UPDATED QUESTIONS AND ANSWERS 2022/2023 GUARANTEED SUCCESS A+ NURSING CARE OF PATIENTS WI, Exams of Nursing

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UPDATED QUESTIONS AND ANSWERS 2022/

GUARANTEED SUCCESS A+

NURSING CARE OF PATIENTS WITH VENTILATION

DISORDER

1. The nurse, preparing instruction for a patient diagnosed with bacterial pneumonia, would expect which of the following classes of medication to be prescribed? Select all that apply. a. antibiotics b. steroids c. bronchodilators d. antiemetics e. antihistamines
2. A clinic is being conducted to provide influenza (flu) and pneumonia vaccines for adults. Prior to administration of a flu vaccine, the nurse must assess for which of the following? a. current antibiotic therapy b. pulse oximeter saturation level c. allergy to mercury d. allergy to eggs
3. Which of the following would the nurse assess in the patient with the nursing diagnosis of Ineffective Airway Clearance? Select all that apply. a. Assess skin color at least every four hours. b. Assess breath sounds at least every four hours. c. Assess oxygen saturation level at least every four hours. d. Assess vital signs daily. e. Assess respiratory rates every shift.
4. The nurse, caring for a patient diagnosed with severe acute respiratory syndrome (SARS), should assess for which of the following? Select all that apply. a. nasal flaring b. restlessness c. anxiety d. decreased level of consciousness e. sputum production
5. The nurse should instruct a patient who is prescribed INH and rifampin for the treatment of tuberculosis to report which of the following side effects? Select all that apply. a. fever b. yellow tint to the skin c. episodic pain in the upper-left quadrant d. diarrhea

e. change in stool color

6. A patient diagnosed with tuberculosis is prescribed ethambutol (Myambutol). Prior to initiating this medication, the nurse should instruct the patient on which of the following? a. if the patient has an allergy to eggs b. having a baseline visual exam c. having an influenza (flu) vaccine d. having a baseline ECG (electrocardiogram)
7. A patient diagnosed with a restrictive lung disease due to an intrinsic cause is least likely to demonstrate which of the following during an assessment? a. chronic productive cough of prolonged duration b. progressive exertional dyspnea c. dry cough d. hemoptysis
8. A patient with chronic obstructive lung disease tells the nurse that he does not always wear the prescribed oxygen at home because it is cumbersome and he is rarely short of breath. Which of the following is the nurse’s best response to this patient? a. “Wearing the oxygen will help keep your blood oxygen saturation levels up so your heart does not have to work at hard and will not become enlarged.” b. “You really should wear it at least while sleeping.” c. “It seems like you are doing fine without it.” d. “Keep the oxygen at home and if you become short of breath, you know to put it on until you are able to breath normally again.”
9. A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation? a. until three consecutive sputum specimens for acid fast bacilli are negative b. until the Mantoux test (PPD) converts from positive to negative c. until the patient has orders for discharge d. until the chest x-ray is normal
10. The nurse is providing teaching to a patient prescribed isoniazide (INH). Select the patient statement that indicates a need for further medication instruction. a. “I will take the INH? hour after eating breakfast.” b. “I will make sure I tell all my health care providers that I am taking INH.” c. “Tuna fish is one of my favorite foods. I will hate having to give it up.” d. “I will make sure I get my laboratory tests drawn to monitor my liver function.” 11. Select the statement that indicates that a patient diagnosed with asthma needs additional teaching at discharge. Select all that apply. a. “I know I shouldn’t smoke, but one or two cigarettes a day shouldn’t be harmful.” b. “I should monitor my peak flow daily and record it in a diary.” c. “I should rinse my mouth after each use of my corticosteroid inhaler.” d. “Using a spacer with my inhaler will allow for better and more accurate medication delivery.” e. “I can also use some herbal remedies I’ve read about to manage my symptoms.”

