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Student nursing study blog Student nursing study blog Document Transcript

  • Student Nursing Study Blogamys nursing blogSkip to contentHome10 Diagnoses 4 Student NursesAssessment Documentation ExamplesNCLEX QuesStudy NotesAirway – Pneumonia and TB1. Clients with chronic illnesses are more likely to get pneumoniawhen which of the following situations is present?A. DehydrationB. Group livingC. MalnutritionD. Severe periodontal disease2. Which of the following pathophysiological mechanisms that occursin the lung parenchyma allows pneumonia to develop?1. Atelectasis2. Bronchiectasis3. Effusion
  • 4. Inflammation3. Which of the following organisms most commonly causescommunity-acquired pneumonia in adults?1. Haemiphilus influenzae2. Klebsiella pneumoniae3. Steptococcus pneumoniae4. Staphylococcus aureus4. An elderly client with pneumonia may appear with which of thefollowing symptoms first?1. Altered mental status and dehydration2. Fever and chills3. Hemoptysis and dyspnea4. Pleuritic chest pain and cough5. When auscultating the chest of a client with pneumonia, the nursewould expect to hear which of the following sounds over areas ofconsolidation?1. Bronchial2. Bronchovestibular3. Tubular4. Vesicular
  • 6. A diagnosis of pneumonia is typically achieved by which of thefollowing diagnostic tests?1. ABG analysis2. Chest x-ray3. Blood cultures4. sputum culture and sensitivity7. A client with pneumonia develops dyspnea with a respiratory rate of32 breaths/minute and difficulty expelling his secretions. The nurseauscultates his lung fields and hears bronchial sounds in the left lowerlobe. The nurse determines that the client requires which of the followingtreatments first?1. Antibiotics2. Bed rest3. Oxygen4. Nutritional intake8. A client has been treated with antibiotic therapy for right lower-lobepneumonia for 10 days and will be discharged today. Which of thefollowing physical findings would lead the nurse to believe it isappropriate to discharge this client?1. Continued dyspnea
  • 2. Fever of 102*F3. Respiratory rate of 32 breaths/minute4. Vesicular breath sounds in right base9. The right forearm of a client who had a purified protein derivative(PPD) test for tuberculosis is reddened and raised about 3mm where thetest was given. This PPD would be read as having which of the followingresults?1. Indeterminate2. Needs to be redone3. Negative4. Positive10. A client with primary TB infection can expect to develop which of thefollowing conditions?1. Active TB within 2 weeks2. Active TB within 1 month3. A fever that requires hospitalization4. A positive skin test11. A client was infected with TB 10 years ago but never developed thedisease. He’s now being treated for cancer. The client begins to developsigns of TB. This is known as which of the following types of infection?
  • 1. Active infection2. Primary infection3. Superinfection4. Tertiary infection12. A client has active TB. Which of the following symptoms will heexhibit?1. Chest and lower back pain2. Chills, fever, night sweats, and hemoptysis3. Fever of more than 104*F and nausea4. Headache and photophobia13. Which of the following diagnostic tests is definitive for TB?1. Chest x-ray2. Mantoux test3. Sputum culture4. Tuberculin test14. A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done?1. To confirm the diagnosis2. To determine if a repeat skin test is needed3. To determine the extent of the lesions
  • 4. To determine if this is a primary or secondary infection15. A chest x-ray should a client’s lungs to be clear. His Mantoux test ispositive, with a 10mm if induration. His previous test was negative.These test results are possible because:1. He had TB in the past and no longer has it.2. He was successfully treated for TB, but skin tests always staypositive.3. He’s a “seroconverter”, meaning the TB has gotten to hisbloodstream.4. He’s a “tuberculin converter,” which means he has been infectedwith TB since his last skin test.16. A client with a positive skin test for TB isn’t showing signs of activedisease. To help prevent the development of active TB, the client shouldbe treated with isonaizid, 300mg daily, for how long?1. 10 to 14 days2. 2 to 4 weeks3. 3 to 6 months4. 9 to 12 months17. A client with a productive cough, chills, and night sweats is suspectedof having active TB. The physician should take which of the followingactions?
