Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

A 35-year-old patient using the incentive spirometer following abdominal surgery

A 55-year-old patient who is eating in the chair following a rhinoplasty

A 40-year-old patient who refuses to cough and deep breath following a splenectomy

A24-year-old patient ambulating in the hall following an appendectomy

Answer and Explanation

The Correct Answer is C

C. This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.
A. This patient is actively using an incentive spirometer, which is a device that encourages deep breathing and helps keep the lungs clear. This practice significantly reduces the risk of developing pneumonia by preventing atelectasis (collapse of part of the lung) and promoting lung expansion.

B. This patient is out of bed and eating, which indicates they are relatively mobile and maintaining normal respiratory function. Rhinoplasty, a surgical procedure on the nose, generally does not impair lung function or significantly increase the risk of pneumonia. Being active and upright further reduces the risk of HAP.
D. This patient is actively ambulating, which is highly beneficial for lung function and overall recovery. Walking and moving around helps to prevent respiratory complications, including pneumonia, by promoting lung expansion and circulation.

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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Orange juice is highly acidic and can irritate the esophagus, leading to increased heartburn symptoms. Regular consumption of acidic beverages like orange juice can exacerbate GERD symptoms, making this a likely contributing factor to the client's heartburn.
A. Consuming low-fat meats is generally not a contributing factor to heartburn. Low-fat meats are less likely to cause reflux compared to high-fat foods, which can relax the lower esophageal sphincter and increase the risk of acid reflux.
C. Eating dinner early in the evening is generally recommended for managing GERD. This practice allows more time for the stomach to empty before lying down to sleep, reducing the likelihood of acid reflux during the night.
D. Sleeping on a large wedge-style pillow is also generally recommended for managing GERD. Elevating the head and upper body during sleep can help prevent acid from flowing back into the esophagus.

A. Pleural friction rub B. Expiratory wheeze C. Rhonchi D. Fine rales

Correct Answer is B

Explanation

B. Expiratory wheezes are high-pitched, musical sounds produced by air passing through narrowed or obstructed airways. Wheezing is a hallmark sign of asthma, particularly during an exacerbation, and is usually more pronounced during expiration due to the increased effort required to expel air through the narrowed airways.
A. A pleural friction rub is a grating sound produced by the movement of inflamed pleural surfaces rubbing together. It is typically heard in conditions such as pleuritis (inflammation of the pleura) or pleurisy. This sound is not commonly associated with asthma exacerbations.
C. Rhonchi are low-pitched, snoring-like sounds that occur due to the presence of mucus or other secretions in the larger airways. While rhonchi can be heard in conditions with increased mucus production, such as bronchitis, they are not typically the primary sound associated with asthma exacerbations.
D. Fine rales, also known as crackles, are high-pitched, popping sounds heard during inspiration. They are usually associated with conditions involving fluid in the alveoli, such as pulmonary edema or interstitial lung disease. Crackles are not characteristic of asthma.

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Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Correct Answer is B

Explanation

Gas exchange occurs in which of the following structures?

The nurse is caring for a patient admitted with COPD, who is having difficulty breathing. Which actions can the nurse take to provide support? Select all that apply

The patient with emphysema comes to the emergency department with difficulty breathing. What finding should the nurse anticipate during data collection? Select all that apply

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A newly diagnosed patient asks the nurse to explain asthma. Which of the following explanations by the nurse is correct?

Which breakfast menu is most appropriate for a patient with diabetes?

Your client has told you that they have been experiencing intermittent upper abdominal pain about 3 hours after eating and at times will even be awaken in the middle of the night by this pain. You suspect that your client may have which type of peptic ulcer?

A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease (GERD) about minimizing the effects of reflux during sleep. Which of the following client statements indicates an understanding of the teaching?