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1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort

D
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.

Cognitive Level: Application Text Reference: p. 568
Nursing Process: Diagnosis NCLEX: Physiological Integrity

2. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first?
a. Azithromycin (Zithromax)
b. Acetaminophen (Tylenol)
c. Guaifenesin (Robitussin)
d. Codeine phosphate (Codeine)

A
Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

Cognitive Level: Application Text Reference: pp. 563, 566
Nursing Process: Implementation NCLEX: Physiological Integrity

3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
a. hyperresonance on percussion.

b. increased vocal fremitus on palpation.
c. fine crackles in all lobes on auscultation.
d. asymmetric chest expansion on inspection.

B
Rationale: Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion. Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric chest expansion is not typical with pneumonia.

Cognitive Level: Application Text Reference: p. 565
Nursing Process: Assessment NCLEX: Physiological Integrity

4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
a. splint the chest when coughing.
b. maintain fluid restrictions.
c. wear the nasal oxygen cannula.
d. try the pursed-lip breathing technique.

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 in patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia.

Cognitive Level: Application Text Reference: p. 568
Nursing Process: Implementation NCLEX: Physiological Integrity

5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia?
a. 24-year-old patient who has had temperatures ranging from 100.6° to 101° F
b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours
c. 50-year-old patient who has an oxygen saturation of 91% on room air
d. 72-year-old patient with a pulse of 102 and a blood pressure (BP) of 90/56

C
Rationale: The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria. The other patients do not meet the criteria for discharge.

Cognitive Level: Application Text Reference: p. 563
Nursing Process: Planning NCLEX: Physiological Integrity

6. A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is
a. hyperthermia related to infectious illness.
b. ineffective airway clearance related to thick secretions.
c. impaired transfer ability related to weakness.
d. impaired gas exchange related to respiratory congestion.

D
Rationale: All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

Cognitive Level: Application Text Reference: p. 566
Nursing Process: Diagnosis NCLEX: Physiological Integrity

7. The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next?
a. Check the patient's pulse rate.
b. Obtain an oxygen saturation.
c. Notify the health care provider.
d. Document the change.

B
Rationale: New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change in status.

Cognitive Level: Application Text Reference: p. 565
Nursing Process: Implementation NCLEX: Physiological Integrity

8. Following discharge teaching, the nurse evaluates that the patient who was admitted with pneumonia understands measures to prevent a reoccurrence of the pneumonia when the patient states,
a. "I will increase my food intake to 3000 calories a day."
b. "I will need to use home oxygen therapy for 3 months."
c. "I will seek medical treatment for any upper respiratory infections."
d. "I will do deep-breathing and coughing exercises for the next 6 weeks."

D
Rationale: Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep breathing and coughing exercises or both for 6 to 8 weeks after discharge. Although caloric needs are increased during the acute infection, 3000 calories daily will lead to obesity and increase the risk for pneumonia. Patients with acute lower respiratory infections do not usually require home oxygen therapy. Upper respiratory infections require medical treatment only when they fail to resolve in 7 days.

Cognitive Level: Application Text Reference: p. 569
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to
a. turn and reposition immobile patients at least every 2 hours.
b. position patients with altered consciousness in lateral positions.
c. monitor frequently for respiratory symptoms in patients who are immunosuppressed.
d. provide for continuous subglottic aspiration in patients receiving enteral feedings.

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 pneumonias in immune compromised 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.

Cognitive Level: Application Text Reference: p. 567
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

10. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. Increased vocal fremitus is palpable over the right chest.
c. The patient coughs up small amounts of green mucous.
d. The patient's white blood cell (WBC) count is 9000/µl.

D
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

Cognitive Level: Application Text Reference: p. 569
Nursing Process: Evaluation NCLEX: Physiological Integrity

11. The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant
a. turns the patient over to the right side.
b. splints the patient's chest during coughing.
c. elevates the patient's head to 45 degrees.
d. assists the patient to get up to the bathroom.