  • 1. Admit him to the hospital in respiratory isolation2. Prescribe isoniazid and tell him to go home and rest3. Give a tuberculin test and tell him to come back in 48 hours andhave it read.4. Give a prescription for isoniazid, 300mg daily for 2 weeks, andsend him home.18. A client is diagnosed with active TB and started on triple antibiotictherapy. What signs and symptoms would the client show if therapy isinadequate?1. Decreased shortness of breath2. Improved chest x-ray3. Nonproductive cough4. Positive acid-fast bacilli in a sputum sample after 2 months oftreatment.19. A client diagnosed with active TB would be hospitalized primarily forwhich of the following reasons?1. To evaluate his condition2. To determine his compliance3. to prevent spread of the disease4. To determine the need for antibiotic therapy.
  • 20. A high level of oxygen exerts which of the following effects on thelung?1. Improves oxygen uptake2. Increases carbon dioxide levels3. Stabilizes carbon dioxide levels4. Reduces amount of functional alveolar surface area21. A 24-year-old client comes into the clinic complaining of right-sidedchest pain and shortness of breath. He reports that it started suddenly.The assessment should include which of the following interventions?1. Auscultation of breath sounds2. Chest x-ray3. Echocardiogram4. Electrocardiogram (ECG)22. A client with shortness of breath has decreased to absent breathsounds on the right side, from the apex to the base. Which of thefollowing conditions would best explain this?1. Acute asthma2. Chronic bronchitis3. Pneumonia4. Spontaneous pneumothorax
  • 23. Which of the following treatments would the nurse expect for aclient with a spontaneous pneumothorax?1. Antibiotics2. Bronchodilators3. Chest tube placement4. Hyperbaric chamber24. Which of the following methods is the best way to confirm thediagnosis of a pneumothorax?1. Auscultate breath sounds2. Have the client use an incentive spirometer3. Take a chest x-ray4. stick a needle in the area of decreased breath sounds25. A pulse oximetry gives what type of information about the client?1. Amount of carbon dioxide in the blood2. Amount of oxygen in the blood3. Percentage of hemoglobin carrying oxygen4. Respiratory rate26. What effect does hemoglobin amount have on oxygenation status?1. No effect
  • 2. More hemoglobin reduces the client’s respiratory rate3. Low hemoglobin levels cause reduces oxygen-carrying capacity4. Low hemoglobin levels cause increased oxygen-carrying capacity.27. Which of the following statements best explains how opening upcollapsed alveoli improves oxygenation?1. Alveoli need oxygen to live2. Alveoli have no effect on oxygenation3. Collapsed alveoli increase oxygen demand4. Gaseous exchange occurs in the alveolar membrane.28. Continuous positive airway pressure (CPAP) can be providedthrough an oxygen mask to improve oxygenation in hypoxic patients bywhich of the following methods?1. The mask provides 100% oxygen to the client.2. The mask provides continuous air that the client can breathe.3. The mask provides pressurized oxygen so the client can breathemore easily.4. The mask provides pressurized at the end of expiration to opencollapsed alveoli.29. Which of the following best describes pleural effusion?1. The collapse of alveoli
  • 2. The collapse of bronchiole3. The fluid in the alveolar space4. The accumulation of fluid between the linings of the pleural space.30. If a pleural effusion develops, which of the following actions bestdescribes how the fluid can be removed from the pleural space andproper lung status restored?1. Inserting a chest tube2. Performing thoracentesis3. Performing paracentesis4. Allowing the pleural effusion to drain by itself.31. A comatose client needs a nasopharyngeal airway for suctioning.After the airway is inserted, he gags and coughs. Which action should thenurse take?1. Remove the airway and insert a shorter one.2. Reposition the airway.3. Leave the airway in place until the client gets used to it.4. Remove the airway and attempt suctioning without it.32. An 87-year-old client requires long term ventilator therapy. He has atracheostomy in place and requires frequent suctioning. Which of thefollowing techniques is correct?
  • 1. Using intermittent suction while advancing the catheter.2. Using continuous suction while withdrawing the catheter.3. Using intermittent suction while withdrawing the catheter.4. Using continuous suction while advancing the catheter.33. A client’s ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate?1. Metabolic acidosis2. Respiratory alkalosis3. Metabolic alkalosis4. Respiratory acidosis34. A police officer brings in a homeless client to the ER. A chest x-raysuggests he has TB. The physician orders an intradermal injection of 5tuberculin units/0.1 ml of tuberculin purified derivative. Which needle isappropriate for this injection?1. 5/8” to ½” 25G to 27G needle.2. 1” to 3” 20G to 25G needle.3. ½” to 3/8” 26 or 27G needle.4. 1” 20G needle.35. A 76-year old client is admitted for elective knee surgery. Physicalexamination reveals shallow respirations but no signs of respiratorydistress. Which of the following is a normal physiologic change related toaging?
