Nokea
To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which of the following assessments should the nurse make?
- A. Lung sounds
- B. Heart sounds
- C. Blood pressure
- D. Peripheral edema
Correct Answer: D
Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distension, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale.
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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 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 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.
The nurse is caring for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which of the following actions should the nurse take first?
- A. Assist the patient to sit up at the bedside.
- B. Splint the patient's chest during coughing.
- C. Medicate the patient with the prescribed morphine.
- D. Have the patient use the prescribed incentive spirometer.
Correct Answer: C
Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.
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.