PNR 309 Midterm UPDATED ACTUAL Questions and
CORRECT Answers
The nurse is preparing to interview an older-adult client. a)Ensure all assistive devices are in place.
Which of the following actions is most appropriate?
a)Ensure all assistive devices are in place. All assistive devices, such as glasses and hearing aids, should be in place when
b)Interview the client and caregiver together. interviewing an older-adult client. It is best to interview the client and caregiver
c) Perform the interview before administering analgesics. separately to ensure a reliable assessment related to elder mistreatment. The
d) Move on to the next question if the client does not client should be free from pain during the assessment and may need extra time to
respond quickly. respond to questions.
A 70-year-old man has just been diagnosed with chronic a)As soon as possible
obstructive pulmonary disease (COPD). At what point
should the nurse begin to include the client's wife in the In the management of chronic illness, it is desirable to include family caregivers in
teaching around the management of the disease? client education and symptom-management efforts as early in the diagnosis as
a) As soon as possible possible.
b) When the client requests assistance from his spouse
and family
c) When the client becomes unable to manage his
symptoms independently
d) After the client has had the opportunity to adjust to his
treatment regimen
A nurse who is providing care for an 81-year-old female c)Continued activity prevents deconditioning.
client recognizes the need to maximize the client's
mobility during her recovery from surgery. Which of the Older adults are highly susceptible to deconditioning, a process that can be
following statements provides the best rationale for the slowed or prevented by regular physical activity. This consideration supersedes
nurse's actions? any possible effect on pharmacokinetics, prevention of cognitive deficits, or the
a) Lack of stimulation contributes to the development of client's sense of purpose.
cognitive deficits in older adults.
b) Pharmacokinetics are improved by client mobility.
c)Continued activity prevents deconditioning.
d)Regularly scheduled physical rehabilitation provides an
important sense of purpose for older clients.
The nurse is assessing an elderly client who has arrived to a)Elder mistreatment
the emergency department via ambulance from home
where she lives with her adult daughter. The client has a There are several types of elder mistreatment. In this scenario, the nurse would
large pressure ulcer on the sacrum, three large bruises suspect elder mistreatment related to physical neglect (pressure ulcers), physical
on the upper back, appears depressed and withdrawn. abuse (bruises), or psychological or emotional abuse (withdrawn and depressed).
Which of the following would the nurse suscept related
to this client?
a) Elder mistreatment
b) Social isolation
c) A stroke
d)Hypoglycemia
,Which of the following are symptoms of an overwhelmed ALL ANSWERS ARE CORRECT
caregiver? (Select all that apply.)
a) Powerlessness Caregivers may develop a sense of being overwhelmed and have feelings of
b) Depression inadequacy, powerlessness, and depression. The stress of caregiving may result in
c) Resentment emotional problems such as depression, anger, and resentment. The burden of
d) Inadequacy caregiving may lead to social isolation, which can be characterized by increased
e) Fatigue time commitments and fatigue.
The nurse is caring for a client admitted to the hospital a)Hyperthermia related to infectious illness
with pneumonia. Upon assessment, the nurse notes a
temperature of 38.6°C (101.5°F), a productive cough with Because the client has spiked a temperature and has a diagnosis of pneumonia,
yellow sputum, and a respiratory rate of 20 the logical nursing diagnosis is hyperthermia related to infectious illness. There is
breaths/minute. Which of the following nursing diagnoses no evidence of a chill, and the client's breathing pattern is within normal limits at
is most appropriate based upon this assessment? 20 breaths/minute. There is no evidence of ineffective airway clearance from the
a)Hyperthermia related to infectious illness information given because the client is expectorating sputum.
b)Ineffective thermoregulation related to chilling
c)Ineffective breathing pattern related to pneumonia
d)Ineffective airway clearance related to thick secretions
Which of the following physical assessment findings in a a)Basilar crackles
client with a lower respiratory problem best supports the
nursing diagnosis of ineffective airway clearance? The presence of adventitious breath sounds indicates that there is accumulation of
a) Basilar crackles secretions in the lower airways. This would be consistent with a nursing diagnosis
b) Respiratory rate of 28 of ineffective airway clearance because the client is retaining secretions.
