PNR 309- Midterm EXAM 2024 with
Complete Solutions/ Correct-Verified
Answers
The nurse is caring for a client admitted to the hospital with pneumonia. Upon assessment,
the nurse notes a temperature of 38.6°C (101.5°F), a productive cough with yellow sputum,
and a respiratory rate of 20 breaths/minute. Which of the following nursing diagnoses is most
appropriate based upon this assessment?
a)Hyperthermia related to infectious illness
b)Ineffective thermoregulation related to chilling
c)Ineffective breathing pattern related to pneumonia
d)Ineffective airway clearance related to thick secretions - ANSWER a)Hyperthermia related
to infectious illness
Because the client has spiked a temperature and has a diagnosis of pneumonia, the logical
nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a
chill, and the client's breathing pattern is within normal limits at 20 breaths/minute. There
is no evidence of ineffective airway clearance from the information given because the client
is expectorating sputum.
Which of the following physical assessment findings in a client with a lower respiratory
problem best supports the nursing diagnosis of ineffective airway clearance?
a)Basilar crackles
b)Respiratory rate of 28
c)Oxygen saturation of 85%
d)Presence of greenish sputum - ANSWER a)Basilar crackles
The presence of adventitious breath sounds indicates that there is accumulation of
secretions in the lower airways. This would be consistent with a nursing diagnosis of
ineffective airway clearance because the client is retaining secretions.
,Which of the following clinical manifestations should the nurse expect to find during
assessment of a client admitted with pneumococcal pneumonia?
a)Hyper-resonance on percussion
b)Vesicular breath sounds in all lobes
c)Increased tactile fremitus on palpation
d)Fine crackles in all lobes on auscultation - ANSWER c)Increased tactile fremitus on palpation
A typical physical examination finding for a client with pneumonia is increased tactile fremitus
on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial
breath sounds, and crackles in the affected area.
Which of the following is the priority nursing intervention in helping a client expectorate thick
lung secretions?
a)Humidify the oxygen as able
b)Administer cough suppressant q4hr
c)Teach client to splint the affected area
d)Increase fluid intake to 3 L/day if tolerated - ANSWER d)Increase fluid intake to 3 L/day if
tolerated
Although several interventions may help the client expectorate mucus, the highest priority
should be on increasing fluid intake, which will liquefy the secretions so that the client can
expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary
intervention. Teaching the client to splint the affected area may also be helpful, but does
not liquefy the secretions so that they can be removed.
The nurse is providing discharge teaching to an older-adult client with COPD and pneumonia.
Which of the following vaccines should the nurse recommend that this client receive?
a)Staphylococcus aureus
b)Haemophilus influenzae
c)Pneumococcal
,d)Bacille Calmette-Guérin (BCG) - ANSWER c)Pneumococcal
The pneumococcal vaccine is important for clients with a history of heart or lung disease,
recovering from a severe illness, age 65 or over, or living in a long-term care facility.
The nurse is providing discharge teaching to a client that was hospitalized with pneumonia.
Which of the following client statements about measures to prevent a relapse indicates
that the teaching has been effective?
a)"I will seek immediate medical treatment for any upper respiratory infections."
b)"I will increase my food intake to 2 400 calories a day to keep my immune system well."
c)"I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
d)"I must use home oxygen therapy for three months and then will have a chest x-ray to re-
evaluate." - ANSWER c)"I should continue to do deep-breathing and coughing exercises for at
least 6 weeks."
It is important for the client to continue with coughing and deep-breathing exercises for 6-8
weeks until all of the infection has cleared from the lungs. A client should seek medical
treatment for upper respiratory infections that persist for more than 7 days. Increased fluid
intake, not caloric intake, is required to liquefy secretions. Home O2 is not a requirement
unless the client's oxygenation saturation is below normal.
The nurse is admitting a client to the medical unit with a diagnosis of pneumonia. Which of the
following prescriptions should the nurse verify has been completed before administering a
dose of trimethoprim-sulfamethoxazole to the client?
a)Orthostatic blood pressures
b)Sputum culture and sensitivity
c)Pulmonary function evaluation
d)Serum laboratory studies ordered for the morning - ANSWER b)Sputum culture and sensitivity
The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory
before administering trimethoprim-sulfamethoxazole. It is important that the organisms are
, correctly identified (by the culture) before their numbers are affected by the antibiotic; the
test will also determine whether the proper antibiotic has been ordered (sensitivity testing).
Although antibiotic administration should not be unduly delayed while waiting for the client to
expectorate sputum, all of the other options will not be affected by the administration of
antibiotics.
Which of the following nursing interventions is most appropriate to enhance oxygenation in a
client with unilateral malignant lung disease?
a)Positioning client on right side
b)Maintaining adequate fluid intake
c)Positioning client with "good lung down"
d)Performing postural drainage every 4 hours - ANSWER c)Positioning client with "good lung
down"
Therapeutic positioning identifies the best position for the client assuring stable oxygenation
status. Research indicates that positioning the client with the unaffected lung (good lung)
dependent best promotes oxygenation in clients with unilateral lung disease. For bilateral lung
disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and
performing postural drainage will facilitate airway clearance, but positioning is most
appropriate to enhance oxygenation.
The nurse is admitting a client with acute respiratory distress related to cor pulmonale. Which
of the following nursing interventions is most appropriate during admission of this client?
a)Perform a comprehensive health history with the client to review prior respiratory problems.
b)Complete a full physical examination to determine the effect of the respiratory distress
on other body functions.
c)Delay any physical assessment of the client and review with the family the client's history
of respiratory problems.
d)Perform a physical assessment of the respiratory system and ask specific questions related
to this episode of respiratory distress. - ANSWER d)Perform a physical assessment of the
respiratory system and ask specific questions related to this episode of respiratory distress.
