NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
Chapter 27: Lower Respiratory Problems
Medical-Surgical Nursing, 15th Edition
MULTIPLE CHOICE
1. After 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 cough effort
b.
Profuse green sputum
c.
Respiratory rate of 28 breaths/minute
d.
Resting pulse oximetry (SpO2) of 85%
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.
DIF: Cognitive Level: Analyze (analysis) REF: 505
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
2. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding
would the nurse expect?
a.
Increased tactile fremitus c. Hyperresonance to percussion
b.
Dry, nonproductive cough d. A grating sound on auscultation
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.
DIF: Cognitive Level: Apply (application) REF: 503
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action
should the nurse plan to promote airway clearance?
,NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
a.
Restrict oral fluids during the day.
b.
Teach pursed-lip breathing technique.
c.
Assist the patient to splint the chest when coughing.
d.
Encourage the patient to wear the nasal O2 cannula.
ANS: C
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 O 2 will
improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to
improve gas exchange in patients with chronic obstructive pulmonary disease but will not
improve airway clearance.
DIF: Cognitive Level: Apply (application) REF: 505
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
,NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
4. 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 my health care provider if I still feel tired after a week.”
b.
“I will continue to do deep breathing and coughing exercises at home.”
c.
“I will schedule two appointments for the pneumonia and influenza vaccines.”
d.
“I will cancel my follow-up chest x-ray appointment if I feel better next week.”
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for
several weeks. The pneumococcal and influenza vaccines can be given at the same time in
different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate
resolution of pneumonia.
DIF: Cognitive Level: Apply (application) REF: 506
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
5. Which action should the nurse plan to prevent aspiration in a high-risk patient?
a.
Turn and reposition an immobile patient at least every 2 hours.
b.
Place a patient with altered consciousness in a side-lying position.
c.
Insert a nasogastric tube for feeding a patient with high calorie needs.
d.
Monitor respiratory symptoms in a patient who is immunosuppressed.
ANS: B
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more
likely to occur. 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 O 2 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.
DIF: Cognitive Level: Apply (application) REF: 505
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
6. 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 is
effective?
a.
Bronchial breath sounds are heard at the right base.
b.
The patient coughs up small amounts of green mucus.
, NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
c.
The patient’s white blood cell (WBC) count is 9000/µL.
d.
Increased tactile fremitus is palpable over the right chest.
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.
DIF: Cognitive Level: Apply (application) REF: 504
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Chapter 27: Lower Respiratory Problems
Medical-Surgical Nursing, 15th Edition
MULTIPLE CHOICE
1. After 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 cough effort
b.
Profuse green sputum
c.
Respiratory rate of 28 breaths/minute
d.
Resting pulse oximetry (SpO2) of 85%
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.
DIF: Cognitive Level: Analyze (analysis) REF: 505
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
2. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding
would the nurse expect?
a.
Increased tactile fremitus c. Hyperresonance to percussion
b.
Dry, nonproductive cough d. A grating sound on auscultation
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.
DIF: Cognitive Level: Apply (application) REF: 503
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action
should the nurse plan to promote airway clearance?
,NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
a.
Restrict oral fluids during the day.
b.
Teach pursed-lip breathing technique.
c.
Assist the patient to splint the chest when coughing.
d.
Encourage the patient to wear the nasal O2 cannula.
ANS: C
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 O 2 will
improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to
improve gas exchange in patients with chronic obstructive pulmonary disease but will not
improve airway clearance.
DIF: Cognitive Level: Apply (application) REF: 505
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
,NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
4. 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 my health care provider if I still feel tired after a week.”
b.
“I will continue to do deep breathing and coughing exercises at home.”
c.
“I will schedule two appointments for the pneumonia and influenza vaccines.”
d.
“I will cancel my follow-up chest x-ray appointment if I feel better next week.”
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for
several weeks. The pneumococcal and influenza vaccines can be given at the same time in
different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate
resolution of pneumonia.
DIF: Cognitive Level: Apply (application) REF: 506
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
5. Which action should the nurse plan to prevent aspiration in a high-risk patient?
a.
Turn and reposition an immobile patient at least every 2 hours.
b.
Place a patient with altered consciousness in a side-lying position.
c.
Insert a nasogastric tube for feeding a patient with high calorie needs.
d.
Monitor respiratory symptoms in a patient who is immunosuppressed.
ANS: B
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more
likely to occur. 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 O 2 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.
DIF: Cognitive Level: Apply (application) REF: 505
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
6. 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 is
effective?
a.
Bronchial breath sounds are heard at the right base.
b.
The patient coughs up small amounts of green mucus.
, NURSING 119c27 QUESTIONS AND CORRECT ANSWERS 2022
c.
The patient’s white blood cell (WBC) count is 9000/µL.
d.
Increased tactile fremitus is palpable over the right chest.
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.
DIF: Cognitive Level: Apply (application) REF: 504
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