12. Which of the following patients would the nurse identify as being at risk for developing cor pulmonale? Select all that apply. a. patient with left ventricular heart failure b. patient experiencing a massive pulmonary embolism c. patient with chronic obstructive pulmonary disease (COPD) d. patient with polycythemia vera e. patient with deep vein thrombosis
13. A patient, diagnosed with chronic bronchitis, has the nursing diagnosis Ineffective Airway Clearance related to inadequate cough and excess mucous production. Which of the following interventions is of the least value in resolving the nursing diagnosis? a. Check the pulse oximetry reading. b. Increase fluid intake up to 2 liters/day. c. Suction the patient. d. Provide chest physiotherapy.
14. After a chest tube is inserted into a patient with a pneumothorax, which of the following should the nurse assess in the drainage system? a. bubbling in the water seal chamber immediately after insertion b. no evidence of tidaling c. vigorous bubbling in the suction control chamber d. large amount of bloody drainage in the drainage collection chamber
15. The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which of the following findings would indicate the possibility of tension pneumothorax? a. new onset of decreased breath sounds over the right lung b. blood pressure of 170/ c. pulse oximetry readings ranging from 94 to 96% d. crackles and wheezing heard in both lungs
16. Which of the following assessment findings would indicate that a victim of a motor vehicle accident is experiencing a pneumothorax? a. hyperresonance to percussion at the apex of the left lung b. dullness to percussion at the base of the left lung c. crackles throughout the left lung d. shallow breathing
17. The nurse caring for patients with end-stage lung disease determines that which of the following patients may qualify for single lung transplant? a. 62- year-old female with diabetes mellitus controlled by insulin therapy b. 50- year-old male with multi-vessel CAD and chronic renal insufficiency c. 32- year-old male patient with HIV d. 43-year-old female with hepatitis C confirmed by histologic findings of liver disease by biopsy
18. The nurse, caring for a patient diagnosed with lung cancer, determines that the patient might be experiencing superior vena cava syndrome when which of the following is assessed? a. face and neck swelling

b. hourly urine outputs 250 to 500 mL c. calcium level of 14.0 mg/dL d. flat jugular veins

19. Which of the following clinical manifestations is not expected in a patient diagnosed with an occupational lung disease? a. wet sounding crackles in the lungs b. chronic cough c. clubbing of the fingers d. excess sputum with varying amounts of black fluid
20. A patient comes into the emergency department with acute shortness of breath and copious secretions. The patient states the problem started a few hours after arriving at work. Which of the following is the most likely cause of the patient’s acute respiratory problem? a. reaction to the agent used to clean the carpeting in the office b. environmental air temperature 72 degrees c. received annual flu vaccine one week ago d. did not finish breakfast but had a protein bar for a snack
21. A patient states, “I’ve been sick for days and all the doctor does is take a chest x-ray, hand me prescriptions, and tell me I have bronchitis.” The nurse realizes that this patient’s treatment a. is appropriate for the diagnosis. b. should include more diagnostic tests. c. is inadequate for the diagnosis of bronchitis. d. should include hospitalization.
22. A patient who is diagnosed with primary atypical pneumonia tells the nurse that he “doesn’t feel too sick.” The nurse’s best response is which of the following? a. “Give it a few days and you will.” b. “You’re lucky.” c. “You must be recovering from the illness.” d. “This type of pneumonia is usually mild in its effects.”
23. A patient who was admitted with symptoms of hypoxia is changed from a face mask to a nasal cannula for oxygen delivery. The nurse realizes that this patient’s condition is a. deteriorating. b. improving. c. stabilizing. d. compounded with another health issue.
24. A patient who is in the hospital is diagnosed with sudden acute respiratory syndrome ( SARS). The best nursing intervention for this patient is to implement which of the following? a. standard precautions b. standard precautions and droplet precautions c. standard precautions and contact precautions d. standard, contact, and airborne precautions
25. A patient with a lung abscess is being discharged from the hospital. Appropriate discharge instructions for this patient should include which of the following?

a. complete the entire prescription of antibiotics b. expect symptoms to become worse. c. return to routine activities of daily living. d. lung abscesses rarely cause other problems once treatment is started.

