VERIFIED SOLUTIONS GRADED A+
◍ The nurse determines that additional discharge teaching is needed
for a patient with pneumonia when the patient states what?
"I will take all medications as prescribed."
"Breathing exercises may help prevent future infections."
"I should take antibiotics for all upper respiratory infections."
"I will seek medical attention if I develop a fever or productive
cough.". Answer: "I should take antibiotics for all upper respiratory
infections."
◍ A patient has been admitted with a suspected lung abscess. During
the assessment, the nurse is aware that the most common
manifestation of a lung abscess is which of these?
Fever
Vomiting
Purulent sputum that has a foul odor and taste
Increased breath sounds on auscultation over the involved segment of
lung.. Answer: Purulent sputum that has a foul odor and taste
◍ A patient with asthma who has undergone a total hip replacement
complains on the third postoperative day of shortness of breath and
slight chest pain and notes that "something is wrong." Temperature is
98.8° F, blood pressure 168/98 mm Hg, pulse 96, respirations 32, and
,oxygen saturation is 89% on room air. What is the priority nursing
action?
Notify the health care provider and document the vital signs.
Apply oxygen and place the patient in a semi-Fowler's position.
Obtain an electrocardiogram (ECG) and administer albuterol
nebulizers.
Administer the prescribed antihypertensive medication and reassess in
15 minutes.. Answer: Apply oxygen and place the patient in a semi-
Fowler's position.
◍ The nurse is monitoring a patient who is having a thoracentesis for
recurrent pleural effusion. Which of these assessment findings would
be of most concern?
Removal of 1000 mL of pleural fluid
Restlessness and sudden complaint of dyspnea
SpO 2 reading of 96% while on 2 L/minute of oxygen
Patient complaint of pressure at the needle insertion site. Answer:
Restlessness and sudden complaint of dyspnea
◍ The nurse is caring for a patient who has a nasogastric tube. What
actions should the nurse perform to prevent aspiration in this patient?
Select all that apply.
Monitor gastric residual volumes.
Feed the patient in a reclined position.
Lower the head of the bed to 10 degrees.
Elevate the head of the bed 30 to 45 degrees.
,Encourage the patient to sit upright for all meals.. Answer: Monitor
gastric residual volumes.
Elevate the head of the bed 30 to 45 degrees.
Encourage the patient to sit upright for all meals.
◍ A 46-year-old patient who has undergone total left knee
arthroplasty complains of shortness of breath and slight chest pain.
Temperature is 98° F, blood pressure 140/86 mmHg, respirations 30,
and oxygen saturation 92% on room air. The nurse suspects that the
patient is experiencing which condition?
Pneumonia
Unstable angina
Pulmonary embolus
Chronic obstructive pulmonary disease (COPD) exacerbation.
Answer: Pulmonary embolus
◍ What is the priority nursing intervention in helping a patient
expectorate thick lung secretions?
Humidify the oxygen as able.
Administer cough suppressant.
Teach the patient to splint the affected area.
Increase fluid intake to 3 L/day if tolerated.. Answer: Increase fluid
intake to 3 L/day if tolerated.
, ◍ When the patient with a persistent cough is diagnosed with
pertussis (instead of acute bronchitis), the nurse knows that treatment
will include which type of medication?
Antibiotic
Corticosteroid
Bronchodilator
Cough suppressant. Answer: Antibiotic
◍ To ease pleuritic pain caused by pneumonia, what nursing
interventions should be performed?
Instructing the patient to splint the chest when coughing
Offering the patient an incentive spirometer every four hours
Instructing the patient in how to perform abdominal breathing
Encouraging the patient use shallow breathing during episodes of
pain. Answer: Instructing the patient to splint the chest when
coughing
◍ The nurse is reviewing the laboratory reports for the patient
receiving cefuroxime. The nurse determines that the medication is
having the intended effect by noting which laboratory result?
Sodium 138 mEq/L
Platelets 175,000 per µL
White blood cell count 4500/mm³
Blood urea nitrogen (BUN) 8 mmol/L. Answer: White blood cell
count 4500/mm³