  • 1. Increased elastic recoil of the lungs2. Increased number of functional capillaries in the alveoli3. Decreased residual volume4. Decreased vital capacity.36. A 79-year-old client is admitted with pneumonia. Which nursingdiagnosis should take priority?1. Acute pain related to lung expansion secondary to lung infection2. Risk for imbalanced fluid volume related to increased insensiblefluid losses secondary to fever.3. Anxiety related to dyspnea and chest pain.4. Ineffective airway clearance related to retained secretions.37. A community health nurse is conducting an educational session withcommunity members regarding TB. The nurse tells the group that one ofthe first symptoms associated with TB is:1. A bloody, productive cough2. A cough with the expectoration of mucoid sputum3. Chest pain4. Dyspnea38. A nurse evaluates the blood theophylline level of a client receivingaminophylline (theophylline) by intravenous infusion. The nurse would
  • determine that a therapeutic blood level exists if which of the followingwere noted in the laboratory report?1. 5 mcg/mL2. 15 mcg/mL3. 25 mcg/mL4. 30 mcg/mL39. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for aclient with TB. A nurse reviews the medical record of the client. Which ofthe following, if noted in the client’s history, would require physiciannotification?1. Heart disease2. Allergy to penicillin3. Hepatitis B4. Rheumatic fever40. A client is experiencing confusion and tremors is admitted to anursing unit. An initial ABG report indicates that the PaCO2 level is 72 mmHg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the clientis most likely experiencing:1. Carbon monoxide poisoning2. Carbon dioxide narcosis3. Respiratory alkalosis4. Metabolic acidosis
  • 41. A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interpretsthe results as:1. Positive2. Negative3. Inconclusive4. The need for repeat testing.42. A nurse is caring for a client diagnosed with TB. Which assessment,if made by the nurse, would not be consistent with the usual clinicalpresentation of TB and may indicate the development of a concurrentproblem?1. Nonproductive or productive cough2. Anorexia and weight loss3. Chills and night sweats4. High-grade fever43. A nurse is teaching a client with TB about dietary elements thatshould be increased in the diet. The nurse suggests that the clientincrease intake of:1. Meats and citrus fruits2. Grains and broccoli3. Eggs and spinach4. Potatoes and fish
  • 44. Which of the following would be priority assessment data to gatherfrom a client who has been diagnosed with pneumonia? Select all thatapply.1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest pain.4. Presence of peripheral edema5. Color of nail beds45. A client with pneumonia has a temperature of 102.6*F (39.2*C), isdiaphoretic, and has a productive cough. The nurse should include whichof the following measures in the plan of care?1. Position changes q4h2. Nasotracheal suctioning to clear secretions3. Frequent linen changes4. Frequent offering of a bedpan.46. The cyanosis that accompanies bacterial pneumonia is primarilycaused by which of the following?1. Decreased cardiac output2. Pleural effusion3. Inadequate peripheral circulation
  • 4. Decreased oxygenation of the blood.47. Which of the following mental status changes may occur when aclient with pneumonia is first experiencing hypoxia?1. Coma2. Apathy3. Irritability4. Depression48. A client with pneumonia has a temperature ranging between 101*and 102*F and periods of diaphoresis. Based on this information, whichof the following nursing interventions would be a priority?1. Maintain complete bedrest2. Administer oxygen therapy3. Provide frequent linen changes.4. Provide fluid intake of 3 L/day49. Which of the following would be an appropriate expected outcomefor an elderly client recovering from bacterial pneumonia?1. A respiratory rate of 25 to 30 breaths per minute2. The ability to perform ADL’s without dyspnea3. A maximum loss of 5 to 10 pounds of body weight4. Chest pain that is minimized by splinting the ribcage.
