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 caring for a patient who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?
Correct Answer: D
Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.
Question 3 of 5
The nurse is caring for a patient with primary pulmonary hypertension (PPH) who has been taking a calcium channel blocker with no effect. Which of the following medications should the nurse expect that the patient will receive next?
Correct Answer: C
Rationale: Iloprost has revolutionized care for PPH. It is now the treatment of choice for select patients unresponsive to calcium channel blockers. It is a long-acting chemically stable prostacyclin analogue, which is administered in an aerosolized form (100-150 mcg/day). Bosentan is an oral form of prostacyclin used to treat PPH. Nifedipine and diltiazem are calcium channel blockers.
Question 4 of 5
The health care provider writes a prescription for bacteriological testing for a patient who has a positive tuberculosis skin test. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Three consecutive sputum specimens are obtained on different days for bacteriological testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated.
Question 5 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.