26. A patient who is on isoniazid (INH) for pulmonary tuberculosis tells the nurse he doesn’t like taking the medication because it makes his “fingers burn.” The nurse concludes that the patient is experiencing which of the following? a. a common side effect of isoniazid (INH) that will go away after completing the medication b. a common side effect of isoniazid (INH) that can be treated with pyridoxine c. a long-term complication of isoniazid (INH) that has no treatment d. a common complication of isoniazid (INH) that can be treated with vitamin B injections
27. A patient who had a Mantoux test for tuberculosis two days ago has a 2 mm area of erythema at the site of the test. The nurse concludes that this patient’s response a. is negative. b. is positive for tuberculosis. c. should be followed up with a tine test. d. is unable to determine the presence of tuberculosis.
28. A patient tells the nurse he had the bacilli Calmette-Guérin (BCG) vaccination as a child because his mother had tuberculosis. This patient will be screened for tuberculosis by doing which of the following? a. conducting a tine test b. conducting a Mantoux test c. conducting both the tine and Mantoux tests d. conducting a chest x-ray
29. A patient who is taking rifampin (Rifadin) as part of his treatment for tuberculosis asks about making an appointment for a urologist because his urine is “bright orange.” The nurse realizes that this patient is experiencing which of the following? a. a secondary urinary tract infection b. a common side effect of rifampin therapy c. the onset of a kidney stone d. early renal failure
30. The nurse is providing care to a patient with pulmonary tuberculosis. Which of the following should the nurse do to ensure personal protection while caring for this patient? a. Wear a gown and eye goggles. b. Wear a gown and surgical mask. c. Wear a gown and HEPA mask. d. Wear a gown and sterile gloves.
31. A patient is diagnosed with histoplasmosis. Which of the following elements of this patient’s history would help explain the reason for the disease? a. lives in a city with chemical plants b. drives a vehicle that uses diesel fuel

c. is an electrical engineer d. works part-time for his grandparents’ fresh poultry business

32. A patient with lung cancer is demonstrating signs of complete tumor response after two courses of chemotherapy. The nurse concludes that this response is which of the following? a. good for a long-term survival from the disease b. an indication that radiation therapy is needed c. an indication that surgery can be performed d. a contraindication for further chemotherapy
33. A patient who is receiving radiation therapy for lung cancer complains of ongoing fatigue. Appropriate teaching for this patient includes that a. this is a complication of radiation therapy and will continue for years. b. there is nothing that can help the fatigue c. frequent rest periods and good nutrition can help with the fatigue. d. restricting caloric intake often helps with the fatigue.
34. A patient is diagnosed with pleurisy. The nurse instructs the patient to alleviate the associated chest pain by which of the following? a. only taking the prescribed analgesic when the pain is severe b. teaching the patient how to splint the affected area when coughing c. advising the patient to maintain bed rest d. warning the patient to expect a fever to develop
35. A 20-year-old patient who is asking questions about smoking cessation tells the nurse about an upcoming class on scuba diving. The nurse identifies that this patient might be at risk for developing which of the following? a. pleural effusion b. pleurisy c. pneumothorax d. hemothorax
36. The nurse observes air bubbles in a patient’s chest tube water seal chamber. The nurse interprets this finding as which of the following? a. normal b. an emergency c. an indication that the pneumothorax is worsening d. an indication to remove the chest tube
37. During the assessment of a patient’s respiratory status, the nurse notes paradoxical lung movements. This finding is consistent with which of the following? a. flail chest b. pleurisy c. pneumothorax d. pneumonia
38. The nurse is providing care to a patient with a differential diagnosis of carbon monoxide poisoning. Which of the following would be consistent with this diagnosis? Select all that apply. a. cherry-red mucous membranes b. circumoral pallor

