Exam 3 NUR 2242c c7 (Concept 3 Family Dynamics Concept
25 Infection Concept 31 Stress Concept 32 Coping Concept
38 Interpersonal Violence Concept 52 Caregiving Chapter
31: Care of Patients with Infectious Respiratory Problems)
Questions With Complete Solutions
A client admitted for pneumonia has been tachypneic for several
days. When the nurse starts an IV to give fluids, the client
questions this action, saying "I have been drinking tons of water.
How am I dehydrated?" What response by the nurse is best?
a. "Breathing so quickly can be dehydrating."
b. "Everyone with pneumonia is dehydrated."
c. "This is really just to administer your antibiotics."
d. "Why do you think you are so dehydrated?" Correct Answer
ANS: A
Tachypnea and mouth breathing, both seen in pneumonia,
increase insensible water loss and can lead to a degree of
dehydration. The other options do not give the client useful
information.
A client has been diagnosed with an empyema. What
interventions should the nurse anticipate providing to this client?
(Select all that apply.)
a. Assisting with chest tube insertion
b. Facilitating pleural fluid sampling
c. Performing frequent respiratory assessment
d. Providing antipyretics as needed
e. Suctioning deeply every 4 hours Correct Answer ANS: A, B,
C, D
,The client with an empyema is often treated with chest tube
insertion, which facilitates obtaining samples of the pleural fluid
for analysis and re-expands the lungs. The nurse should perform
frequent respiratory system assessments. Antipyretic
medications are also used. Suction is only used when needed
and is not done deeply to prevent tissue injury.
A diabetic patient who is hospitalized tells the nurse, "I don't
understand why I can keep my blood sugar under control at
home with diet alone, but when I get sick, my blood sugar goes
up." Which response by the nurse is appropriate?
a. "It is probably just coincidental that your blood sugar is high
when you are ill."
b. "Stressors such as illness cause the release of hormones that
increase blood sugar."
c. "Increased blood sugar occurs because the kidneys are not
able to metabolize glucose as well during stressful times."
d. "Your diet is different here in the hospital than at home, and
that is the most likely cause of the increased glucose level."
Correct Answer ANS: B
The release of cortisol, epinephrine, and norepinephrine
increases blood glucose levels. The increase in blood sugar is
not coincidental. The kidneys do not control blood glucose. A
diabetic patient who is hospitalized will be on an appropriate
diet to help control blood glucose.
A mother is talking with the community-based nurse concerning
her adult son. The son is mentally challenged and not able to
live on his own. The mother is concerned about her son's
,welfare when she is no longer able to care for him. The best
response by the nurse would be which of the following?
a. "Let's look into the community resources that are available to
assist you."
b. "You have raised your son well, and he will be okay on his
own."
c. "Contact your distant relatives to see if anyone would take
your son."
d. "There are places for mentally challenged adults; let's place
him there." Correct Answer ANS: A
The mother, with the assistance of the nurse, can research
resources in the community that will service and care for her son
when she is no longer able to do so. How the son is raised does
not mean that he will be okay on his own. Distant relatives may
not want or be able to care for the son, so this may not be a
viable option. Placing the son is too general of an option, and he
may not do well in this setting.
A nurse admits a client from the emergency department. Client
data are listed below:
70 years of age
History of diabetes
On insulin twice a day
Reports new-onset dyspnea and productive cough Crackles and
rhonchi heard throughout the lungs
Dullness to percussion LLL
Afebrile
Oriented to person only WBC: 5,200/mm3
PaO2 on room air 65 mm Hg
What action by the nurse is the priority?
, a. Administer oxygen at 4 liters per nasal cannula.
b. Begin broad-spectrum antibiotics.
c. Collect a sputum sample for culture.
d. Start an IV of normal saline at 50 mL/hr. Correct Answer
ANS: A
All actions are appropriate for this client who has manifestations
of pneumonia. However, airway and breathing come first, so
begin oxygen administration and titrate it to maintain saturations
greater than 95%. Start the IV and collect a sputum culture, and
then begin antibiotics.
A nurse is caring for a patient in the emergency department who
has been a victim of intimate partner violence. What is most
important for the nurse to include in the plan of care?
a. Medication to calm the perpetrator of the violence
b. A list of community resources
c. A referral for self-defense training
d. A referral to the victim's religious advisor Correct Answer
ANS: B
Providing education that will address immediate safety needs for
the patient is a priority action for the nurse. The nurse is not
creating a plan for the perpetrator, nor is it the responsibility of
the victim to receive medication for another person. Self-defense
training does not meet the immediate safety concern for the
patient and may aggravate the perpetrator further. Accessing
support from a religious advisor is good for ongoing support, but
it does not address the immediate need for safety information.
