CHAPTER 27: LOWER RESPIRATORY PROBLEMS EXAM QUESTIONS WITH COMPLETE SOLUTIONS VERIFIED
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
a. Weak, nonproductive coug...
1. Following assessment of a patient with pneumonia, the nurse identifies a
nursing diagnosis of ineffective airway clearance. Which assessment data best
supports this 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%
ANS: A
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.
TOP: Nursing Process: Diagnosis
2. The nurse assesses the chest of a patient with pneumococcal pneumonia.
Which finding would the nurse expect?
a. Increased tactile fremitus
b. Dry, nonproductive cough
c. Hyperresonance to percussion
d. A grating sound on auscultation
,ANS: A
Increased tactile fremitus over the area of pulmonary consolidation is expected with
bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal
pneumonia typically presents with a loose, productive cough. Adventitious breath
sounds such as crackles and wheezes are typical. A grating sound is more
representative of a pleural friction rub rather than pneumonia.
TOP: Nursing Process: Assessment
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the
nurses most appropriate action to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Teach the patient about the need for fluid restrictions.
c. Encourage the patient to wear the nasal oxygen cannula.
d. Instruct the patient on the pursed lip breathing technique.
ANS: A
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.
,4. The nurse provides discharge instructions to a patient who was hospitalized
for pneumonia. Which statement, if made by the patient, indicates a good
understanding of the instructions?
a. I will call the doctor if I still feel tired after a week.
b. I will continue to do the deep breathing and coughing exercises at home.
c. I will schedule two appointments for the pneumonia and influenza vaccines.
d. Ill cancel my chest x-ray appointment if Im feeling better in a couple weeks.
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is
expected for several weeks. The Pneumovax and influenza vaccines can be given at
the same time in different arms. Explain that a follow-up chest x-ray needs to be done in
6 to 8 weeks to evaluate resolution of pneumonia.
TOP: Nursing Process: Evaluation
5. The nurse develops a plan of care to prevent aspiration in a high-risk patient.
Which nursing action will be
most effective?
a. Turn and reposition immobile patients at least every 2 hours.
b. Place patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in patients who are immunosuppressed.
, d. Insert nasogastric tube for feedings for patients with swallowing problems.
ANS: B
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 pneumonia in immunocompromised patients, but it will not
decrease the risk for aspiration. Conditions that increase the risk of aspiration include
decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol
intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration
is more likely to occur. Other high-risk groups are those who are seriously ill, have poor
dentition, or are receiving acid-reducing medications.
TOP: Nursing Process: Implementation
6. A patient with right lower-lobe pneumonia has been treated with IV antibiotics
for 3 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. The patient coughs up small amounts of green mucus.
c. The patients white blood cell (WBC) count is 9000/L.
d. Increased tactile fremitus is palpable over the right chest.
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