exam 2 Nur 130
70+ Questions with Correct Answers
1. Which is the most important risk factor for development of chronic obstruc- tive
pulmonary disease (COPD)?
Genetic abnormalities
Occupational exposure Air
pollution
Cigarette smoking: Cigarette smoking
2. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumo- cystis carinii
pneumonia. Which nursing diagnosis has the highest priority?
Activity intolerance
Imbalanced nutrition: Less than body requirements Impaired
oral mucous membranes
Impaired gas exchange: impaired gas exchange
3. During a community health fair, a nurse is teaching a group of seniors about promoting
health and preventing infection. Which intervention would best pro- mote infection
prevention for senior citizens who are at risk of pneumococcal and influenza infections?
Take all prescribed medications Drink
six glasses of water daily Exercise daily
Receive vaccinations: Receive vaccinations
,4. A client admitted with multiple traumatic injuries receives massive fluid re- suscitation.
Later, the physician suspects that the client has aspirated stomach contents. The nurse knows
that this client is at highest risk for:
bronchial asthma. renal
failure.
chronic obstructive pulmonary disease (COPD). acute
respiratory distress syndrome (ARDS).: ARDS
A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is
associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near
,drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow
obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's
history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.
5. A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the
occurrence of postoperative pneumonia in this client?
Administering pain medications, frequent repositioning, and limiting fluid intake
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
Administering oxygen, coughing, breathing deeply, and maintaining bed rest Coughing,
breathing deeply, maintaining bed rest, and using an incentive spirometer: Coughing, breathing deeply,
frequent repositioning, and using an incentive spirometer Explanation:
Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the
client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.
6. Which would be least likely to contribute to a case of hospital-acquired pneu- monia?
Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's
defenses.
A nurse washes her hands before beginning client care. Host defenses
are impaired.
A highly virulent organism is present.: A nurse washes her hands before beginning client care
7. Which should a nurse encourage in clients who are at the risk of pneumococ- cal and
influenza infections?
Using incentive spirometry Mobilizing
early
, Receiving vaccinations
Using prescribed opioids: Receiving vaccinations
8. During discharge teaching, a nurse is instructing a client about pneumonia. The client
demonstrates his understanding of relapse when he states that he must:
turn and reposition himself every 2 hours. maintain fluid
intake of 40 oz (1,200 ml) per day. continue to take
antibiotics for the entire 10 days.
follow up with the physician in 2 weeks.: continue to take antibiotics for the entire 10 days. Explanation:
The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed
10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these
interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.
9. A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention
should the nurse include when planning this client's care? Elevating the head of the bed 30
degrees
Encouraging increased fluid intake Maintaining a
cool room temperature
Turning the client every 2 hours: Encouraging increased fluid intake Explanation:
Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2
hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the
diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with
secretions
10. A patient comes to the clinic with fever, cough, and chest discomfort. The nurse
auscultates crackles in the left lower base of the lung and suspects that the patient may have
70+ Questions with Correct Answers
1. Which is the most important risk factor for development of chronic obstruc- tive
pulmonary disease (COPD)?
Genetic abnormalities
Occupational exposure Air
pollution
Cigarette smoking: Cigarette smoking
2. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumo- cystis carinii
pneumonia. Which nursing diagnosis has the highest priority?
Activity intolerance
Imbalanced nutrition: Less than body requirements Impaired
oral mucous membranes
Impaired gas exchange: impaired gas exchange
3. During a community health fair, a nurse is teaching a group of seniors about promoting
health and preventing infection. Which intervention would best pro- mote infection
prevention for senior citizens who are at risk of pneumococcal and influenza infections?
Take all prescribed medications Drink
six glasses of water daily Exercise daily
Receive vaccinations: Receive vaccinations
,4. A client admitted with multiple traumatic injuries receives massive fluid re- suscitation.
Later, the physician suspects that the client has aspirated stomach contents. The nurse knows
that this client is at highest risk for:
bronchial asthma. renal
failure.
chronic obstructive pulmonary disease (COPD). acute
respiratory distress syndrome (ARDS).: ARDS
A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is
associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near
,drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow
obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's
history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.
5. A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the
occurrence of postoperative pneumonia in this client?
Administering pain medications, frequent repositioning, and limiting fluid intake
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
Administering oxygen, coughing, breathing deeply, and maintaining bed rest Coughing,
breathing deeply, maintaining bed rest, and using an incentive spirometer: Coughing, breathing deeply,
frequent repositioning, and using an incentive spirometer Explanation:
Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the
client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.
6. Which would be least likely to contribute to a case of hospital-acquired pneu- monia?
Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's
defenses.
A nurse washes her hands before beginning client care. Host defenses
are impaired.
A highly virulent organism is present.: A nurse washes her hands before beginning client care
7. Which should a nurse encourage in clients who are at the risk of pneumococ- cal and
influenza infections?
Using incentive spirometry Mobilizing
early
, Receiving vaccinations
Using prescribed opioids: Receiving vaccinations
8. During discharge teaching, a nurse is instructing a client about pneumonia. The client
demonstrates his understanding of relapse when he states that he must:
turn and reposition himself every 2 hours. maintain fluid
intake of 40 oz (1,200 ml) per day. continue to take
antibiotics for the entire 10 days.
follow up with the physician in 2 weeks.: continue to take antibiotics for the entire 10 days. Explanation:
The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed
10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these
interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.
9. A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention
should the nurse include when planning this client's care? Elevating the head of the bed 30
degrees
Encouraging increased fluid intake Maintaining a
cool room temperature
Turning the client every 2 hours: Encouraging increased fluid intake Explanation:
Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2
hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the
diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with
secretions
10. A patient comes to the clinic with fever, cough, and chest discomfort. The nurse
auscultates crackles in the left lower base of the lung and suspects that the patient may have