c) Oxygen saturation of 85%
d) Presence of greenish sputum
Which of the following clinical manifestations should the c)Increased tactile fremitus on palpation
nurse expect to find during assessment of a client
admitted with pneumococcal pneumonia? A typical physical examination finding for a client with pneumonia is increased
a)Hyper-resonance on percussion tactile fremitus on palpation. Other signs of pulmonary consolidation include
b)Vesicular breath sounds in all lobes dullness to percussion, bronchial breath sounds, and crackles in the affected area.
c)Increased tactile fremitus on palpation
d)Fine crackles in all lobes on auscultation
Which of the following is the priority nursing intervention d)Increase fluid intake to 3 L/day if tolerated
in helping a client expectorate thick lung secretions?
a)Humidify the oxygen as able Although several interventions may help the client expectorate mucus, the highest
b)Administer cough suppressant q4hr priority should be on increasing fluid intake, which will liquefy the secretions so
c) Teach client to splint the affected area that the client can expectorate them more easily. Humidifying the oxygen is also
d) Increase fluid intake to 3 L/day if tolerated helpful, but is not the primary intervention. Teaching the client to splint the
affected area may also be helpful, but does not liquefy the secretions so that they
can be removed.
, The nurse is providing discharge teaching to an older- c)Pneumococcal
adult client with COPD and pneumonia. Which of the
following vaccines should the nurse recommend that this The pneumococcal vaccine is important for clients with a history of heart or lung
client receive? disease, recovering from a severe illness, age 65 or over, or living in a long-term
a) Staphylococcus aureus care facility.
b) Haemophilus influenzae
c)Pneumococcal
d)Bacille Calmette-Guérin (BCG)
The nurse is providing discharge teaching to a client that c)"I should continue to do deep-breathing and coughing exercises for at least 6
was hospitalized with pneumonia. Which of the following weeks."
client statements about measures to prevent a relapse
indicates that the teaching has been effective? It is important for the client to continue with coughing and deep-breathing
a) "I will seek immediate medical treatment for any upper exercises for 6-8 weeks until all of the infection has cleared from the lungs. A
respiratory infections." client should seek medical treatment for upper respiratory infections that persist
b) "I will increase my food intake to 2 400 calories a day to for more than 7 days. Increased fluid intake, not caloric intake, is required to
keep my immune system well." liquefy secretions. Home O2 is not a requirement unless the client's oxygenation
c) "I should continue to do deep-breathing and coughing saturation is below normal.
exercises for at least 6 weeks."
d) "I must use home oxygen therapy for three months and
then will have a chest x-ray to re-evaluate."
The nurse is admitting a client to the medical unit with a b)Sputum culture and sensitivity
diagnosis of pneumonia. Which of the following
prescriptions should the nurse verify has been completed The nurse should ensure that the sputum for culture and sensitivity was sent to the
before administering a dose of trimethoprim- laboratory before administering trimethoprim-sulfamethoxazole. It is important
sulfamethoxazole to the client? that the organisms are correctly identified (by the culture) before their numbers
a) Orthostatic blood pressures are affected by the antibiotic; the test will also determine whether the proper
b) Sputum culture and sensitivity antibiotic has been ordered (sensitivity testing). Although antibiotic administration
c) Pulmonary function evaluation should not be unduly delayed while waiting for the client to expectorate sputum,
d) Serum laboratory studies ordered for the morning all of the other options will not be affected by the administration of antibiotics.
Which of the following nursing interventions is most c)Positioning client with "good lung down"
appropriate to enhance oxygenation in a client with
unilateral malignant lung disease? Therapeutic positioning identifies the best position for the client assuring stable
a)Positioning client on right side oxygenation status. Research indicates that positioning the client with the
b)Maintaining adequate fluid intake unaffected lung (good lung) dependent best promotes oxygenation in clients
c)Positioning client with "good lung down" with unilateral lung disease. For bilateral lung disease, the right lung down has
d)Performing postural drainage every 4 hours best ventilation and perfusion. Increasing fluid intake and performing postural
drainage will facilitate airway clearance, but positioning is most appropriate to
enhance oxygenation.