A
Rationale: Positioning the patient with the left (or "good" lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia.

Cognitive Level: Application Text Reference: p. 569
Nursing Process: Implementation NCLEX: Physiological Integrity

12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen?
a. After the patient rinses the mouth with mouthwash
b. As soon as the order is received from the health care provider
c. Right after the patient gets up in the morning
d. After the skin test is administered

C
Rationale: Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no need to wait until the tuberculin skin test is administered.

Cognitive Level: Application Text Reference: p. 572
Nursing Process: Implementation NCLEX: Physiological Integrity

13. A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the disease can be transmitted to others until
a. the chest x-ray shows resolution of the tuberculosis.
b. three sputum smears for acid-fast bacilli are negative.
c. TB medications have been taken for 6 months.
d. sputum cultures on 3 consecutive days are negative.

B
Rationale: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest x-rays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment. Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum smears are usually done to establish that treatment has been effective.

Cognitive Level: Application Text Reference: p. 574
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB
a. demonstrates correct use of a nebulizer.
b. reports daily to the public health department.
c. washes dishes and personal items after use.
d. covers the mouth and nose when coughing.

D
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.

Cognitive Level: Application Text Reference: p. 574
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan?
a. "Take vitamin B6 daily to prevent peripheral nerve damage."
b. "Read a newspaper daily to check for changes in vision."
c. "Schedule an audiometric examination to monitor for hearing loss."
d. "Avoid wearing soft contact lenses to avoid orange staining."

A
Rationale: Peripheral neurotoxicity associated can be prevented by taking vitamin B6 when being treated with INH. Visual changes, hearing problems, and orange staining are adverse effects of other TB medications.

Cognitive Level: Application Text Reference: p. 573
Nursing Process: Planning NCLEX: Physiological Integrity

16. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops
a. yellow-tinged skin.
b. changes in hearing.
c. orange-colored urine.
d. thickening of the nails.

A
Rationale: Noninfectious hepatitis is a toxic effect of INH, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

Cognitive Level: Application Text Reference: pp. 572-573
Nursing Process: Implementation NCLEX: Physiological Integrity

17. An alcoholic and homeless patient is diagnosed with active TB. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Giving the patient written instructions about how to take the medications
b. Teaching the patient about the high risk for infecting others unless treatment is followed
c. Arranging for a daily noontime meal at a community center and give the medication then
d. Educating the patient about the long-term impact of TB on health

C
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.

Cognitive Level: Application Text Reference: pp. 572, 575
Nursing Process: Implementation NCLEX: Physiological Integrity

18. After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). The nurse discusses the treatment regimen with the patient with the knowledge that
a. directly observed therapy (DOT) will be necessary if the medications have not been taken correctly.
b. the positive sputum smears indicate that the patient is experiencing toxic reactions to the medications.
c. twice-weekly administration may be used to improve compliance with the treatment regimen.
d. a regimen using only INH and rifampin (Rifadin) will be used for the last 4 months of drug therapy.

A
Rationale: After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. The nurse will need to initiate DOT if the patient has not been consistently taking the medications. Toxic reactions to the medications would not result in a positive sputum smear. Twice-weekly medication administration is not one of the options for therapy. INH and rifampin are used for the last 4 months of drug therapy only if the initial four-drug regimen has been effective as evidenced by negative sputum smears.

Cognitive Level: Application Text Reference: pp. 571-572
Nursing Process: Implementation NCLEX: Physiological Integrity

19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
a. use and side effects of INH.
b. standard four-drug therapy for TB.
c. need for annual repeat TB skin testing.
d. recommendation guidelines for bacille Calmette-Guérin (BCG) vaccine.

A
Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.

Cognitive Level: Application Text Reference: p. 572
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

20. During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases the patient's tolerance of the drug by
a. cooling the solution to 80° F before administration.
b. keeping the patient flat in bed for 1 hour after the infusion is completed.
c. diluting the amphotericin B in 500 ml of sterile water.
d. giving diphenhydramine (Benadryl) 1 hour before starting the infusion.

