NCLEX Pneumonia Study Questions

NCLEX Pneumonia Study Questions Leave the first rating Students also studied Terms in this set (10) Science MedicineNursing Save EKG rhythms 60 terms MelFlanPreview NUR 150 TB NCLEX Questions 23 terms klh2774Preview CIC Practice Test 2 135 terms hhoward4Preview Respira 41 terms Bro The nurse is caring for a pt w/ COPD and pneumonia who has an order for ABGs to be drawn. What is the min lenth of time the nurse should paln to hold pressure on punture site?

• min
• min

10 min 15 min

• min

An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.The pt is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation?Thoracentesis Bronchoscopy ABGs Pulmonary Function Tests ABGs To promote airway clearance in a pt with pneumonia, what should the nurse instruct the pt to do? Select all that apply.

a) Maintain adequate fluid intake.

b) Splint the chest when coughing.

c) Maintain a 30-degree elevation.

d) Maintain a semi-fowlers position.

e) Instruct pt to cough at end of exhalation.

A, B, E

Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration.The RN should instruct pt to splint the chest while coughing. This will reduce discomfort and allow for more effective coughing.Coughing at end of exhalation promotes efficient cough.Pt position should be upright sitting with head slightly flexed.

The RN caring for a pt admitted to the hospital with pneumonia. Upon assessment, the RN notes a temp of 101.4, a productive cough w/ yellow sputum, and a RR of

• Which nursing diagnosis is most appropriate based on

this assessment?Hyperthermia related to infectious illness.Ineffective thermoregulation related to chilling Ineffective breathing pattern related to pneumonia Ineffective airway clearance related to thick secretions Hyperthermia related to infectious illness.B/c the pt has a spiked temp and has diagnosis of pneumonia, the logical nursing diagnosis is this. There is no evidence of a chill and her breathing pattern is w/in normal limits 12-20 breaths/min. there is no evidence of ineffective airway clearance from info given b/c pt is expectorating sputum.Which clinical manifestations should the nurse expect to find during assessment of a pt admitted with pneumonia?Hyper-resonance on percussion.Vesicular breath sounds in all lobes.Increased vocal fremitus on palpation.Fine crackles in all lobes on auscultation.Increased vocal fremitus on palpation.This is a typical physical finding. With pleural effusion, there may be dullness to percussion over the affected area.During discharge teaching for a 65 y.o. pt with COPD and pneumonia, which vaccine should the nurse recommend that this pt receive?Pneumococcal

• Aureus

Haemophilus influenzae Bacille-Calmette-Guerin (BCG) Pneumococcal This vaccine is important for pt's w/ a hx of heart or lung disease, recovering from severe illness, age 65 or over, or living in a long-term care facility.The RN evaluates that discharge teaching for a pt hospitalized with pneumonia has been EFFECTIVE when the pt makes which statement about measures to prevent a relapse?

a) I will seek immediate medical treatment for any upper

resp infections.

b) I should cont. to do deep-breathing and coughing

exercises for at least 12 wks.

c) I will increase my food intake to 2400 cal/day to keep

my immune system well.

d) I must have a follow-up chest x-ray in 6-8 wks to

evaluate the pneumonia's resolution.D After admitting a pt from home to the medical unit w/ a dx of pneumonia, which physician orders will the RN verify have been completed before administering a dose of cefuroxime (Ceftin) to the pt?Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum lab studies ordered for AM Sputum culture and sensitivity This is community acquired pneumonia. It is important that the organism is correctly identified before the antibiotic takes effect. The test will determine whether the proper antibiotic has been ordered.

A 73 y.o. female pt who lives alone is admitted to the hospital w/ dx of pneumococcal pneumonia. Which clinical manifestation, if observed by the RN, indicates that the pt is likely to by hypoxic?Sudden onset of confusion.Oral temp of 102.3 Coarse crackles in lung bases Clutching the chest on inspiration Sudden onset of confusion.Confusion or stupor may be the only clinical manifestation of pneumonia in an older pt.The RN cares for a 50 y.o. pt w/ pneumonia that has been unresponsive to two different antibiotics. Which task is most important for the nurse to complete before administering a newly prescribed antibiotic?Teach the pt to cough and deep breathe Take the temp, pulse, and RR Obtain a sputum specimen for culture and Gram stain Check the pt's O2 saturation by pulse oximetry Obtain a sputum specimen for culture and Gram stain.To identify the organism.