  • 50. Which of the following symptoms is common in clients with TB?1. Weight loss2. Increased appetite3. Dyspnea on exertion4. Mental status changes51. The nurse obtains a sputum specimen from a client with suspectedTB for laboratory study. Which of the following laboratory techniques ismost commonly used to identify tubercle bacilli in sputum?1. Acid-fast staining2. Sensitivity testing3. Agglunitnation testing4. Dark-field illumination52. Which of the following antituberculus drugs can cause damage to theeighth cranial nerve?1. Streptomycin2. Isoniazid3. Para-aminosalicylic acid4. Ethambutol hydrochloride
  • 53. The client experiencing eighth cranial nerve damage will most likelyreport which of the following symptoms?1. Vertigo2. Facial paralysis3. Impaired vision4. Difficulty swallowing54. Which of the following family members exposed to TB would be athighest risk for contracting the disease?1. 45-year-old mother2. 17-year-old daughter3. 8-year-old son4. 76-year-old grandmother55. The nurse is teaching a client who has been diagnosed with TB howto avoid spreading the disease to family members. Which statement(s)by the client indicate(s) that he has understood the nurses instructions?Select all that apply.1. “I will need to dispose of my old clothing when I return home.”2. “I should always cover my mouth and nose when sneezing.”3. “It is important that I isolate myself from family when possible.”4. “I should use paper tissues to cough in and dispose of themproperly.”5. “I can use regular plate and utensils whenever I eat.”
  • 56. A client has a positive reaction to the PPD test. The nurse correctlyinterprets this reaction to mean that the client has:1. Active TB2. Had contact with Mycobacterium tuberculosis3. Developed a resistance to tubercle bacilli4. Developed passive immunity to TB.57. INH treatment is associated with the development of peripheralneuropathies. Which of the following interventions would the nurseteach the client to help prevent this complication?1. Adhere to a low cholesterol diet2. Supplement the diet with pyridoxine (vitamin B6)3. Get extra rest4. Avoid excessive sun exposure.58. The nurse should include which of the following instructions whendeveloping a teaching plan for clients receiving INH and rifampin fortreatment for TB?1. Take the medication with antacids2. Double the dosage if a drug dose is forgotten3. Increase intake of dairy products4. Limit alcohol intake
  • 59. The public health nurse is providing follow-up care to a client withTB who does not regularly take his medication. Which nursing actionwould be most appropriate for this client?1. Ask the client’s spouse to supervise the daily administration of themedications.2. Visit the clinic weekly to ask him whether he is taking hismedications regularly.3. Notify the physician of the client’s non-compliance and request adifferent prescription.4. Remind the client that TB can be fatal if not taken properly.1. 2. Clients with chronic illnesses generally have poor immunesystems. Often, residing in group living situations increases thechance of disease transmission.2. 4. The common feature of all type of pneumonia is an inflammatorypulmonary response to the offending organism or agent.Atelectasis and bronchiecrasis indicate a collapse of a portion ofthe airway that doesn’t occur in pneumonia. An effusion is anaccumulation of excess pleural fluid in the pleural space, whichmay be a secondary response to pneumonia.
  • 3. 3. Pneumococcal or streptococcal pneumonia, causedby streptococcus pneumoniae, is the most common cause ofcommunity-acquired pneumonia. H. influenzae is the mostcommon cause of infection in children. Klebsiella species is themost common gram-negative organism found in the hospitalsetting. Staphylococcus aureus is the most common cause ofhospital-acquired pneumonia.4. 1. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chestpain are common symptoms of pneumonia, but elderly clients mayfirst appear with only an altered mental status and dehydration dueto a blunted immune response.5. 1. Chest auscultation reveals bronchial breath sounds over areas ofconsolidation. Bronchiovesicular are normal over midlobe lungregions, tubular sounds are commonly heard over large airways,and vesicular breath sounds are commonly heard in the bases ofthe lung fields.6. 4. Sputum C & S is the best way to identify the organism causingthe pneumonia. Chest x-ray will show the area of lungconsolidation. ABG analysis will determine the extent of hypoxiapresent due to the pneumonia, and blood cultures will helpdetermine if the infection is systemic.7. 3. The client is having difficulty breathing and is probablybecoming hypoxic. As an emergency measure, the nurse canprovide oxygen without waiting for a physicians order. Antibioticsmay be warranted, but this isn’t a nursing decision. The clientshould be maintained on bedrest if he is dyspneic to minimize hisoxygen demands, but providing additional will deal moreimmediately with his problem. The client will need nutritional
  • support, but while dyspneic, he may be unable to spare the energyneeded to eat and at the same time maintain adequate oxygenation.8. 4. If the client still has pneumonia, the breath sounds in the rightbase will be bronchial, not the normal vesicular breath sounds. Ifthe client still has dyspnea, fever, and increased respiratory rate, heshould be examined by the physician before discharge because hemay have another source of infection or still have pneumonia.9. 3. This test would be classed as negative. A 5mm raised area wouldbe a positive result if a client was HIV+ or had recent close contactwith someone diagnosed with TB. Indeterminate isn’t a term usedto describe results of a PPD test. If the PPD is reddened and raised10mm or more, it’s considered positive according to the CDC.10. 4. A primary TB infection occurs when the bacillus has successfullyinvaded the entire body after entering through the lungs. At this point,the bacilli are walled off and skin tests read positive. However, all butinfants and immunosuppressed people will remain asymptomatic. Thegeneral population has a 10% risk of developing active TB over theirlifetime, in many cases because of a break in the body’s immunedefenses. The active stage shows the classic symptoms of TB: fever,hemoptysis, and night sweats.11. 1. Some people carry dormant TB infections that may develop intoactive disease. In addition, primary sites of infection containing TBbacilli may remain inactive for years and then activate when the client’sresistance is lowered, as when a client is being treated for cancer. There’sno such thing as tertiary infection, and superinfection doesn’t apply inthis case.