D
Rationale: Administration of an antihistamine before giving the amphotericin B will reduce the incidence of hypersensitivity reactions. Cooling the solution and keeping the patient flat after infusion are not indicated. Amphotericin B does not need to be diluted in 500 ml of fluid, although the nurse should ensure adequate hydration in the patient receiving this drug.

Cognitive Level: Application Text Reference: p. 575
Nursing Process: Implementation NCLEX: Physiological Integrity

21. The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask?
a. "How long have you lived in the United States?"
b. "Is there any family history of TB?"
c. "Have you received the BCG vaccine for TB?"
d. "Do you take any over-the-counter (OTC) medications?"

C
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test; another method for screening (such as a chest x-ray) will be used in determining whether the patient has a TB infection. The other information may also be valuable but is not as pertinent to the decision about doing TB skin testing.

Cognitive Level: Application Text Reference: p. 572
Nursing Process: Assessment NCLEX: Physiological Integrity

22. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member
a. washes the hands before entering the patient's room.
b. puts on a surgical face mask before visiting the patient.
c. brings food from a "fast-food" restaurant to the patient.
d. hands the patient a tissue from the box at the bedside.

B
Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

Cognitive Level: Application Text Reference: p. 574
Nursing Process: Implementation NCLEX: Physiological Integrity

23. The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will monitor workers for
a. shortness of breath.
b. chest pain.
c. elevated temperature.
d. barrel-chest.

A
Rationale: The nurse will monitor for the earliest signs of occupational lung disease, which are dyspnea and a cough. The other symptoms are also consistent with occupational lung disease but would occur much later, after significant lung involvement has occurred.

Cognitive Level: Application Text Reference: pp. 577-578
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

24. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about
a. reasons for annual sputum cytology testing.
b. CT screening for lung cancer.
c. erlotinib (Tarceva) therapy to prevent tumor risk.
d. options for smoking cessation.

D
Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Tarceva may be used to in patients who have lung cancer, but not to reduce risk for developing tumors.

Cognitive Level: Application Text Reference: pp. 582, 584
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

25. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Tell me what you know about the various treatments available."
c. "Surgery is the treatment of choice for stage I lung cancer."
d. "Did you have bad experiences with previous surgeries?"

B
Rationale: More assessment of the patient's concerns about surgery is indicated; an open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery.

Cognitive Level: Application Text Reference: pp. 583-584
Nursing Process: Implementation NCLEX: Psychosocial Integrity

26. An hour after a left upper lobectomy, a patient complains of 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 action should the nurse take first?
a. Assist the patient to deep breathe and cough.
b. Milk the chest tube gently to remove any clots.
c. Medicate the patient with the ordered morphine.
d. Notify the surgeon about the large air leak.

C
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.

Cognitive Level: Application Text Reference: p. 594
Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon, maybe this week." The best response by the nurse is
a. "Are you afraid that the treatment for your cancer will not be effective?"
b. "Can you tell me what it is that makes you think you will die so soon?"
c. "Would you like to talk to the hospital chaplain about your feelings?"
d. "Do you think that taking an antidepressant medication would be helpful?"

B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

Cognitive Level: Application Text Reference: pp. 583-584
Nursing Process: Implementation NCLEX: Psychosocial Integrity

28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should
a. position the patient so that the right chest is dependent.
b. administer high-flow oxygen using a non-rebreathing mask.
c. cover the sucking chest wound with an occlusive dressing.
d. tape a nonporous dressing on three sides over the chest wound.

D
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 patient should receive oxygen, but this will have no effect on the development of tension pneumothorax.

Cognitive Level: Application Text Reference: p. 586
Nursing Process: Implementation NCLEX: Physiological Integrity

29. The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about
a. a large air leak in the water-seal chamber.
b. 400 ml of blood in the collection chamber.
c. severe pain with each deep patient inspiration.
d. subcutaneous emphysema at the insertion site.

