NSG320 Topic 3 Chapter 28 NCLEX Exam
Questions With Correct Answers
A,B,E.
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...
A,B,E.
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. - answer✔✔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.
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. - answer✔✔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.
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
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. - answer✔✔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
C.
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. - answer✔✔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
D.
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. - answer✔✔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.
A.
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