AMS exam 3 – ZIP Ch 28 – Upper resp probz – Flashcards
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Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
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Weak, nonproductive cough effort
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A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?
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Assist the patient to splint the chest when coughing.
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The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?
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Place patients with altered consciousness in side-lying positions.
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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 has been effective?
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The patient's white blood cell (WBC) count is 9000/µL.
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A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?
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Three sputum smears for acid-fast bacilli are negative.
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The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
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"My husband will be sleeping in the guest bedroom."
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A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse?
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Explain that orange discolored urine and tears are normal while taking this medication.
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An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
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Arrange for a daily noon meal at a community center where the drug will be administered.
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After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
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Ask the patient whether medications have been taken as directed.
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Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
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Use and side effects of isoniazid (INH)
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An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?
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Require the use of protective equipment.
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The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include?
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Options for smoking cessation
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A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?
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"Tell me what you know about the various treatments available."
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The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
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400 mL of blood in the collection chamber
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A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
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Paradoxic chest movement
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When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
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Insertion of a chest tube with a chest drainage system
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The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care?
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Frequent use of an incentive spirometer
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The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?
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Observe for distended neck veins.
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A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?
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Patient reports decreased exertional dyspnea.
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A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
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Position the patient sitting upright on the edge of the bed and leaning forward.
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A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
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Blood cultures from two sites
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The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
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Oxygen saturation is 88%.
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A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
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Impaired gas exchange related to respiratory congestion
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A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?
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Elevate the head of the bed to a semi-Fowler's position.
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The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
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A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
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The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?
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Medicate the patient with prescribed morphine.
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A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
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Appropriate use of cough suppressants
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Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
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Teaching patients about the need for adult pertussis immunizations
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The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
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"I will use the incentive spirometer every hour or two during the day."
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After change-of-shift report, which patient should the nurse assess first?
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64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