c. diarrhea d. nausea e. dizziness

39. A patient is diagnosed with a tension pneumothorax. Which of the following would be consistent with this diagnosis? Select all that apply. a. hypertension b. distended neck veins c. bradycardia d. absent breath sounds on the affected side e. tracheal deviation toward unaffected side
40. The nurse is reviewing the results of the patient’s diagnostic tests. Based on the chart above, which of the following physician orders would the nurse most likely question based on the patient’s most likely diagnosis? a. fluid restriction of 1500 mL per 24 hours b. administer acetylcysteine (Mucomyst) c. perform endotracheal suctioning as needed d. administer azithromycin
41. The nurse is reviewing the patient’s diagnostic test results from the time of admission. Based on the chart above, which of the following statements made by the patient indicates that the patient requires further education? a.. “I have to be in isolation so that I won’t infect anyone else.” b. “I’m surprised that the hospital has to report this to the health department.” c. “Adults have the worst time with the disease when compared to kids.” d. “Just go ahead and give me an antibiotic so that I can get on with my life.”

42. The patient has developed pulmonary tuberculosis. Rank the following findings in order of occurrence based on the normal progression of this disease. a. The patient visits the physician’s office with complaints of fatigue, night sweats, and has lost 10 pounds over the last 3 months. b. The patient’s purified protein derivative test is positive. The patient develops a cough with blood-tinged sputum. A chest x-ray indicates the presence of a cavitary lesion. c. The patient is admitted to the hospital for treatment of pulmonary tuberculosis. d. The patient begins to feel better. e. The patient does not complain of any symptoms associated with pulmonary tuberculosis. 43. The student nurse is learning about how to care for patients who have had thoracic surgery following a diagnosis of lung cancer. The intensive care unit nurse is assessing the student’s understanding. Which of the following statements by the student indicates the need for further education? Select all that apply. a. “I should assess the patient’s respiratory system at least every four hours.” b. “I really shouldn’t even offer narcotic pain medications to this patient because it will result in severe respiratory depression.” c. “If there are items that the patient needs frequently, I should keep them across the hospital room. This will ensure that the patient will get better faster.” d. “The patient’s head of bed should be maintained between 15 and 30 degrees.” e. “The area between the visceral and parietal pleura must be filled with positive pressure to work appropriately and this can be accomplished with a functioning chest tube.”
43. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%
44. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.
45. A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.
46. Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. “I will call the doctor if I still feel tired after a week.” b. “I will need to use home oxygen therapy for 3 months.”

c. “I will continue to do the deep breathing and coughing exercises at home.” d. “I will schedule two appointments for the pneumonia and influenza vaccines.”

48. Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
49. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient’s white blood cell (WBC) count is 9000/μl. d. Increased tactile fremitus is palpable over the right chest.
50. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible.
51. Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.
52. The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.
53. Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. “Your urine, sweat, and tears will be orange colored.” b. “Read a newspaper daily to check for changes in vision.” c. “Take vitamin B6 daily to prevent peripheral nerve damage.” d. “Call the health care provider if you notice any hearing loss.”
54. When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin.

b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails.

55. 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? a. Educating the patient about the long-term impact of TB on health b. Giving the patient written instructions about how to take the medications c. Teaching the patient about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community center and giving the medication then
56. After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.
57. A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Guérin (BCG) vaccine.
58. When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient’s room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a “fast-food” restaurant to the patient.
59. Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? a. Teach about symptoms of lung disease. b. Treat workers who inhale dust particles. c. Monitor workers for shortness of breath. d. Require the use of protective equipment.
60. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about a. computed tomography (CT) screening for lung cancer.

b. options for smoking cessation. c. reasons for annual sputum cytology testing. d. erlotinib (Tarceva) therapy to prevent tumor risk.