CORRECT Answers
The nurse is preparing to interview an older-adult client. a)Ensure all assistive devices are in place.
Which of the following actions is most appropriate?
a)Ensure all assistive devices are in place. All assistive devices, such as glasses and hearing aids, should be in place when
b)Interview the client and caregiver together. interviewing an older-adult client. It is best to interview the client and caregiver
c) Perform the interview before administering analgesics. separately to ensure a reliable assessment related to elder mistreatment. The
d) Move on to the next question if the client does not client should be free from pain during the assessment and may need extra time to
respond quickly. respond to questions.
A 70-year-old man has just been diagnosed with chronic a)As soon as possible
obstructive pulmonary disease (COPD). At what point
should the nurse begin to include the client's wife in the In the management of chronic illness, it is desirable to include family caregivers in
teaching around the management of the disease? client education and symptom-management efforts as early in the diagnosis as
a) As soon as possible possible.
b) When the client requests assistance from his spouse
and family
c) When the client becomes unable to manage his
symptoms independently
d) After the client has had the opportunity to adjust to his
treatment regimen
A nurse who is providing care for an 81-year-old female c)Continued activity prevents deconditioning.
client recognizes the need to maximize the client's
mobility during her recovery from surgery. Which of the Older adults are highly susceptible to deconditioning, a process that can be
following statements provides the best rationale for the slowed or prevented by regular physical activity. This consideration supersedes
nurse's actions? any possible effect on pharmacokinetics, prevention of cognitive deficits, or the
a) Lack of stimulation contributes to the development of client's sense of purpose.
cognitive deficits in older adults.
b) Pharmacokinetics are improved by client mobility.
c)Continued activity prevents deconditioning.
d)Regularly scheduled physical rehabilitation provides an
important sense of purpose for older clients.
The nurse is assessing an elderly client who has arrived to a)Elder mistreatment
the emergency department via ambulance from home
where she lives with her adult daughter. The client has a There are several types of elder mistreatment. In this scenario, the nurse would
large pressure ulcer on the sacrum, three large bruises suspect elder mistreatment related to physical neglect (pressure ulcers), physical
on the upper back, appears depressed and withdrawn. abuse (bruises), or psychological or emotional abuse (withdrawn and depressed).
Which of the following would the nurse suscept related
to this client?
a) Elder mistreatment
b) Social isolation
c) A stroke
d)Hypoglycemia
,Which of the following are symptoms of an overwhelmed ALL ANSWERS ARE CORRECT
caregiver? (Select all that apply.)
a) Powerlessness Caregivers may develop a sense of being overwhelmed and have feelings of
b) Depression inadequacy, powerlessness, and depression. The stress of caregiving may result in
c) Resentment emotional problems such as depression, anger, and resentment. The burden of
d) Inadequacy caregiving may lead to social isolation, which can be characterized by increased
e) Fatigue time commitments and fatigue.
The nurse is caring for a client admitted to the hospital a)Hyperthermia related to infectious illness
with pneumonia. Upon assessment, the nurse notes a
temperature of 38.6°C (101.5°F), a productive cough with Because the client has spiked a temperature and has a diagnosis of pneumonia,
yellow sputum, and a respiratory rate of 20 the logical nursing diagnosis is hyperthermia related to infectious illness. There is
breaths/minute. Which of the following nursing diagnoses no evidence of a chill, and the client's breathing pattern is within normal limits at
is most appropriate based upon this assessment? 20 breaths/minute. There is no evidence of ineffective airway clearance from the
a)Hyperthermia related to infectious illness information given because the client is expectorating sputum.
b)Ineffective thermoregulation related to chilling
c)Ineffective breathing pattern related to pneumonia
d)Ineffective airway clearance related to thick secretions
Which of the following physical assessment findings in a a)Basilar crackles
client with a lower respiratory problem best supports the
nursing diagnosis of ineffective airway clearance? The presence of adventitious breath sounds indicates that there is accumulation of
a) Basilar crackles secretions in the lower airways. This would be consistent with a nursing diagnosis
b) Respiratory rate of 28 of ineffective airway clearance because the client is retaining secretions.
