Nokea
The nurse is conducting a chest assessment on a patient with pneumococcal pneumonia. Which of the following findings should the nurse expect to assess?
- A. Vesicular breath sounds
- B. Increased tactile fremitus
- C. Dry, nonproductive cough
- D. Hyper-resonance to percussion
Correct Answer: B
Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.
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The nurse is caring for a patient who had a thoracotomy 1 hour ago and reports incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which of the following actions is best for the nurse to take next?
- A. Administer the prescribed PRN morphine.
- B. Assist the patient to deep breathe and cough.
- C. Milk the chest tube gently to remove any clots.
- D. Tape the area around the insertion site of the chest tube.
Correct Answer: A
Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
The nurse is providing pre-operative instruction for a patient who is scheduled for a left pneumonectomy for cancer of the lung. Which of the following information should the nurse include related to postoperative care?
- A. Positioning on the right side
- B. Bed rest for the first 24 hours
- C. Frequent use of an incentive spirometer
- D. Chest tubes to water-seal chest drainage
Correct Answer: C
Rationale: Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis.
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 in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first?
- A. Position the patient so that the right chest is dependent.
- B. Keep the head of the patient's bed at no more than 30 degrees elevation.
- C. Tape a nonporous dressing on three sides over the chest wound.
- D. Cover the sucking chest wound firmly with an occlusive dressing.
Correct Answer: C
Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30-45 degrees to facilitate breathing.
Which of the following information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
- A. Chest x-ray shows no upper lobe infiltrates.
- B. TB medications have been taken for 6 months.
- C. Mantoux testing shows an induration of 10 mm.
- D. Three sputum smears for acid-fast bacilli are negative.
Correct Answer: D
Rationale: Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment.