N311: Chapter 28 (Lewis) - Lower Respiratory Problems 2024- 2025 (Rationales)

N311: Chapter 28
(Lewis) - Lower
Respiratory
Problems 2024-
2025 (Rationales)
A 71-year-old patient is admitted with acute respiratory
distress related to cor pulmonale. Which nursing intervention is
most appropriate during admission of this patient?
A. Perform a comprehensive health history with the patient to
review prior respiratory problems.
B. Complete a full physical examination to determine the effect
of the respiratory distress on other body functions.
C. Delay any physical assessment of the patient and review with
the family the patient's history of respiratory problems.
D. Perform a physical assessment of the respiratory system and
ask specific questions related to this episode of respiratory
distress. - ANSWER-D. Perform a physical assessment of the
respiratory system and ask specific questions related to this
episode of respiratory distress.
Because the patient is having respiratory difficulty, the nurse
should ask specific questions about this episode and perform a
physical assessment of this system. Further history taking and
physical examination of other body systems can proceed once
the patient's acute respiratory distress is being managed.
The nurse is caring for a patient admitted to the hospital with
pneumonia. Upon assessment, the nurse notes a temperature
of 101.4° F, a productive cough with yellow sputum, and a
respiratory rate of 20. Which nursing diagnosis is most
appropriate based upon this assessment?
A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions -
ANSWER-A. Hyperthermia related to infectious illness
Because the patient has spiked a temperature and has a
diagnosis of pneumonia, the logical nursing diagnosis is
hyperthermia related to infectious illness. There is no evidence
of a chill, and her breathing pattern is within normal limits at 20
breaths/minute. There is no evidence of ineffective airway
clearance from the information given because the patient is
expectorating sputum.
Which physical assessment finding in a patient with a lower
respiratory problem best supports the nursing diagnosis of
ineffective airway clearance?
A. Basilar crackles
B. Respiratory rate of 28
C. Oxygen saturation of 85%
D. Presence of greenish sputum - ANSWER-A. Basilar crackles
The presence of adventitious breath sounds indicates that
there is accumulation of secretions in the lower airways. This
would be consistent with a nursing diagnosis of ineffective
airway clearance because the patient is retaining secretions.
The rapid respiratory rate, low oxygen saturation, and presence
of greenish sputum may occur with a lower respiratory
problem, but do not definitely support the nursing diagnosis of
ineffective airway clearance.
Which clinical manifestation should the nurse expect to find
during assessment of a patient admitted with pneumonia?
A. Hyperresonance on percussion
B. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation
D. Fine crackles in all lobes on auscultation - ANSWER-C.
Increased vocal fremitus on palpation
A typical physical examination finding for a patient with
pneumonia is increased vocal fremitus on palpation. Other
signs of pulmonary consolidation include bronchial breath
sounds, egophony, and crackles in the affected area. With
pleural effusion, there may be dullness to percussion over the
affected area.
What is the priority nursing intervention in helping a patient
expectorate thick lung secretions?
A. Humidify the oxygen as able.
B. Administer cough suppressant q4hr.
C. Teach patient to splint the affected area.
D. Increase fluid intake to 3 L/day if tolerated. - ANSWER-D.
Increase fluid intake to 3 L/day if tolerated.
Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing
fluid intake, which will liquefy the secretions so that the patient
can expectorate them more easily. Humidifying the oxygen is
also helpful but is not the primary intervention. Teaching the
patient to splint the affected area may also be helpful in
decreasing discomfort but does not assist in expectoration of
thick secretions.
During discharge teaching for a 65-year-old patient with chronic
obstructive pulmonary disease (COPD) and pneumonia, which
vaccine should the nurse recommend that this patient receive?
A. Pneumococcal
B. Staphylococcus aureus
C. Haemophilus influenzae
D. Bacille-Calmette-Guerin (BCG) - ANSWER-A. Pneumococcal