Med-Surg Lewis Chapter 28 NCLEX Lower Respiratory
Problems Exam Questions And 100% Correct Answers
2024-2025
During evaluation of a patient who is diagnosed with pneumonia, the nurse identifies
that the patient has the nursing diagnosis of Ineffective airway clearance. Which of the
following assessment data best supports this nursing 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% - ANSWER ANS: A
This cough is weak and nonproductive, which indicates the patient's inability to clear
the airway. The remainder of the data would support such diagnoses as impaired gas
exchange and ineffective breathing pattern.
The nurse is performing an assessment of the chest of a patient diagnosed with
pneumococcal pneumonia. What does the nurse expect to find?
a. Increased tactile fremitus
b. Dry, nonproductive cough
c. Hyperresonance to percussion
d. A grating sound on auscultation - ANSWER ANS: A
One would expect the bacterial pneumonias to present with increased tactile fremitus
over the area of pulmonary consolidation. Dullness to percussion would be expected.
Classically, pneumococcal pneumonia presents with a loose, productive cough.
Crackles and wheezes are typical adventitious breath sounds. The grating sound
described is more typical of a pleural friction rub than pneumonia.
A patient with bacterial pneumonia presents with rhonchi and thick sputum. Which of
the following is the most appropriate action by the nurse to facilitate airway clearance?
a. Assist the patient to splint the chest while coughing.
,b. Instruct the patient on fluid restriction.
c. Encourage the patient to wear the nasal oxygen cannula.
d. Teach the patient the pursed lip breathing technique. - ANSWER ANS: A
Splinting of the chest during cough can make it less painful and coughing more
effective. Fluids are to be encouraged to liquefy the 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 providing discharge instructions to a patient who was hospitalized with
pneumonia. Which of the following statements by the patient indicates that he has
understood his discharge instructions?
a. "I'll call the doctor if I am still tired in a week."
b. "I'll continue doing the deep breathing and coughing at home."
c. "I'll make two appointments to get the pneumonia and influenza vaccine.
d. "I can cancel my chest x-ray appointment if I'm feeling better in a couple weeks." -
ANSWER ANS: B
It is essential for the patient to continue to cough and deep breathe after discharge.
Fatigue can be expected for several weeks. The Pneumovax and influenza vaccines can
be given at the same time in different arms. Inform the patient that a followup chest x-ray
should be done in 6 to 8 weeks to assess resolution of pneumonia
The nurse develops a plan of care for the prevention of aspiration for a high-risk patient.
Which nursing action would be most effective?
a. Turn and reposition immobile patients at least every 2 hours.
b. Position patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in clients who are immunosuppressed.
d. Insert nasogastric tube for feedings for patients experiencing dysphagia. - ANS: B
The aspiration risk is reduced by placing patients in a side-lying or upright position
when they have a decreased level of consciousness. Frequent turning will prevent
pooling of secretions in an immobilized patient but will not reduce aspiration risk in
at-risk patients. Monitoring parameters such as breath sounds and oxygen saturation
will provide early detection of pneumonia in the immunocompromised patient but will
, not reduce aspiration risk. Conditions that put a patient at risk for aspiration include
decreased level of consciousness such as seizure, anesthesia, head injury, stroke, and
alcohol intake; difficulty swallowing; and nasogastric intubation with or without tube
feeding. Loss of consciousness impairs the gag and cough reflexes, creating an
opportunity for aspiration. Other high-risk groups include the seriously ill, those with
poor dentition, and patients on acid-reducing medications.
A patient is treated with IV antibiotics for 3 days for right lower-lobe pneumonia. Which
assessment data gathered by the nurse indicates that the therapy has been effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient expectorates small amounts of green sputum.
c. The patient's white blood cell (WBC) count is 9000/µL.
d. There is increased tactile fremitus palpable over the right chest. - ANSWER ANS: C
The normal WBC count reflects that the antibiotics have been effective. All the other
data indicate a change in treatment will be required.
The health care provider orders bacteriologic testing for a patient who has tested
positive to a tuberculosis skin test. Which action does the nurse perform?
a. Instruct about the purpose of the blood tests.
b. Make an appointment for a chest x-ray.
c. Teach the need for collecting sputum specimens consecutively for 2 to 3 days.
d. Instruct the patient to cough up three specimens as soon as possible. -ANSWER ANS:
C
For bacteriologic diagnosis of M. tuberculosis, sputum specimens are collected over a
period of 2 to 3 consecutive days. Not all the specimens must be collected from the
patient on the same day. Blood cultures are not used for testing for tuberculosis. Chest
x-ray is not a type of bacteriologic testing. However great the findings of chest x-ray,
only chest x-ray examination can't diagnose TB because there are other diseases that
may appear like TB.
A patient is admitted with active tuberculosis (TB). The nurse should question a health
care provider's order to discontinue airborne precautions unless which assessment
finding is documented?
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