61. A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have radiation than surgery.” Which response by the nurse is most appropriate? a. “Are you afraid that the surgery will be very painful?” b. “Did you have bad experiences with previous surgeries?” c. “Surgery is the treatment of choice for stage I lung cancer.” d. “Tell me what you know about the various treatments available.”
62. An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.
63. A patient with newly diagnosed lung cancer tells the nurse, “I think I am going to die pretty soon.” Which response by the nurse is best? a. “Would you like to talk to the hospital chaplain about your feelings?” b. “Can you tell me what it is that makes you think you will die so soon?” c. “Are you afraid that the treatment for your cancer will not be effective?” d. “Do you think that taking an antidepressant medication would be helpful?”
64. The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.
65. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.
66. When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.

67. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.
68. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.
69. To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. Peripheral edema
70. A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the BP is less than 140/90 mm Hg. b. the patient reports decreased exertional dyspnea. c. the heart rate is between 60 and 100 beats/minute. d. the patient’s chest x-ray indicates clear lung fields.
71. A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.
72. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. “I will make an appointment to see the doctor every year.” b. “I will not turn the home oxygen up higher than 2 L/minute.” c. “I will not worry if I feel a little short of breath with exercise.” d. “I will call the health care provider right away if I develop a fever.”
73. Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray.

c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites.

74. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.
75. A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)
76. Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.
77. A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.
78. The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patient’s bed to 10 degrees. b. splint the patient’s chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.
79. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of
    42. The nurse’s first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patient’s health care provider. d. offer emotional support and reassurance.

80. After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)
81. The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. “Is there any family history of TB?” b. “Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?” c. “How long have you lived in the United States?” d. “Do you take any over-the-counter (OTC) medications?”
82. A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patient’s bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.
83. 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? a. Assist the patient to sit up at the bedside. b. Splint the patient’s chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.
84. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The BP is 98/56 mm Hg. b. The oxygen saturation is 94%. c. The patient’s central intravenous line is disconnected. d. The international normalized ratio (INR) is prolonged.
85. A patient who was admitted the previous day with pneumonia complains of a sharp pain “whenever I take a deep breath.” Which action will the nurse take next? a. Listen to the patient’s lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient’s health care provider.

86. The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.)

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a. Obtain the oxygen saturation. b. Check the patient’s pulse rate. c. Document the change in status. d. Notify the health care provider. 

87. The nurse administering influenza vaccinations to a group of office workers would not offer the vaccine to a client who a. has a history of asthma. b. is allergic to eggs. c. is allergic to sulfa drugs. d. takes amoxicillin for a bladder infection.
88. The nurse notes that a client in a long-term care facility has become increasingly confused in the last few days. The resident’s vital signs are temperature 97.7° F, pulse rate 80 beats/min, respirations 20 breaths/min, and blood pressure mm Hg. The nurse would suspect a. cancer of the lung. b. plural effusion. c. pneumonia. d. tuberculosis (TB).
89. The nurse writing an infection control policy for a home health care agency would include the information that the rise in TB cases in recent years is related to the a. aging of the U.S. population. b. emergence of antibiotic-resistant bacteria. c. increase in HIV infection. d. rise in illegal drug use.
90. The nurse would know that the client most likely to exhibit a false-negative Mantoux reaction is the client who is a. being treated for sickle cell disease. b. HIV-positive. c. malnourished. d. previously diagnosed with TB.
91. The nurse caring for a client recently diagnosed with active TB would include in the teaching plan which information regarding medications? a. Clients must report daily to the health department to receive their medication. b. Clients are usually admitted to the hospital to initiate treatment for TB. c. Medications are generally given for 6 to 8 weeks. d. TB is treated with three or more medications to prevent organism resistance.
92. The nurse caring for a client with cystic fibrosis would select as the highest priority the nursing diagnosis of a. Activity Intolerance. b. Anxiety.

c. Risk for Deficient Fluid Volume. d. Risk for Ineffective Airway Clearance.