25 Infection Concept 31 Stress Concept 32 Coping Concept
38 Interpersonal Violence Concept 52 Caregiving Chapter
31: Care of Patients with Infectious Respiratory Problems)
Questions With Complete Solutions
A client admitted for pneumonia has been tachypneic for several
days. When the nurse starts an IV to give fluids, the client
questions this action, saying "I have been drinking tons of water.
How am I dehydrated?" What response by the nurse is best?
a. "Breathing so quickly can be dehydrating."
b. "Everyone with pneumonia is dehydrated."
c. "This is really just to administer your antibiotics."
d. "Why do you think you are so dehydrated?" Correct Answer
ANS: A
Tachypnea and mouth breathing, both seen in pneumonia,
increase insensible water loss and can lead to a degree of
dehydration. The other options do not give the client useful
information.
A client has been diagnosed with an empyema. What
interventions should the nurse anticipate providing to this client?
(Select all that apply.)
a. Assisting with chest tube insertion
b. Facilitating pleural fluid sampling
c. Performing frequent respiratory assessment
d. Providing antipyretics as needed
e. Suctioning deeply every 4 hours Correct Answer ANS: A, B,
C, D
,The client with an empyema is often treated with chest tube
insertion, which facilitates obtaining samples of the pleural fluid
for analysis and re-expands the lungs. The nurse should perform
frequent respiratory system assessments. Antipyretic
medications are also used. Suction is only used when needed
and is not done deeply to prevent tissue injury.
A diabetic patient who is hospitalized tells the nurse, "I don't
understand why I can keep my blood sugar under control at
home with diet alone, but when I get sick, my blood sugar goes
up." Which response by the nurse is appropriate?
a. "It is probably just coincidental that your blood sugar is high
when you are ill."
b. "Stressors such as illness cause the release of hormones that
increase blood sugar."
c. "Increased blood sugar occurs because the kidneys are not
able to metabolize glucose as well during stressful times."
d. "Your diet is different here in the hospital than at home, and
that is the most likely cause of the increased glucose level."
Correct Answer ANS: B
The release of cortisol, epinephrine, and norepinephrine
increases blood glucose levels. The increase in blood sugar is
not coincidental. The kidneys do not control blood glucose. A
diabetic patient who is hospitalized will be on an appropriate
diet to help control blood glucose.
A mother is talking with the community-based nurse concerning
her adult son. The son is mentally challenged and not able to
live on his own. The mother is concerned about her son's
,welfare when she is no longer able to care for him. The best
response by the nurse would be which of the following?
a. "Let's look into the community resources that are available to
assist you."
b. "You have raised your son well, and he will be okay on his
own."
c. "Contact your distant relatives to see if anyone would take
your son."
d. "There are places for mentally challenged adults; let's place
him there." Correct Answer ANS: A
The mother, with the assistance of the nurse, can research
resources in the community that will service and care for her son
when she is no longer able to do so. How the son is raised does
not mean that he will be okay on his own. Distant relatives may
not want or be able to care for the son, so this may not be a
viable option. Placing the son is too general of an option, and he
may not do well in this setting.
A nurse admits a client from the emergency department. Client
data are listed below:
70 years of age
History of diabetes
On insulin twice a day
Reports new-onset dyspnea and productive cough Crackles and
rhonchi heard throughout the lungs
Dullness to percussion LLL
Afebrile
Oriented to person only WBC: 5,200/mm3
PaO2 on room air 65 mm Hg
What action by the nurse is the priority?
, a. Administer oxygen at 4 liters per nasal cannula.
b. Begin broad-spectrum antibiotics.
c. Collect a sputum sample for culture.
d. Start an IV of normal saline at 50 mL/hr. Correct Answer
ANS: A
All actions are appropriate for this client who has manifestations
of pneumonia. However, airway and breathing come first, so
begin oxygen administration and titrate it to maintain saturations
greater than 95%. Start the IV and collect a sputum culture, and
then begin antibiotics.
A nurse is caring for a patient in the emergency department who
has been a victim of intimate partner violence. What is most
important for the nurse to include in the plan of care?
a. Medication to calm the perpetrator of the violence
b. A list of community resources
c. A referral for self-defense training
d. A referral to the victim's religious advisor Correct Answer
ANS: B
Providing education that will address immediate safety needs for
the patient is a priority action for the nurse. The nurse is not
creating a plan for the perpetrator, nor is it the responsibility of
the victim to receive medication for another person. Self-defense
training does not meet the immediate safety concern for the
patient and may aggravate the perpetrator further. Accessing
support from a religious advisor is good for ongoing support, but
it does not address the immediate need for safety information.
