ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 30 Questions
Question 1 of 5
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?
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.
Question 2 of 5
The nurse is conducting a chest assessment on a patient with pneumococcal pneumonia. Which of the following findings should the nurse expect to assess?
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.
Question 3 of 5
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?
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.
Question 4 of 5
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?
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.
Question 5 of 5
Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?
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.