  • 12. 2. Typical signs and symptoms are chills, fever, night sweats, andhemoptysis. Chest pain may be present from coughing, but isn’t usual.Clients with TB typically have low-grade fevers, not higher than 102*F.Nausea, headache, and photophobia aren’t usual TB symptoms.13. 3. The sputum culture for Myobacterium tuberculosis is the onlymethod of confirming the diagnosis. Lesions in the lung may not be bigenough to be seen on x-ray. Skin tests may be falsely positive or falselynegative.14. 3. If the lesions are large enough, the chest x-ray will show theirpresence in the lungs. Sputum culture confirms the diagnosis. There canbe false-positive and false-negative skin test results. A chest x-ray can’tdetermine if this is a primary or secondary infection.15. 4. A tuberculin converter’s skin test will be positive, meaning he hasbeen exposed to an infected with TB and now has a cell-mediatedimmune response to the skin test. The client’s blood and x-ray resultsmay stay negative. It doesn’t mean the infection has advanced to theactive stage. Because his x-ray is negative, he should be monitored every6 months to see if he develops changes in his x-ray or pulmonaryexamination. Being a seroconverter doesn’t mean the TB has gotten intohis bloodstream; it means it can be detected by a blood test.16. 4. Because of the increased incidence of resistant strains of TB, thedisease must be treated for up to 24 months in some cases, but treatmenttypically lasts for 9-12 months. Isoaizid is the most common medicationused for the treatment of TB, but other antibiotics are added to theregimen to obtain the best results.
  • 17. 1. The client is showing s/s of active TB and, because of theproductive cough, is highly contagious. He should be admitted to thehospital, placed in respiratory isolation, and three sputum culturesshould be obtained to confirm the diagnosis. He would most likely begiven isoniazid and two or three other antitubercular antibiotics until thediagnosis is confirmed, then isolation and treatment would continue ifthe cultures were positive for TB. After 7 to 10 days, three moreconsecutive sputum cultures will be obtained. If they’re negative, hewould be considered non-contagious and may be sent home, althoughhe’ll continue to take the antitubercular drugs for 9 to 12 months.18. 4. Continuing to have acid-fast bacilli in the sputum after 2 monthsindicated continued infection.19. 3. The client with active TB is highly contagious until threeconsecutive sputum cultures are negative, so he’s put in respiratoryisolation in the hospital.20. 4. Oxygen toxicity causes direct pulmonary trauma, reducing theamount of alveolar surface area available for gaseous exchange, whichresults in increased carbon dioxide levels and decreased oxygen uptake.21. 1. Because the client is short of breath, listening to breath sounds is agood idea. He may need a chest x-ray and an ECG, but a physician mustorder these tests. Unless a cardiac source for the client’s pain isidentified, he won’t need an echocardiogram.22. 4. A spontaneous pneumothorax occurs when the client’s lungcollapses, causing an acute decrease in the amount of functional lung
  • used in oxygenation. The sudden collapse was the cause of his chest painand shortness of breath. An asthma attack would show wheezing breathsounds, and bronchitis would have rhonchi. Pneumonia would havebronchial breath sounds over the area of consolidation.23. 3. The only way to reexpand the lung is to place a chest tube on theright side so the air in the pleural space can be removed and the lungreexpanded.24. 3. A chest x-ray will show the area of collapsed lung if pneumothoraxis present as well as the volume of air in the pleural space. Listening tobreath sounds won’t confirm a diagnosis. An IS is used to encouragedeep breathing. A needle thoracostomy is done only in an emergency andonly by someone trained to do it.25. 