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N311: Chapter 28 (Lewis) - Lower Respiratory Problems, Questions and Correct Answers With Rationale. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admissi

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N311: Chapter 28 (Lewis) - Lower
Respiratory Problems, Questions and
Correct Answers With Rationale.
A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing
intervention is most appropriate during admission of this patient?

A. Perform a comprehensive health history with the patient 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 patient and review with the family the patient'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.

D. Perform a physical assessment of the respiratory system and ask specific questions related to this
episode of respiratory distress.

Because the patient is having respiratory difficulty, the nurse should ask specific questions about this
episode and perform a physical assessment of this system. Further history taking and physical
examination of other body systems can proceed once the patient's acute respiratory distress is being
managed.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse
notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20.
Which nursing diagnosis 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

A. Hyperthermia related to infectious illness

Because the patient 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 her breathing
pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance
from the information given because the patient is expectorating sputum.

Which physical assessment finding in a patient 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

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 patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of
greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing
diagnosis of ineffective airway clearance.

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Which clinical manifestation should the nurse expect to find during assessment of a patient admitted
with pneumonia?

A. Hyperresonance on percussion
B. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation
D. Fine crackles in all lobes on auscultation

C. Increased vocal fremitus on palpation

A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on
palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and
crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected
area.

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What is the priority nursing intervention in helping a patient expectorate thick lung secretions?

A. Humidify the oxygen as able.
B. Administer cough suppressant q4hr.
C. Teach patient to splint the affected area.
D. Increase fluid intake to 3 L/day if tolerated.

D. Increase fluid intake to 3 L/day if tolerated.

Although several interventions may help the patient expectorate mucus, the highest priority should be

,on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them
more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the
patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in
expectoration of thick secretions.

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During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD)
and pneumonia, which vaccine should the nurse recommend that this patient receive?

A. Pneumococcal
B. Staphylococcus aureus
C. Haemophilus influenzae
D. Bacille-Calmette-Guerin (BCG)

A. Pneumococcal

The pneumococcal vaccine is important for patients 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. A Staphylococcus aureus
vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not
be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for
infants in parts of the world where tuberculosis (TB) is prevalent.

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective
when the patient makes which statement about measures to prevent a relapse?

A. "I will seek immediate medical treatment for any upper respiratory infections."
B. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks."
C. "I will increase my food intake to 2400 calories a day to keep my immune system well."
D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient
should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may
be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks,
not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric
intake, is required to liquefy secretions.

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to
do (select all that apply)?

A. Maintain adequate fluid intake.
B. Splint the chest when coughing.

, C. Maintain a 30-degree elevation.
D. Maintain a semi-Fowler's position.
E. Instruct patient to cough at end of exhalation.

A. Maintain adequate fluid intake.
B. Splint the chest when coughing.
E. Instruct patient to cough at end of exhalation.

Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should
instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more
effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should
be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician
orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to
the patient?

A. Orthostatic blood pressures
B. Sputum culture and sensitivity
C. Pulmonary function evaluation
D. Serum laboratory studies ordered for AM

B. Sputum culture and sensitivity

The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before
administering the cefuroxime as this is community-acquired pneumonia. It is important that the
organisms are correctly identified (by the culture) before the antibiotic takes effect. 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 patient to expectorate sputum,
orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the
administration of antibiotics.

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During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the
patient related to a history of which risk factors for this type of cancer (select all that apply)?

A. Asbestos exposure
B. Exposure to uranium
C. Chronic interstitial fibrosis
D. History of cigarette smoking
E. Geographic area in which he was born

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Exam (elaborations)

N311: Chapter 28 (Lewis) - Lower Respiratory Problems, Questions and Correct Answers With Rationale. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admissi

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