Patient Data

Exhibits

Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Rhonchi in the right lung

Symmetric chest expansion

Oxygen saturation greater than 949%

PaCO2 55 mm Hg on a blood gas

Client ambulates without shortness of breath

Diminished breath sounds in the right lung

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.

B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.

C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.

D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.

E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.

F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.

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Correct Answer is ["B","D","F"]

Explanation

B. Encourage the client to take breaks from the oxygen mask every few hours: While supplemental oxygen may be necessary for clients with pneumonia who are hypoxemic, encouraging periodic breaks from the oxygen mask allows the client to mobilize and promote lung expansion, which can improve ventilation and oxygenation.

D. Ambulation helps prevent complications such as pneumonia-associated atelectasis by promoting lung expansion and mobilizing respiratory secretions. However, it's essential to ensure that ambulation is safe and appropriate based on the client's condition and mobility status.

F. Elevating the head of the bed promotes optimal lung expansion, reduces the work of breathing, and helps improve oxygenation in clients with pneumonia. This position also facilitates drainage of respiratory secretions and decreases the risk of aspiration.

A. Fever is often a sign of infection and can increase metabolic demand and oxygen consumption. Treating fever with antipyretics helps reduce metabolic demand, discomfort, and respiratory distress, thereby potentially improving ventilation and oxygenation.

C. Suctioning may be necessary to remove respiratory secretions in clients with pneumonia who are unable to clear their airways effectively. However, routine suctioning should be avoided unless clinically indicated, as it may cause discomfort and irritation to the airways.

E. Quick, shallow breaths (hyperventilation) can lead to respiratory alkalosis and impair oxygenation. Instead, clients with pneumonia should be encouraged to breathe slowly and deeply to promote effective gas exchange and lung expansion.

G. Teaching the client to cough at least once an hour: While coughing can help clear respiratory secretions and improve ventilation in clients with pneumonia, coughing excessively or unnecessarily may cause fatigue and discomfort. Clients should be encouraged to cough as needed to clear secretions but not excessively.

A. Decreased cough and sputum. B. Decreased appetite and weight loss. C. A positive sputum smear and culture. D. Vertigo and tinnitus.

Correct Answer is A

Explanation

A. Isoniazid is an antitubercular medication commonly used in the treatment of active tuberculosis (TB). One of the primary goals of TB treatment is to reduce the symptoms associated with the infection, such as cough and sputum production.

B. While weight loss and decreased appetite can be symptoms of active tuberculosis, the goal of treatment with isoniazid is to improve symptoms and promote recovery.

C. A positive sputum smear and culture would indicate ongoing TB infection or treatment failure, rather than the effectiveness of isoniazid therapy.

D. Vertigo (dizziness) and tinnitus (ringing in the ears) are not typical side effects or outcomes associated with isoniazid therapy.

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Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Correct Answer is ["B","D","F"]

Explanation

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Correct Answer is A

Explanation

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

An adult client is admitted with AIDS and oral Candide albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Patient Data

Exhibits

Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings