Nokea
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.
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Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?
- A. Turn and reposition immobile patients at least every 2 hours.
- B. Place patients with altered consciousness in side-lying positions.
- C. Monitor for respiratory symptoms in patients who are immuno-suppressed.
- D. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
Correct Answer: B
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.
The nurse is providing teaching to a patient with pneumonia. Which of the following patient statements indicate a good understanding of the discharge instructions given by the nurse?
- A. I will call the doctor if I still feel tired after a week.
- B. I will need to use home oxygen therapy for 3 months.
- C. I will continue to do the deep-breathing and coughing exercises at home.
- D. I will schedule two appointments for the pneumonia and influenza vaccines.
Correct Answer: C
Rationale: Patients should continue to cough and deep breathe after discharge for up to 6-8 weeks. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumonia and influenza vaccines can be given at the same time.
The nurse is caring for a patient with bacterial pneumonia who has pleurisy. Which of the following actions should the nurse implement to promote airway clearance?
- A. Assist the patient to splint the chest when coughing.
- B. Educate the patient about the need for fluid restrictions.
- C. Encourage the patient to wear the nasal oxygen cannula.
- D. Instruct the patient on the pursed lip breathing technique.
Correct Answer: A
Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
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.
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.