PT 2

45問 • 1年前

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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?

Position the patient sitting up on the side of the bed.

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?

"I will call the health care provider right away if I develop a fever."

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites

The nurse is caring 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?

O2 saturation is 88%.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

Piperacillin/tazobactam (Zosyn)

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?

The patient is being treated with antiretrovirals for HIV infection.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 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 priority?

Impaired gas exchange related to respiratory congestion

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

UAP lower the head of the patient's bed to 15 degrees.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?

Elevate the head of the bed to a semi-Fowler's position.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?

Tape a nonporous dressing on three sides over the wound.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?

The epoprostenol (Flolan) infusion is disconnected.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next?

Auscultate for breath sounds.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Appropriate use of cough suppressants

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

Teaching patients about the need for adult pertussis immunizations

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

Placing the patient on droplet precautions in a private hospital room

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

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?

"I will use the incentive spirometer every hour or two during the day."

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every 8 hours.

After change-of-shift report, which patient should the nurse assess first?

A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?

Age, Blood pressure, Blood urea nitrogen (BUN) level, Presence of confusion, Respiratory rate

The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful?

The patient rapidly inhales the medication.

The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching?

The patient removes the facial mask when misting stops.

A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure?

Withhold bronchodilators for 6 to 12 hours before the examination.

Which information will the nurse include in the asthma teaching plan for a patient being discharged?

Tremors are an expected side effect of rapidly acting bronchodilators.

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?

O2 saturation is >90%.

A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next?

Administer a bronchodilator and recheck the peak flow.

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful?

The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about

1-antitrypsin testing.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline?

The patient takes cimetidine (Tagamet HB) daily.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?

Teach the patient how to use pursed-lip breathing.

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care?

Offer high-calorie protein snacks between meals and at bedtime.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis?

The patient reports a productive cough for 3 months every winter.

The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?

The patient puffs up the cheeks while exhaling.

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?

Pulse oximetry reading of 92%

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?

Peripheral edema

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate?

Maintain the pulse oximetry level at 90% or greater.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching?

O2 use can improve the patient's prognosis and quality of life.

A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important?

Keep the air entrainment ports clean and unobstructed.

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?

Give the prescribed albuterol (Ventolin HFA) before the therapy.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?

Walk 15 to 20 minutes a day at least 3 times/week.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate?

Chronic low self-esteem related to physical dependence

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation?

Encourage the patient to sit up at the bedside in a chair and lean forward.

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