c) Oxygen saturation of 85%
d) Presence of greenish sputum
Which of the following clinical manifestations should the c)Increased tactile fremitus on palpation
nurse expect to find during assessment of a client
admitted with pneumococcal pneumonia? A typical physical examination finding for a client with pneumonia is increased
a)Hyper-resonance on percussion tactile fremitus on palpation. Other signs of pulmonary consolidation include
b)Vesicular breath sounds in all lobes dullness to percussion, bronchial breath sounds, and crackles in the affected area.
c)Increased tactile fremitus on palpation
d)Fine crackles in all lobes on auscultation
Which of the following is the priority nursing intervention d)Increase fluid intake to 3 L/day if tolerated
in helping a client expectorate thick lung secretions?
a)Humidify the oxygen as able Although several interventions may help the client expectorate mucus, the highest
b)Administer cough suppressant q4hr priority should be on increasing fluid intake, which will liquefy the secretions so
c) Teach client to splint the affected area that the client can expectorate them more easily. Humidifying the oxygen is also
d) Increase fluid intake to 3 L/day if tolerated helpful, but is not the primary intervention. Teaching the client to splint the
affected area may also be helpful, but does not liquefy the secretions so that they
can be removed.
, The nurse is providing discharge teaching to an older- c)Pneumococcal
adult client with COPD and pneumonia. Which of the
following vaccines should the nurse recommend that this The pneumococcal vaccine is important for clients with a history of heart or lung
client receive? disease, recovering from a severe illness, age 65 or over, or living in a long-term
a) Staphylococcus aureus care facility.
b) Haemophilus influenzae
c)Pneumococcal
d)Bacille Calmette-Guérin (BCG)
The nurse is providing discharge teaching to a client that c)"I should continue to do deep-breathing and coughing exercises for at least 6
was hospitalized with pneumonia. Which of the following weeks."
client statements about measures to prevent a relapse
indicates that the teaching has been effective? It is important for the client to continue with coughing and deep-breathing
a) "I will seek immediate medical treatment for any upper exercises for 6-8 weeks until all of the infection has cleared from the lungs. A
respiratory infections." client should seek medical treatment for upper respiratory infections that persist
b) "I will increase my food intake to 2 400 calories a day to for more than 7 days. Increased fluid intake, not caloric intake, is required to
keep my immune system well." liquefy secretions. Home O2 is not a requirement unless the client's oxygenation
c) "I should continue to do deep-breathing and coughing saturation is below normal.
exercises for at least 6 weeks."
d) "I must use home oxygen therapy for three months and
then will have a chest x-ray to re-evaluate."
The nurse is admitting a client to the medical unit with a b)Sputum culture and sensitivity
diagnosis of pneumonia. Which of the following
prescriptions should the nurse verify has been completed The nurse should ensure that the sputum for culture and sensitivity was sent to the
before administering a dose of trimethoprim- laboratory before administering trimethoprim-sulfamethoxazole. It is important
sulfamethoxazole to the client? that the organisms are correctly identified (by the culture) before their numbers
a) Orthostatic blood pressures are affected by the antibiotic; the test will also determine whether the proper
b) Sputum culture and sensitivity antibiotic has been ordered (sensitivity testing). Although antibiotic administration
c) Pulmonary function evaluation should not be unduly delayed while waiting for the client to expectorate sputum,
d) Serum laboratory studies ordered for the morning all of the other options will not be affected by the administration of antibiotics.
Which of the following nursing interventions is most c)Positioning client with "good lung down"
appropriate to enhance oxygenation in a client with
unilateral malignant lung disease? Therapeutic positioning identifies the best position for the client assuring stable
a)Positioning client on right side oxygenation status. Research indicates that positioning the client with the
b)Maintaining adequate fluid intake unaffected lung (good lung) dependent best promotes oxygenation in clients
c)Positioning client with "good lung down" with unilateral lung disease. For bilateral lung disease, the right lung down has
d)Performing postural drainage every 4 hours best ventilation and perfusion. Increasing fluid intake and performing postural
drainage will facilitate airway clearance, but positioning is most appropriate to
enhance oxygenation.
