Final Exam Med Surg
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-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.
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-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.
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's 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-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.
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. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks." - ANS-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
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-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.
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 patient's white blood cell (WBC) count is 9000/µL.
d. Increased tactile fremitus is palpable over the right chest. - ANS-ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other data
suggest that a change in treatment is needed.
The health care provider writes an order for bacteriologic testing for a patient who has a positive
tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
d. Instruct the patient to expectorate three specimens as soon as possible. - ANS-ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M.
tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not
used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on
chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based
on chest x-ray findings because other diseases can mimic the appearance of 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?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative. - ANS-ANS: D
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum,
and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to
determine whether treatment has been successful. Taking medications for 6 months is
necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6
months of therapy. Repeat Mantoux testing would not be done because the result will not
change even with effective treatment.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which
statement, if made by the patient, indicates that teaching was effective?
a. "I will avoid being outdoors whenever possible."
b. "My husband will be sleeping in the guest bedroom."
c. "I will take the bus instead of driving to visit my friends."
d. "I will keep the windows closed at home to contain the germs." - ANS-ANS: B
Teach the patient how to minimize exposure to close contacts and household members. Homes
should be well ventilated, especially the areas where the infected person spends a lot of time.
While still infectious, the patient should sleep alone, spend as much time as possible outdoors,
and minimize time in congregate settings or on public transportation.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having
orange discolored urine and tears. Which is the best response by the nurse?
a. Ask if the patient is experiencing shortness of breath, hives, or itching.
b. Ask the patient about any visual abnormalities such as red-green color discrimination.
c. Explain that orange discolored urine and tears are normal while taking this medication.
d. Advise the patient to stop the drug and report the symptoms to the health care provider. -
ANS-ANS: C
Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop
taking the medication. The findings are not indicative of an allergic reaction. Alterations in
red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is
a different TB medication.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should
notify the health care provider if the patient exhibits which finding?
a. Yellow-tinged skin
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices - ANS-ANS: A
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-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.
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-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.
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's 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-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.
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. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks." - ANS-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
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-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.
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 patient's white blood cell (WBC) count is 9000/µL.
d. Increased tactile fremitus is palpable over the right chest. - ANS-ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other data
suggest that a change in treatment is needed.
The health care provider writes an order for bacteriologic testing for a patient who has a positive
tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
d. Instruct the patient to expectorate three specimens as soon as possible. - ANS-ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M.
tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not
used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on
chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based
on chest x-ray findings because other diseases can mimic the appearance of 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?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative. - ANS-ANS: D
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum,
and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to
determine whether treatment has been successful. Taking medications for 6 months is
necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6
months of therapy. Repeat Mantoux testing would not be done because the result will not
change even with effective treatment.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which
statement, if made by the patient, indicates that teaching was effective?
a. "I will avoid being outdoors whenever possible."
b. "My husband will be sleeping in the guest bedroom."
c. "I will take the bus instead of driving to visit my friends."
d. "I will keep the windows closed at home to contain the germs." - ANS-ANS: B
Teach the patient how to minimize exposure to close contacts and household members. Homes
should be well ventilated, especially the areas where the infected person spends a lot of time.
While still infectious, the patient should sleep alone, spend as much time as possible outdoors,
and minimize time in congregate settings or on public transportation.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having
orange discolored urine and tears. Which is the best response by the nurse?
a. Ask if the patient is experiencing shortness of breath, hives, or itching.
b. Ask the patient about any visual abnormalities such as red-green color discrimination.
c. Explain that orange discolored urine and tears are normal while taking this medication.
d. Advise the patient to stop the drug and report the symptoms to the health care provider. -
ANS-ANS: C
Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop
taking the medication. The findings are not indicative of an allergic reaction. Alterations in
red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is
a different TB medication.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should
notify the health care provider if the patient exhibits which finding?
a. Yellow-tinged skin
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices - ANS-ANS: A