93. A client is noncompliant with the continuation phase of treatment for TB. The nurse assigns the diagnosis Ineffective Coping and plans interventions that will a. allow the client to continue to work from home. b. increase the client’s sense of control. c. isolate the client from the family until the disease is under control. d. require the client to report medication use.
94. To prevent the complication of atelectasis in an 82-year-old woman with a hip fracture, the nurse would a. ambulate the client frequently. b. frequently reposition the client. c. suction the upper airway. d. supply oxygen.
95. The nurse has made the nursing diagnosis Ineffective Breathing Pattern related to tachypnea secondary to chest pain for a client with pneumonia. After administration of an analgesic, the nurse would a. encourage the use of an incentive spirometer. b. monitor the client’s respiratory pattern. c. reposition the client flat in bed. d. request that the client cough.
96. To increase the level of comfort for a client with a lung abscess, the nurse would include which intervention in the care plan? a. Encourage activity before meals. b. Offer frequent oral hygiene. c. Provide easy-to-eat milk products. d. Restrict fluid intake.
97. A client has small cell carcinoma of the lung. The nurse should anticipate providing which intervention to the client? a. Educating the client and family about planned chemotherapy b. Instructing the client on home care of a chest tube system c. Preparing the client for lung resection d. Providing a referral to hospice
98. The nurse would know that a client who has just begun treatment for pulmonary TB with rifampin has a good understanding of this medication with the statement that a. “I told my wife to throw away all our spoons and forks before I come home.” b. “I won’t go to any family gatherings for 6 months.” c. “It’s going to be important to remember to cover my nose when I sneeze.” d. “My urine will look orange because of the medication.”
99. A client had chest surgery this morning and has a chest tube attached to a closed-chest drainage system. When the nurse notes no tidaling of fluid, the nurse would first a. attach the system to suction. b. milk the chest tube.

c. notify the physician immediately. d. reposition the client.

100. The nurse notes intermittent bubbling in the water-seal chamber of a chest tube in place for a client with pneumothorax. The nurse’s most appropriate action is to a. change the drainage unit. b. clamp the chest tube. c. encourage respiratory exercises. d. place petrolatum gauze around the chest tube.
101. A client has accidentally disconnected a chest tube while turning over in bed. The suction tubing is on the floor. The most appropriate action by the nurse is to a. call the physician immediately and prepare the client for reinsertion. b. clamp the chest tube just proximal to the open end. c. reattach the drainage tube to the suction tubing. d. submerge the end of the drainage tube in a bottle of sterile saline.
102. In caring for a client scheduled to have chest tubes removed, the nurse’s most appropriate action would be to a. assist the client to a prone position. b. empty the collection chambers before removal. c. encourage deep breathing during removal. d. medicate for pain hour before removal.
103. On physical examination of a client with pneumonia, the nurse would expect a. absence of whispered pectoriloquy over the affected area. b. increased tactile fremitus over the affected area. c. tympanic percussion notes over the affected area. d. vesicular breath sounds over the affected area.
104. A young female client with cystic fibrosis (CF) wishes to become pregnant but is concerned about the effect of CF on fertility. The nurse bases a response with the understanding that a. breastfeeding will not be possible because of plugged milk glands. b. only about 20% of women with CF are infertile. c. pregnancy carries a high risk of spontaneous abortion (miscarriage). d. women with CF are unlikely to become pregnant.
105. The nurse would assess a client with severe acute respiratory syndrome (SARS) for the major clinical manifestation indicating the onset of the lower respiratory phase, which is a. dry, nonproductive cough. b. hemoptysis. c. pleuritic pain. d. rapid temperature elevation.
106. The nurse would become concerned about the risk of hemorrhage if, in the first 2 hours after surgery, the thoracotomy client’s drainage exceeded a. 50 ml. b. 100 ml. c. 300 ml. d. 750 ml.

