The nurse is preparing to assess Maria’s respiratory system. Which assessment findings are likely to be associated with pneumonia?

Wheezing heard throughout both lung fields

Finger clubbing and pallor

Crackles or rales heard upon auscultation

Edema

Answer and Explanation

The Correct Answer is C

Choice A reason: Wheezing indicates airway narrowing, typical in asthma or COPD, not pneumonia. Pneumonia causes alveolar fluid, producing crackles, so diffuse wheezing doesn’t align with its pathophysiology of consolidation.

Choice B reason: Finger clubbing and pallor suggest chronic hypoxia or anemia, not acute pneumonia. These develop over time, whereas pneumonia presents with acute respiratory signs like crackles, not chronic markers.

Choice C reason: Crackles or rales occur in pneumonia from fluid or pus in alveoli, disrupting airflow. Heard on auscultation, they’re a classic sign, reflecting consolidation or inflammation in affected lung regions.

Choice D reason: Edema is fluid in tissues, linked to heart failure, not pneumonia directly. Pneumonia affects lungs, causing crackles, not peripheral swelling, making this unrelated to typical respiratory findings.

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Correct Answer is D

Explanation

Choice A reason: Restricting fluids to 2 liters per day increases blood viscosity in sickle cell disease, promoting sickling and vaso-occlusion. Adequate hydration is critical to dilute hemoglobin S, so this instruction contradicts evidence-based management for crisis prevention.

Choice B reason: Iron supplements are contraindicated in sickle cell disease unless anemia is iron-deficient, which is rare. Most patients have normal or high iron from hemolysis, so a multivitamin with iron risks overload and organ damage.

Choice C reason: Avoiding caffeine lacks evidence in sickle cell crisis prevention; it’s not a trigger. Moderate intake doesn’t dehydrate significantly or affect sickling, making this instruction irrelevant to discharge teaching for this condition.

Choice D reason: Limiting crowd exposure reduces infection risk, a common sickle cell crisis trigger. Infections cause inflammation and hypoxia, promoting sickling, so this instruction aligns with preventing complications and maintaining patient stability post-discharge.

A. Assess patient pain level associated with the chest tube. B. Check the water-seal chamber for the correct fluid level. C. Document the amount of drainage every 8 hours. D. Obtain samples of drainage for culture from the system.

Correct Answer is C

Explanation

Choice A reason: Assessing pain requires subjective interpretation and clinical judgment to gauge severity and response. This nursing task can’t be delegated, as assistants lack training to evaluate pain’s impact on respiratory status or intervention needs.

Choice B reason: Checking the water-seal chamber involves understanding pneumothorax mechanics and system integrity. This technical skill exceeds an assistant’s scope, requiring a nurse to ensure proper function and detect complications like air leaks.

Choice C reason: Documenting drainage volume is a routine task after RN measurement, involving recording observed data. It fits an assistant’s role, as it requires no analysis or intervention, making it a safe delegation for tracking output.

Choice D reason: Obtaining drainage samples involves sterile technique and system manipulation, risking infection or disruption. This skilled procedure remains a nursing duty, as assistants aren’t trained to handle invasive equipment safely.

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The nurse is preparing to assess Maria’s respiratory system. Which assessment findings are likely to be associated with pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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