.
- C. I will not worry if I feel a little short of breath with exercise.
- D. I will call the health care provider right away if I develop a fever.
Correct Answer: D
Rationale: Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team, annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported.
The nurse is assessing a patient who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
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 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.