Respiratory System | Pneumonia & Tuberculosis NCLEX Quiz 42

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Respiratory System | Pneumonia & Tuberculosis NCLEX Quiz 42 - Quiz

All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.


Questions and Answers
  • 1. 

      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 interprets the results as:

    • A.

      Positive

    • B.

      Negative

    • C.

      Inconclusive

    • D.

      The need for repeat testing.

    Correct Answer
    A. Positive
    Explanation
    The client with HIV+ status is considered to have positive results on PPD skin test with an area greater than 5-mm of induration. The client with HIV is immunosuppressed. making a smaller area of induration positive for this type of client.

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  • 2. 

      A nurse is caring for a client diagnosed with TB. Which assessment. if made by the nurse. would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem?

    • A.

      Nonproductive or productive cough

    • B.

      Anorexia and weight loss

    • C.

      Chills and night sweats

    • D.

      High-grade fever

    Correct Answer
    D. High-grade fever
    Explanation
    The client with TB usually experiences cough (non-productive or productive). fatigue. anorexia. weight loss. dyspnea. hemoptysis. chest discomfort or pain. chills and sweats (which may occur at night). and a low-grade fever.

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  • 3. 

      A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of:

    • A.

      Meats and citrus fruits

    • B.

      Grains and broccoli

    • C.

      Eggs and spinach

    • D.

      Potatoes and fish

    Correct Answer
    A. Meats and citrus fruits
    Explanation
    The nurse teaches the client with TB to increase intake of protein. iron. and vitamin C.

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  • 4. 

      Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.

    • A.

      Auscultation of breath sounds

    • B.

      Auscultation of bowel sounds

    • C.

      Presence of chest pain.

    • D.

      Presence of peripheral edema

    • E.

      Color of nail beds

    Correct Answer(s)
    A. Auscultation of breath sounds
    C. Presence of chest pain.
    E. Color of nail beds
    Explanation
    A respiratory assessment. which includes auscultating breath sounds and assessing the color of the nail beds. is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments. but these are not priority assessments for the patient with pneumonia.

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  • 5. 

      A client with pneumonia has a temperature of 102.6*F (39.2*C). is diaphoretic. and has a productive cough. The nurse should include which of the following measures in the plan of care?

    • A.

      Position changes q4h

    • B.

      Nasotracheal suctioning to clear secretions

    • C.

      Frequent linen changes

    • D.

      Frequent offering of a bedpan.

    Correct Answer
    C. Frequent linen changes
    Explanation
    Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client’s productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

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  • 6. 

      The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?

    • A.

      Decreased cardiac output

    • B.

      Pleural effusion

    • C.

      Inadequate peripheral circulation

    • D.

      Decreased oxygenation of the blood.

    Correct Answer
    D. Decreased oxygenation of the blood.
    Explanation
    A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.

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  • 7. 

      Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia?

    • A.

      Coma

    • B.

      Apathy

    • C.

      Irritability

    • D.

      Depression

    Correct Answer
    C. Irritability
    Explanation
    Clients who are experiencing hypoxia characteristically exhibit irritability. restlessness. or anxiety as initial mental status changes. As the hypoxia becomes more pronounced. the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.

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  • 8. 

      A client with pneumonia has a temperature ranging between 101* and 102*F and periods of diaphoresis. Based on this information. which of the following nursing interventions would be a priority?

    • A.

      Maintain complete bedrest

    • B.

      Administer oxygen therapy

    • C.

      Provide frequent linen changes.

    • D.

      Provide fluid intake of 3 L/day

    Correct Answer
    D. Provide fluid intake of 3 L/day
    Explanation
    A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result the fever and diaphoresis; this is a high-priority intervention.

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  • 9. 

      Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia?

    • A.

      A respiratory rate of 25 to 30 breaths per minute

    • B.

      The ability to perform ADL’s without dyspnea

    • C.

      A maximum loss of 5 to 10 pounds of body weight

    • D.

      Chest pain that is minimized by splinting the ribcage.

    Correct Answer
    B. The ability to perform ADL’s without dyspnea
    Explanation
    An expected outcome for a client recovering from pneumonia would be the ability to perform ADL’s without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is experiencing tachypnea. which would not be expected on recovery. A weight loss of 5-10 pounds is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.

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  • 10. 

      Which of the following symptoms is common in clients with TB?

    • A.

      Weight loss

    • B.

      Increased appetite

    • C.

      Dyspnea on exertion

    • D.

      Mental status changes

    Correct Answer
    A. Weight loss
    Explanation
    TB typically produces anorexia and weight loss. Other signs and symptoms may include fatigue. low-grade fever. and night sweats.

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