3. The pulse oximeter determines the percentage of hemoglobincarrying oxygen. This doesn’t ensure that the oxygen being carriedthrough the bloodstream is actually being taken up by the tissue.26. 3. Hemoglobin carries oxygen to all tissues in the body. If thehemoglobin level is low, the amount of oxygen-carrying capacity is alsolow. More hemoglobin will increase oxygen-carrying capacity and thusincrease the total amount of oxygen available in the blood. If the clienthas been tachypneic during exertion, or even at rest, because oxygendemand is higher than the available oxygen content, then an increase inhemoglobin may decrease the respiratory rate to normal levels.27. 4. Gaseous exchange occurs in the alveolar membrane, so if thealveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as
  • well as other nutrients, from the bloodstream. Collapsed alveoli have noeffect on oxygen demand, though by decreasing the surface areaavailable for gas exchange, they decrease oxygenation of the blood.28. 3. The mask provides pressurized oxygen continuously through bothinspiration and expiration. The mask can be set to deliver any amount ofoxygen needed. By providing the client with pressurized oxygen, theclient has less resistance to overcome in taking his next breath, making iteasier to breathe. Pressurized oxygen delivered at the end of expiration ispositive end-expiratory pressure (PEEP), not continuous positive airwaypressure.29. 4. The pleural fluid normally seeps continually into the pleural spacefrom the capillaries lining the parietal pleura and is reabsorbed by thevisceral pleural capillaries and lymphatics. Any condition that interfereswith either the secretion or drainage of this fluid will lead to a pleuraleffusion.30. 2. Performing thoracentesis is used to remove excess pleural fluid.The fluid is then analyzed to determine if it’s transudative or exudative.Transudates are substances that have passed through a membrane andusually occur in low protein states. Exudates are substances that haveescaped from blood vessels. They contain an accumulation of cells andhave a high specific gravity and a high lactate dehydrogenase level.Exudates usually occur in response to a malignancy, infection, orinflammatory process. A chest tube is rarely necessary because theamount of fluid typically isn’t large enough to warrant such a measure.Pleural effusions can’t drain by themselves.
  • 31. 1. If a client gags or coughs after nasopharyngeal airway placement,the tube may be too long. The nurse should remove it and insert ashorter one. Simply repositioning the airway won’t solve the problem.The client won’t get used to the tube because it’s the wrong size.Suctioning without a nasopharyngeal airway causes trauma to thenatural airway.32. Intermittent suction should be applied during catheter withdrawal.To prevent hypoxia, suctioning shouldn’t last more than 10-seconds at atime. Suction shouldn’t be applied while the catheter is being advanced.33. 4.34. 3. Intradermal injections like those used in TN skin tests areadministered in small volumes (usually 0.5 ml or less) into the outer skinlayers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or27G needle should be inserted about 1/8” below the epidermis.35. 4. Reduction in VC is a normal physiologic change in the older adult.Other normal physiologic changes include decreased elastic recoil of thelungs, fewer functional capillaries in the alveoli, and an increase isresidual volume.36. 4. Pneumonia is an acute infection of the lung parenchyma. Theinflammatory reaction may cause an outpouring of exudate into thealveolar spaces, leading to an ineffective airway clearance related toretained secretions.
