Chapter 28 Nursing Management Lower Respiratory Problems

Topics: Tuberculosis, Pneumonia, Pulmonology / Pages: 36 (7676 words) / Published: Feb 23rd, 2015
Chapter 28: Nursing Management: Lower Respiratory Problems
Test Bank
MULTIPLE CHOICE
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of

ineffective airway clearance. Which assessment data 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%
ANS: A

The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
DIF: Cognitive Level: Apply (application)
REF:
eNCP 28-1
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
2. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would

the nurse expect?
a. Increased tactile fremitus
b. Dry, nonproductive cough
c. Hyperresonance to percussion
d. A grating sound on auscultation
ANS: A

Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
DIF: Cognitive Level: Apply (application)
REF:
527
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse’s most

appropriate action to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Teach 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.
ANS: A

Coughing is less painful and more likely to be effective when the patient splints the chest
during

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