Complete Solutions/ Correct-Verified
Answers
The nurse is caring for a client admitted to the hospital with pneumonia. Upon assessment,
the nurse notes a temperature of 38.6°C (101.5°F), a productive cough with yellow sputum,
and a respiratory rate of 20 breaths/minute. Which of the following nursing diagnoses is most
appropriate based upon this assessment?
a)Hyperthermia related to infectious illness
b)Ineffective thermoregulation related to chilling
c)Ineffective breathing pattern related to pneumonia
d)Ineffective airway clearance related to thick secretions - ANSWER a)Hyperthermia related
to infectious illness
Because the client has spiked a temperature and has a diagnosis of pneumonia, the logical
nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a
chill, and the client's breathing pattern is within normal limits at 20 breaths/minute. There
is no evidence of ineffective airway clearance from the information given because the client
is expectorating sputum.
Which of the following physical assessment findings in a client with a lower respiratory
problem best supports the nursing diagnosis of ineffective airway clearance?
a)Basilar crackles
b)Respiratory rate of 28
c)Oxygen saturation of 85%
d)Presence of greenish sputum - ANSWER a)Basilar crackles
The presence of adventitious breath sounds indicates that there is accumulation of
secretions in the lower airways. This would be consistent with a nursing diagnosis of
ineffective airway clearance because the client is retaining secretions.
,Which of the following clinical manifestations should the nurse expect to find during
assessment of a client admitted with pneumococcal pneumonia?
a)Hyper-resonance on percussion
b)Vesicular breath sounds in all lobes
c)Increased tactile fremitus on palpation
d)Fine crackles in all lobes on auscultation - ANSWER c)Increased tactile fremitus on palpation
A typical physical examination finding for a client with pneumonia is increased tactile fremitus
on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial
breath sounds, and crackles in the affected area.
Which of the following is the priority nursing intervention in helping a client expectorate thick
lung secretions?
a)Humidify the oxygen as able
b)Administer cough suppressant q4hr
c)Teach client to splint the affected area
d)Increase fluid intake to 3 L/day if tolerated - ANSWER d)Increase fluid intake to 3 L/day if
tolerated
Although several interventions may help the client expectorate mucus, the highest priority
should be on increasing fluid intake, which will liquefy the secretions so that the client can
expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary
intervention. Teaching the client to splint the affected area may also be helpful, but does
not liquefy the secretions so that they can be removed.
The nurse is providing discharge teaching to an older-adult client with COPD and pneumonia.
Which of the following vaccines should the nurse recommend that this client receive?
a)Staphylococcus aureus
b)Haemophilus influenzae
c)Pneumococcal
,d)Bacille Calmette-Guérin (BCG) - ANSWER c)Pneumococcal
The pneumococcal vaccine is important for clients with a history of heart or lung disease,
recovering from a severe illness, age 65 or over, or living in a long-term care facility.
The nurse is providing discharge teaching to a client that was hospitalized with pneumonia.
Which of the following client statements about measures to prevent a relapse indicates
that the teaching has been effective?
a)"I will seek immediate medical treatment for any upper respiratory infections."
b)"I will increase my food intake to 2 400 calories a day to keep my immune system well."
c)"I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
d)"I must use home oxygen therapy for three months and then will have a chest x-ray to re-
evaluate." - ANSWER c)"I should continue to do deep-breathing and coughing exercises for at
least 6 weeks."
It is important for the client to continue with coughing and deep-breathing exercises for 6-8
weeks until all of the infection has cleared from the lungs. A client should seek medical
treatment for upper respiratory infections that persist for more than 7 days. Increased fluid
intake, not caloric intake, is required to liquefy secretions. Home O2 is not a requirement
unless the client's oxygenation saturation is below normal.
The nurse is admitting a client to the medical unit with a diagnosis of pneumonia. Which of the
following prescriptions should the nurse verify has been completed before administering a
dose of trimethoprim-sulfamethoxazole to the client?
a)Orthostatic blood pressures
b)Sputum culture and sensitivity
c)Pulmonary function evaluation
d)Serum laboratory studies ordered for the morning - ANSWER b)Sputum culture and sensitivity
The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory
before administering trimethoprim-sulfamethoxazole. It is important that the organisms are
, correctly identified (by the culture) before their numbers are affected by the antibiotic; the
test will also determine whether the proper antibiotic has been ordered (sensitivity testing).
Although antibiotic administration should not be unduly delayed while waiting for the client to
expectorate sputum, all of the other options will not be affected by the administration of
antibiotics.
Which of the following nursing interventions is most appropriate to enhance oxygenation in a
client with unilateral malignant lung disease?
a)Positioning client on right side
b)Maintaining adequate fluid intake
c)Positioning client with "good lung down"
d)Performing postural drainage every 4 hours - ANSWER c)Positioning client with "good lung
down"
Therapeutic positioning identifies the best position for the client assuring stable oxygenation
status. Research indicates that positioning the client with the unaffected lung (good lung)
dependent best promotes oxygenation in clients with unilateral lung disease. For bilateral lung
disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and
performing postural drainage will facilitate airway clearance, but positioning is most
appropriate to enhance oxygenation.
The nurse is admitting a client with acute respiratory distress related to cor pulmonale. Which
of the following nursing interventions is most appropriate during admission of this client?
a)Perform a comprehensive health history with the client to review prior respiratory problems.
b)Complete a full physical examination to determine the effect of the respiratory distress
on other body functions.
c)Delay any physical assessment of the client and review with the family the client's history
of respiratory problems.
d)Perform a physical assessment of the respiratory system and ask specific questions related
to this episode of respiratory distress. - ANSWER d)Perform a physical assessment of the
respiratory system and ask specific questions related to this episode of respiratory distress.
