Med Surg Test bank ( Red HESI Test bank
Med-Surg and other resources)
Which of the following physical assessment findings in a patient
with pneumonia best supports the nursing diagnosis of ineffective
airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles - Ans>>>D. Basilar crackles The presence of
adventitious breath sounds indicates that there is accumulation of
secretions in the lower airways. This would be consistent with a
,nursing diagnosis of ineffective airway clearance because the
patient is retaining secretions.
Which of the following clinical manifestations would the nurse
expect to find during assessment of a patient admitted with
pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath
sounds in all lobes - Ans>>>C. Increased vocal fremitus on
palpation. A typical physical examination finding for a patient with
pneumonia is increased vocal fremitus on palpation. Other signs
of pulmonary consolidation include dullness to percussion,
bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest
priority in helping a patient expectorate thick secretions related to
pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
,D. Teach patient to splint the affected area. - Ans>>>B. Increase
fluid intake to 3L/day if tolerated. Although several interventions
may help the patient expectorate mucus, the highest priority
should be on increasing fluid intake, which will liquefy the
secretions so that the patient can expectorate them more easily.
Humidifying the oxygen is also helpful, but is not the primary
intervention. Teaching the patient to splint the affected area may
also be helpful, but does not liquefy the secretions so that they
can be removed.
During discharge teaching for a 65-year-old patient with
emphysema and pneumonia, which of the following vaccines
should the nurse recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - Ans>>>C. Pneumococcal The
pneumococcal vaccine is important for patients with a history of
heart or lung disease, recovering from a severe illness, age 65 or
over, or living in a long-term care facility.
, 11. The nurse evaluates that discharge teaching for a patient
hospitalized with pneumonia has been most effective when the
patient states which of the following measures to prevent a
relapse?
A. "I will increase my food intake to 2400 calories a day to keep
my immune system well."
B. "I must use home oxygen therapy for 3 months and then will
have a chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper
respiratory infections."
D. "I should continue to do deep-breathing and coughing
exercises for at least 6 weeks." - Ans>>>D. "I should continue to
do deep-breathing and coughing exercises for at least 6 weeks." It
is important for the patient to continue with coughing and deep
breathing exercises for 6 to 8 weeks until all of the infection has
cleared from the lungs. A patient should seek medical treatment
for upper respiratory infections that persist for more than 7 days.
Increased fluid intake, not caloric intake, is required to liquefy
Med-Surg and other resources)
Which of the following physical assessment findings in a patient
with pneumonia best supports the nursing diagnosis of ineffective
airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles - Ans>>>D. Basilar crackles The presence of
adventitious breath sounds indicates that there is accumulation of
secretions in the lower airways. This would be consistent with a
,nursing diagnosis of ineffective airway clearance because the
patient is retaining secretions.
Which of the following clinical manifestations would the nurse
expect to find during assessment of a patient admitted with
pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath
sounds in all lobes - Ans>>>C. Increased vocal fremitus on
palpation. A typical physical examination finding for a patient with
pneumonia is increased vocal fremitus on palpation. Other signs
of pulmonary consolidation include dullness to percussion,
bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest
priority in helping a patient expectorate thick secretions related to
pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
,D. Teach patient to splint the affected area. - Ans>>>B. Increase
fluid intake to 3L/day if tolerated. Although several interventions
may help the patient expectorate mucus, the highest priority
should be on increasing fluid intake, which will liquefy the
secretions so that the patient can expectorate them more easily.
Humidifying the oxygen is also helpful, but is not the primary
intervention. Teaching the patient to splint the affected area may
also be helpful, but does not liquefy the secretions so that they
can be removed.
During discharge teaching for a 65-year-old patient with
emphysema and pneumonia, which of the following vaccines
should the nurse recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - Ans>>>C. Pneumococcal The
pneumococcal vaccine is important for patients with a history of
heart or lung disease, recovering from a severe illness, age 65 or
over, or living in a long-term care facility.
, 11. The nurse evaluates that discharge teaching for a patient
hospitalized with pneumonia has been most effective when the
patient states which of the following measures to prevent a
relapse?
A. "I will increase my food intake to 2400 calories a day to keep
my immune system well."
B. "I must use home oxygen therapy for 3 months and then will
have a chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper
respiratory infections."
D. "I should continue to do deep-breathing and coughing
exercises for at least 6 weeks." - Ans>>>D. "I should continue to
do deep-breathing and coughing exercises for at least 6 weeks." It
is important for the patient to continue with coughing and deep
breathing exercises for 6 to 8 weeks until all of the infection has
cleared from the lungs. A patient should seek medical treatment
for upper respiratory infections that persist for more than 7 days.
Increased fluid intake, not caloric intake, is required to liquefy