B
Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.

Cognitive Level: Application Text Reference: p. 586
Nursing Process: Assessment NCLEX: Physiological Integrity

30. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about
a. complaints of severe pain.
b. heart rate of 110 beats/min.
c. a large bruised area on the chest.
d. paradoxic chest movement.

D
Rationale: Paradoxic chest movement indicates that the patient may have flail chest, which will severely compromise gas exchange and can rapidly lead to hypoxemia. Severe pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Cognitive Level: Application Text Reference: pp. 586, 588
Nursing Process: Assessment NCLEX: Physiological Integrity

31. The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if
a. the breath sounds on one side are decreased.
b. there are wheezes audible throughout both lungs.
c. there is a sucking sound with each patient breath.
d. paradoxic movement of the chest is noted.

A
Rationale: Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest movement is associated with flail chest.

Cognitive Level: Application Text Reference: p. 586
Nursing Process: Assessment NCLEX: Physiological Integrity

32. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse's first action should be to
a. have the patient use the incentive spirometer.
b. medicate the patient with the ordered morphine.
c. splint the patient's chest during coughing.
d. assist the patient to sit up at the bedside.

B
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.

Cognitive Level: Application Text Reference: pp. 591, 594
Nursing Process: Implementation NCLEX: Physiological Integrity

33. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to
a. document the presence of a large air leak.
b. obtain and attach a new collection device.
c. notify the health care provider of a possible pneumothorax.
d. take no further action with the collection device.

C
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.

Cognitive Level: Application Text Reference: p. 591
Nursing Process: Implementation NCLEX: Physiological Integrity

34. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes
a. positioning on the right side.
b. chest tubes to water-seal chest drainage.
c. bedrest for the first 24 hours.
d. frequent use of an incentive spirometer.

D
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.

Cognitive Level: Application Text Reference: pp. 596-597
Nursing Process: Planning NCLEX: Physiological Integrity

35. A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis?
a. Audible crackles at both lung bases
b. 3+ edema in the lower extremities
c. Loud murmur at the mitral area
d. High systemic BP

B
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. Lung crackles, a murmur, and numbness and tingling are not caused by cor pulmonale.

Cognitive Level: Application Text Reference: p. 602
Nursing Process: Assessment NCLEX: Physiological Integrity

36. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action?
a. The international normalized ratio (INR) is prolonged.
b. The central line is disconnected.
c. The oxygen saturation is 90%.
d. The BP is 88/56.

B
Rationale: The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

Cognitive Level: Application Text Reference: p. 601
Nursing Process: Assessment NCLEX: Physiological Integrity

37. A patient with primary pulmonary hypertension is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if
a. the patient reports decreased exertional dyspnea.
b. the blood pressure is less than 140/90 mm Hg.
c. the heart rate is between 60 and 100 beats/minute.
d. the patient's chest x-ray indicates clear lung fields.

A
Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Cognitive Level: Application Text Reference: p. 601
Nursing Process: Evaluation NCLEX: Physiological Integrity

38. A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to
a. position the patient sitting upright on the edge of the bed and leaning forward.
b. instruct the patient about the importance of incentive spirometer use after the procedure.
c. start a peripheral intravenous line to administer the necessary sedative drugs.
d. remove the water pitcher and remind the patient not to eat or drink anything for 8 hours.

A
Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure and there are no restrictions on oral intake, since the patient is not sedated or unconscious.

Cognitive Level: Application Text Reference: p. 596
Nursing Process: Planning NCLEX: Physiological Integrity

39. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states
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 be careful to use sterile technique with my central line."
d. "I will write down my medications and spirometry in a journal."

D
Rationale: After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results. 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 and patients would not usually have a central IV line.