  • 37. 2. One of the first pulmonary symptoms includes a slight cough withthe expectoration of mucoid sputum.38. 2. The therapeutic theophylline blood level range from 10-20mcg/mL.39. 3. Isoniazid and rafampin are contraindicated in clients with acuteliver disease or a history of hepatic injury.40. 2. Carbon dioxide narcosis is a condition that results from extremehypercapnia, with carbon dioxide levels in excess of 70 mm Hg. Theclient experiences symptoms such as confusion and tremors, which mayprogress to convulsions and possible coma.41. 1. The client with HIV+ status is considered to have positive resultson PPD skin test with an area greater than 5-mm of induration. Theclient with HIV is immunosuppressed, making a smaller area ofinduration positive for this type of client.42. 4. The client with TB usually experiences cough (non-productive orproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chestdiscomfort or pain, chills and sweats (which may occur at night), and alow-grade fever.43. 1. The nurse teaches the client with TB to increase intake of protein,iron, and vitamin C.44. 1, 3, 5. A respiratory assessment, which includes auscultating breathsounds and assessing the color of the nail beds, is a priority for clients
  • with pneumonia. Assessing for the presence of chest pain is also animportant respiratory assessment as chest pain can interfere with theclient’s ability to breathe deeply. Auscultating bowel sounds andassessing for peripheral edema may be appropriate assessments, butthese are not priority assessments for the patient with pneumonia.45. 3. Frequent linen changes are appropriate for this client because ofdiaphoresis. Diaphoresis produces general discomfort. The client shouldbe kept dry to promote comfort. Position changes need to be done every2 hours. Nasotracheal suctioning is not indicated with the client’sproductive cough. Frequent offering of a bedpan is not indicated by thedata provided in this scenario.46. 4. A client with pneumonia has less lung surface available for thediffusion of gases because of the inflammatory pulmonary response thatcreates lung exudate and results in reduced oxygenation of the blood.The client becomes cyanotic because blood is not adequately oxygenatedin the lungs before it enters the peripheral circulation.47. 3. Clients who are experiencing hypoxia characteristically exhibitirritability, restlessness, or anxiety as initial mental status changes. Asthe hypoxia becomes more pronounced, the client may become confusedand combative. Coma is a late clinical manifestation of hypoxia. Apathyand depression are not symptoms of hypoxia.48. 4. A fluid intake of at least 3 L/day should be provided to replace anyfluid loss occurring as a result the fever and diaphoresis; this is a high-priority intervention.
  • 49. 2. An expected outcome for a client recovering from pneumoniawould be the ability to perform ADL’s without experiencing dyspnea. Arespiratory rate of 25 to 30 breaths/minute indicates the client isexperiencing tachypnea, which would not be expected on recovery. Aweight loss of 5-10 pounds is undesirable; the expected outcome wouldbe to maintain normal weight. A client who is recovering frompneumonia should experience decreased or no chest pain.50. 1. TB typically produces anorexia and weight loss. Other signs andsymptoms may include fatigue, low-grade fever, and night sweats.51. 1. The most commonly used technique to identify tubercle bacilli isacid-fast staining. The bacilli have a waxy surface, which makes themdifficult to stain in the lab. However, once they are stained, the stain isresistant to removal, even with acids. Therefore, tubercle bacilli are oftencalled acid-fast bacilli.52. 1. Streptomycin is an aminoglycoside, and eight cranial nervedamage (ototoxicity) is a common side effect from amintoglycodsides.53. 1. The eighth cranial nerve is the vestibulocochlear nerve, which isresponsible for hearing and equilibrium. Streptomycin can damage thisnerve.54. 4. Elderly persons are believed to be at higher risk for contracting TBbecause of decreased immunocompetence. Other high-risk populationsin the US include the urban poor, AIDS, and minority groups.55. 2, 4, 5.
  • 56. 2. A positive PPD test indicates that the client has been exposed totubercle bacilli. Exposure does not necessarily mean that active diseaseexists.57. 2. INH competes with the available vitamin B6 in the body andleaves the client at risk for development of neuropathies related tovitamin deficiency. Supplemental vitamin B6 is routinely prescribed.58. 4. INH and rifampin are hepatoxic drugs. Clients should be warnedto limit intake of alcohol during drug therapy. Both drugs should betaken on an empty stomach. If antacids are needed for GI distress, theyshould be taken 1 hour before or 2 hours after these drugs areadministered. Clients should not double the dosage of these drugsbecause of their potential toxicity. Clients taking INH should avoid foodsthat are rich in tyramine, such as cheese and dairy products, or they maydevelop hypertension.59. 1. Directly observed therapy (DOT) can be implemented with clientswho are not compliant with drug therapy. In DOT, a responsible person,who may be a family member or a health care provider, observes theclient taking the medication. Visiting the client, changing theprescription, or threatening the client will not ensure compliance if theclient will not or cannot follow the prescribed treatment.Rate this:
  • 10 VotesShare:EmailFacebook8TwitterPinterestLinkedInLike this:One Response to Airway – Pneumonia and TB1. soliana says:February 20, 2013 at 9:58 pmI love itLeave a ReplyWhat subject do you need to study?SearchPages 10 Diagnoses 4 Student Nurses Assessment Documentation Examples NCLEX Ques Airway – Obstruction and Asthma Airway – Pneumonia and TB Blood Disorders Cancer Cardiac – MI and HF Cardiac dysrhythmias Cardiac Surgical Patient
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