107. After the physician tells a client that pneumonia has caused the client’s bilateral lobar atelectasis, the client anxiously asks the nurse, “Does that mean my lungs have collapsed?” The most informative response by the nurse would be the following: a. “No, but your pneumonia has permanently damaged your lungs to the point they may never fully inflate.” b. “No; only a lobe in each side has collapsed, but they will inflate as the pneumonia resolves.” c. “Yes; both lungs have collapsed, but they are presently reinflating as your health improves.” d. “Yes; large portions of your lungs have collapsed, but the unaffected portions of your lungs will accommodate your oxygen needs.”
108. The nurse would explain that the client’s diagnosis of interstitial pneumonia means a. pus has accumulated in the major bronchi. b. the alveoli are filled with fluid. c. the small bronchioles are inflamed. d. there is an inflammatory response in the tissue surrounding the air space.
109. A client is admitted with flu-like symptoms that developed after hunting rabbits. The nurse anticipates which of the following initial orders for this client? a. Intubation and mechanical ventilation b. Mantoux TB testing c. Rapid infusion of IV fluids d. Respiratory isolation room
110. A client has undergone a pleurodesis. The priority nursing action after the procedure is to assess the client’s a. respiratory status. b. urine output. c. vital signs. d. wound site.
111. A client is being discharged after treatment for a bronchopleural fistula. Important self- care measures the nurse should teach include a. improving the client’s nutrition. b. management of the chest tube system. c. preventing a recurrence. d. smoking cessation resources.
112. A spinal cord–injured client complains of severe dyspnea in the side-lying position. The nurse anticipates diagnostic testing to reveal a. a pleural abscess. b. a tension pneumothorax. c. bilateral diaphragmatic paralysis. d. pneumonia.
113. A client comes to the clinic complaining of shortness of breath with activity that has gradually gotten worse over several years. An important finding from the nursing history would be the client’s

a. family history of lung cancer. b. occupation as a coal miner. c. previous treatment for “walking pneumonia.” d. recent move from the mountains.

114. A nurse is planning care for a client who has an intrapulmonary restrictive lung disorder. The nurse chooses interventions with the understanding that treatment for this disease a. can assist lung tissue in regenerating. b. is best attained through surgery. c. requires a long course of antibiotics. d. will not reverse the disease process.
115. A client is hospitalized for an exacerbation of sarcoidosis. The nurse anticipates an order to administer a. antipyretics. b. corticosteroids. c. high-dose antibiotics. d. rifampin.
116. A client has an interstitial lung disease (ILD) and has questions related to the disease process. The best explanation by the nurse is that ILD a. causes alveolar walls to thicken and become nonfunctional. b. is a highly contagious disease and close contacts need treatment. c. is caused by a recurrent fungal infection in the lung parenchyma. d. leads to diffuse intrapulmonary cavity formation.
117. A client has been diagnosed with histoplasmosis lung infection. The nurse would anticipate treatment to include a. amphotericin B. b. corticosteroids. c. isoniazid. d. morphine.
118. A client with HIV infection has a history of close exposure to someone with active pulmonary tuberculosis and has developed a cough and low-grade fever. The client’s Mantoux is negative but the client has been admitted to the hospital for further testing. The most appropriate action by the nurse is to (Select all that apply) a. admit the client to a private room. b. anticipate orders for AFB testing. c. place the client in respiratory isolation. d. screen potential roommates carefully. e. select a room close to the nurses’ station.
119. Nurses caring for clients being treated for active pulmonary tuberculosis in the hospital are required to have (Select all that apply) a. an annual chest x-ray. b. an annual skin test for TB. c. no allergies to anti-TB medications. d. properly-fitting particulate respirators.

120. A client is being evaluated for a lung transplant. The nurse assists the client to understand that the psychological assessment includes which of the following? (Select all that apply.) a. Ability to cope with stress and coping mechanisms b. History of compliance with medical regimen c. History of substance abuse d. Occupational and financial resources