SOLVED

 Question 11 The emergency department has treated two patients in the last day with symptoms that may be SARS. The nurse manager is updating staff on the pathophysiology of this disease. Which information would the nurse include? 1. It is thought that SARS is a nonhuman virus that has crossed species. 2. SARS is more common in patients also infected with HIV. 3. SARS is a form of influenza virus, so additional cases are probable. 4. SARS is related to RSV, so young children will be the most likely patients. Question 12 The nurse is preparing to participate in evaluation of the severity of a patient’s community acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation? 1. The patient’s respiratory rates for the last several hours 2. BUN results 3. If the patient has a history of smoking 4. The patient’s gender. 5. The patient’s age Question 13 The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an AP chest x-ray to be done in the x-ray department. How would the nurse transport the patient? 1. Do a portable film in the patient’s room. 2. Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive. 3. Disconnect the drainage system from the wall suction and transport. 4. Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive. Question 14 A patient has been uncooperative with pulmonary hygiene following thoracic surgery because “it hurts more than I can bear.” Which intervention should the nurse employ? 1. Instruct the patient to cough 3 to 4 times with each exhalation. 2. Assist the patient to a sitting position to lean over the bedside table while coughing. 3. Provide the patient with a pillow to splint the incision while coughing. 4. Guide the patient to cough with the glottis open. Question 15 The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. Which nursing diagnosis (NDX) should the nurse choose for this patient? 1. Ineffective Breathing Pattern 2. Ineffective Airway Clearance 3. Potential for Pneumonia 4. Impaired Gas Exchange Question 16 A patient has a diagnosis of Ineffective Airway Clearance as evidenced by the inability to clear thick secretions effectively. Which nursing interventions are appropriate to address this nursing diagnosis? 1. Encourage bedrest to conserve energy. 2. Administer pain medications as needed. 3. Position the patient on the unaffected side. 4. Encourage the patient to provide as much self-care as possible. 5. Encourage slow, deep breaths Question 17 A patient recovering from thoracic surgery is demonstrating evidence of Impaired Gas exchange with a dropping oxygen saturation level. Which nursing intervention is most suited to addressing this nursing diagnosis? 1. Teach the patient to use the incentive spirometer every 1 to 2 hours. 2. Suction as necessary. 3. Splint the chest when coughing. 4. Encourage fluids up to 2.5 liters per day. Question 18 An older adult presents to the emergency department with cough, fever, and elevated temperature. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic? 1. Whenever the drug is received from the pharmacy 2. After the preliminary results of the sputum specimen are obtained 3. Within 30 minutes of the order being received 4. Within 4 hours of diagnosis Question 19 A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses cessation of tidling in the water-seal chamber. What nursing action is indicated? 1. Collaborate with the health care provide regarding need to reinstitute the external suction. 2. Check the connections between the chest tube and the drainage system. 3. No action is necessary as this is an expected occurrence. 4. Have the patient cough forcefully. Question 20 A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection the nurse notes that the patient’s trachea is slight displaced toward the left. Which nursing intervention is priority? 1. Have the patient release his arm and sit up straight for reassessment. 2. Notify the emergency room physician immediately. 3. Auscultate the patient’s lung fields. 4. Position the patient flat in bed without a pillow.