Cognitive Level: Application Text Reference: p. 604
Nursing Process: Evaluation NCLEX: Physiological Integrity

40. A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next?
a. Listen to the patient's lungs.
b. Check the patient's O2 saturation.
c. Have the patient cough forcefully.
d. Notify the patient's health care provider.

A
Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. The re is no indication that the oxygen saturation has decreased The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

Cognitive Level: Application Text Reference: p. 597
Nursing Process: Assessment NCLEX: Physiological Integrity

41. A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give?
a. The skin test will determine if you have a tuberculosis infection.
b. The skin test will indicate whether you have active tuberculosis.
c. The skin test is used to decide which antibiotic therapy will work best.
d. The skin test is done prior to notification of the public health department.

A
Rationale: A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the patient has TB, the nurse should focus on the patient, rather than on the public health concerns.

Cognitive Level: Application Text Reference: p. 571
Nursing Process: Implementation NCLEX: Physiological Integrity

42. All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to the health care provider?
a. The patient has many abdominal bruises.
b. The patient's BP is 90/46.
c. The activated partial thromboplastin time is 2 times the patient baseline.
d. The patient's stool is dark green and liquid.

B
Rationale: The low BP may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin therapy. Subcutaneous heparin administration is given into the subcutaneous tissue of the abdomen and abdominal bruising is not unusual. An aPTT 2 times the baseline indicates a therapeutic heparin level. The patient should be monitored for gastrointestinal bleeding, which would be indicated by black or red stools.

Cognitive Level: Application Text Reference: p. 600
Nursing Process: Assessment NCLEX: Physiological Integrity

43. In developing a teaching plan for a patient who is being discharged with a warfarin (Coumadin) prescription after having a pulmonary embolus, the nurse will include information about
a. where to schedule activated partial thromboplastin time testing.
b. avoidance of a high protein diet.
c. how to obtain enteric-coated aspirin.
d. foods that are high in vitamin K.

D
Rationale: The patient who is taking Coumadin should have a consistent vitamin K intake, since vitamin K interferes with the effect of the medication. INR testing, rather than aPTT testing, is used to monitor for a therapeutic level of Coumadin. Aside from vitamin K, there are no other dietary requirements associated with Coumadin use. Aspirin should be avoided when taking anticoagulant medications because of the effect on platelet function.

Cognitive Level: Application Text Reference: p. 600
Nursing Process: Planning NCLEX: Physiological Integrity

44. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider?
a. BP is 150/90.
b. Pain level is 5/10 with a deep breath.
c. Oxygen saturation is 89%.
d. Respiratory rate is 24 when lying flat.

C
Rationale: Oxygen saturation would be expected to improve after a thoracentesis; a saturation of 89 indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

Cognitive Level: Application Text Reference: p. 596
Nursing Process: Assessment NCLEX: Physiological Integrity

45. All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first?
a. Obtain blood cultures from two sites.
b. Give ciprofloxin (Cipro) 400 mg IV.
c. Send to radiology for chest radiograph.
d. Administer aspirin suppository.

A
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.

Cognitive Level: Application Text Reference: p. 566
Nursing Process: Implementation NCLEX: Physiological Integrity

46. The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess first?
a. A 23-year-year-old patient with cystic fibrosis who has pulmonary function testing scheduled in 30 minutes
b. A 35-year-old patient who was admitted the previous day with bacterial pneumonia and has a temperature of 100.2° F
c. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis an hour previously
d. A 77-year-old patient with TB who has four antitubercular medications due in 15 minutes

C
Rationale: Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate evaluation by the nurse. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

Cognitive Level: Application Text Reference: p. 596
Nursing Process: Planning NCLEX: Physiological Integrity

47. A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse's first action should be to
a. elevate the head of the bed.
b. administer the ordered pain medication.
c. notify the patient's health care provider.
d. offer emotional support and reassurance.

A
Rationale: The patient has symptoms consistent with a pulmonary embolism; elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

Cognitive Level: Application Text Reference: p. 599
Nursing Process: Implementation NCLEX: Physiological Integrity

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