NUR 390 EXAM 1 QUESTIONS WITH
CORRECT ANSWERS
260 QUESTIONS ANSWERS
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess
first?
a. A patient who is complaining of a sore throat and has a muffled voice
b. A patient who has a "scratchy throat" and a positive rapid strep antigen test
c. A patient who is receiving radiation for throat cancer and has severe fatigue
d. A patient with a history of a total laryngectomy whose stoma is red and
inflamed
A patient who is complaining of a sore throat and has a muffled voice
The patient's clinical manifestation of a muffled voice suggests a possible
peritonsillar abscess that could lead to an airway obstruction requiring rapid
assessment and potential treatment. The other patients do not have diagnoses or
symptoms that indicate any life-threatening problems.
-
The nurse obtains the following assessment data on an older patient who has
influenza. Which information will be most important for the nurse to
communicate to the health care provider?
a. Fever of 100.4° F (38° C)
,b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
Diffuse crackles in the lungs
The crackles indicate that the patient may be developing pneumonia, a common
complication of influenza, which would require aggressive treatment. Myalgia,
headache, mild temperature elevation, and sore throat with cough are typical
manifestations of influenza and are treated with supportive care measures such
as over-the-counter pain relievers and increased fluid intake.
-
The nurse is caring for a hospitalized older patient who has nasal packing in
place after a nosebleed. Which assessment finding will require the most
immediate action by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient reports level 8 (0 to 10 scale) pain.
d. The patient's temperature is 100.1° F (37.8° C).
The oxygen saturation is 89%.
Older patients with nasal packing are at risk of aspiration or airway
obstruction. An O2 saturation of 89% should alert the nurse to further assess
for these complications. The other assessment data also indicate a need for
nursing action but not as immediately as the low O2 saturation.
,-
The nurse is reviewing the medical records for five patients who are scheduled
for their yearly physical examinations in September. Which patients should
receive the inactivated influenza vaccination? Select all that apply.
a. A 76-yr-old nursing home resident
b. A 36-yr-old female patient who is pregnant
c. A 42-yr-old patient who has a 15 pack-year smoking history
d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis
e. A 24-yr-old patient who has allergies to penicillin and cephalosporins
A 76-yr-old nursing home resident
A 36-yr-old female patient who is pregnant
A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis
Current guidelines suggest that healthy individuals between 6 months and age
49 years receive intranasal immunization with live, attenuated influenza
vaccine. Individuals who are pregnant, residents of nursing homes, or are
immunocompromised or who have chronic medical conditions should receive
inactivated vaccine by injection. The corticosteroid use by the 30-yr-old patient
increases the risk for infection.
-
Which finding by the nurse most specifically indicates that a patient is not able
to effectively clear the airway?
a. Weak cough effort
, b. Profuse green sputum
c. Respiratory rate of 28 breaths/min
d. Resting pulse oximetry (SpO2) of 85%
Weak cough effort
The weak cough effort indicates that the patient is unable to clear the airway
effectively. A patient who produces profuse sputum may be able to clear it with
effective coughing. An increased respiratory rate or low SpO2 suggest problems
with gas exchange.
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
Increased tactile fremitus
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 coarse crackles and thick sputum.
Which action would the nurse plan to promote airway clearance?
CORRECT ANSWERS
260 QUESTIONS ANSWERS
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess
first?
a. A patient who is complaining of a sore throat and has a muffled voice
b. A patient who has a "scratchy throat" and a positive rapid strep antigen test
c. A patient who is receiving radiation for throat cancer and has severe fatigue
d. A patient with a history of a total laryngectomy whose stoma is red and
inflamed
A patient who is complaining of a sore throat and has a muffled voice
The patient's clinical manifestation of a muffled voice suggests a possible
peritonsillar abscess that could lead to an airway obstruction requiring rapid
assessment and potential treatment. The other patients do not have diagnoses or
symptoms that indicate any life-threatening problems.
-
The nurse obtains the following assessment data on an older patient who has
influenza. Which information will be most important for the nurse to
communicate to the health care provider?
a. Fever of 100.4° F (38° C)
,b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache
Diffuse crackles in the lungs
The crackles indicate that the patient may be developing pneumonia, a common
complication of influenza, which would require aggressive treatment. Myalgia,
headache, mild temperature elevation, and sore throat with cough are typical
manifestations of influenza and are treated with supportive care measures such
as over-the-counter pain relievers and increased fluid intake.
-
The nurse is caring for a hospitalized older patient who has nasal packing in
place after a nosebleed. Which assessment finding will require the most
immediate action by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The patient reports level 8 (0 to 10 scale) pain.
d. The patient's temperature is 100.1° F (37.8° C).
The oxygen saturation is 89%.
Older patients with nasal packing are at risk of aspiration or airway
obstruction. An O2 saturation of 89% should alert the nurse to further assess
for these complications. The other assessment data also indicate a need for
nursing action but not as immediately as the low O2 saturation.
,-
The nurse is reviewing the medical records for five patients who are scheduled
for their yearly physical examinations in September. Which patients should
receive the inactivated influenza vaccination? Select all that apply.
a. A 76-yr-old nursing home resident
b. A 36-yr-old female patient who is pregnant
c. A 42-yr-old patient who has a 15 pack-year smoking history
d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis
e. A 24-yr-old patient who has allergies to penicillin and cephalosporins
A 76-yr-old nursing home resident
A 36-yr-old female patient who is pregnant
A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis
Current guidelines suggest that healthy individuals between 6 months and age
49 years receive intranasal immunization with live, attenuated influenza
vaccine. Individuals who are pregnant, residents of nursing homes, or are
immunocompromised or who have chronic medical conditions should receive
inactivated vaccine by injection. The corticosteroid use by the 30-yr-old patient
increases the risk for infection.
-
Which finding by the nurse most specifically indicates that a patient is not able
to effectively clear the airway?
a. Weak cough effort
, b. Profuse green sputum
c. Respiratory rate of 28 breaths/min
d. Resting pulse oximetry (SpO2) of 85%
Weak cough effort
The weak cough effort indicates that the patient is unable to clear the airway
effectively. A patient who produces profuse sputum may be able to clear it with
effective coughing. An increased respiratory rate or low SpO2 suggest problems
with gas exchange.
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
Increased tactile fremitus
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 coarse crackles and thick sputum.
Which action would the nurse plan to promote airway clearance?
