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 ["A","B","C","D"]

Explanation

Choice A reason: Speech therapists assess swallowing in tracheostomy patients, as the tube alters airway dynamics. Collaboration ensures safe oral intake, preventing aspiration, a critical task aligning with their expertise in dysphagia management.

Choice B reason: Physical therapists plan mobility in tracheostomy care, enhancing strength and preventing atrophy. Collaboration promotes early activity, improving respiratory muscle function and recovery, tailored to the patient’s physical capacity.

Choice C reason: Respiratory therapists provide tracheostomy care, like suctioning and cuff management, maintaining airway patency. Collaboration ensures proper technique, reducing infection or obstruction risks, a core responsibility in respiratory support.

Choice D reason: Dietitians recommend nutrition plans for tracheostomy patients, addressing caloric and swallowing needs. Collaboration optimizes healing and energy, adjusting diets (e.g., thickened liquids) to support recovery and prevent complications.

A. Turn and reposition the patient. B. Assist the patient with incentive spirometry. C. Clamp the chest tube in two places. D. Administer prescribed morphine.

Correct Answer is D

Explanation

Choice A reason: Repositioning may ease discomfort but won’t address severe pain (7/10) or reduced breath sounds post-thoracotomy. It risks dislodging tubes and doesn’t improve atelectasis or bleeding, lacking urgency for this acute scenario.

Choice B reason: Incentive spirometry prevents atelectasis, but pain limits participation. Decreased breath sounds suggest collapse, yet without pain control, this intervention is ineffective, delaying relief and lung expansion needed post-surgery.

Choice C reason: Clamping a chest tube risks tension pneumothorax by trapping air or blood, worsening breathing. With 100 mL drainage, it’s functioning; clamping is contraindicated unless ordered, making it dangerous here.

Choice D reason: Morphine reduces severe pain (7/10), enabling deeper breathing to reverse atelectasis. It addresses the primary barrier to recovery post-thoracotomy, improving ventilation and comfort, aligning with acute pain management protocols.

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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

Nursing management of patients with tracheostomies includes collaboration with other healthcare team members. Match the Health care team member with the correct collaborative task.

Correct Answer is ["A","B","C","D"]

Explanation

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage. Which action would the nurse take?

Correct Answer is D

Explanation

Which potential complication would the nurse identify as a high risk for a patient admitted to the hospital with pancytopenia? (Select all that apply)

Based on Maria’s presenting symptoms and diagnostic test, the nurse suspects the patient will be diagnosed with ___________.

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

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Interpret the ABG results: pH: 7.48, PaCO2: 28 mmHg, PaO2: 55 mmHg, HCO3-: 24 mEq/L, SaO2: 87%

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