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 C

Explanation

Choice A reason: Mantoux induration of 10 mm indicates TB exposure, not active infection status. It’s a diagnostic tool, not a marker for contagiousness, so it doesn’t guide discontinuation of airborne precautions in treatment.

Choice B reason: Six months of TB meds suggests treatment progress, but contagiousness persists until sputum clears. Duration alone isn’t enough; microbiologic evidence is required to lift precautions, per infection control standards.

Choice C reason: Negative sputum smears for acid-fast bacilli (three consecutive) confirm non-infectiousness in TB. This microbiological clearance allows discontinuation of airborne precautions, as the patient no longer spreads viable bacteria via droplets.

Choice D reason: Clear x-ray (no infiltrates) shows healing, but sputum can remain infectious. Radiologic improvement lags behind contagiousness, so negative smears, not imaging, determine when precautions can safely end.

A. True B. False

Correct Answer is A

Explanation

Choice A reason: Hospitalized patients often have immobility, surgery, or illness, increasing VTE risk via stasis, vessel injury, and hypercoagulability (Virchow’s triad). Studies show up to 60% of VTE cases occur in this setting, confirming the statement.

Choice B reason: False implies low VTE risk in hospitals, contradicting evidence. Inactivity and acute conditions elevate risk significantly, with prophylaxis standard in guidelines, as immobility alone triples clot formation likelihood.

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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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Correct Answer is C

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Correct Answer is A

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