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10 Diagnoses 4 Student Nurses
Assessment Documentation Examples
NCLEX Ques
Study Notes
Airway – Pneumonia and TB
1. Clients with chronic illnesses are more likely to get pneumonia
when which of the following situations is present?
A. Dehydration
B. Group living
C. Malnutrition
D. Severe periodontal disease
2. Which of the following pathophysiological mechanisms that occurs
in the lung parenchyma allows pneumonia to develop?
1. Atelectasis
2. Bronchiectasis
3. Effusion

2. 4. Inflammation
3. Which of the following organisms most commonly causes
community-acquired pneumonia in adults?
1. Haemiphilus influenzae
2. Klebsiella pneumoniae
3. Steptococcus pneumoniae
4. Staphylococcus aureus
4. An elderly client with pneumonia may appear with which of the
following symptoms first?
1. Altered mental status and dehydration
2. Fever and chills
3. Hemoptysis and dyspnea
4. Pleuritic chest pain and cough
5. When auscultating the chest of a client with pneumonia, the nurse
would expect to hear which of the following sounds over areas of
consolidation?
1. Bronchial
2. Bronchovestibular
3. Tubular
4. Vesicular

3. 6. A diagnosis of pneumonia is typically achieved by which of the
following diagnostic tests?
1. ABG analysis
2. Chest x-ray
3. Blood cultures
4. sputum culture and sensitivity
7. A client with pneumonia develops dyspnea with a respiratory rate of
32 breaths/minute and difficulty expelling his secretions. The nurse
auscultates his lung fields and hears bronchial sounds in the left lower
lobe. The nurse determines that the client requires which of the following
treatments first?
1. Antibiotics
2. Bed rest
3. Oxygen
4. Nutritional intake
8. A client has been treated with antibiotic therapy for right lower-lobe
pneumonia for 10 days and will be discharged today. Which of the
following physical findings would lead the nurse to believe it is
appropriate to discharge this client?
1. Continued dyspnea

4. 2. Fever of 102*F
3. Respiratory rate of 32 breaths/minute
4. Vesicular breath sounds in right base
9. The right forearm of a client who had a purified protein derivative
(PPD) test for tuberculosis is reddened and raised about 3mm where the
test was given. This PPD would be read as having which of the following
results?
1. Indeterminate
2. Needs to be redone
3. Negative
4. Positive
10. A client with primary TB infection can expect to develop which of the
following conditions?
1. Active TB within 2 weeks
2. Active TB within 1 month
3. A fever that requires hospitalization
4. A positive skin test
11. A client was infected with TB 10 years ago but never developed the
disease. He’s now being treated for cancer. The client begins to develop
signs of TB. This is known as which of the following types of infection?

5. 1. Active infection
2. Primary infection
3. Superinfection
4. Tertiary infection
12. A client has active TB. Which of the following symptoms will he
exhibit?
1. Chest and lower back pain
2. Chills, fever, night sweats, and hemoptysis
3. Fever of more than 104*F and nausea
4. Headache and photophobia
13. Which of the following diagnostic tests is definitive for TB?
1. Chest x-ray
2. Mantoux test
3. Sputum culture
4. Tuberculin test
14. A client with a positive Mantoux test result will be sent for a chest x-
ray. For which of the following reasons is this done?
1. To confirm the diagnosis
2. To determine if a repeat skin test is needed
3. To determine the extent of the lesions

6. 4. To determine if this is a primary or secondary infection
15. A chest x-ray should a client’s lungs to be clear. His Mantoux test is
positive, with a 10mm if induration. His previous test was negative.
These test results are possible because:
1. He had TB in the past and no longer has it.
2. He was successfully treated for TB, but skin tests always stay
positive.
3. He’s a “seroconverter”, meaning the TB has gotten to his
bloodstream.
4. He’s a “tuberculin converter,” which means he has been infected
with TB since his last skin test.
16. A client with a positive skin test for TB isn’t showing signs of active
disease. To help prevent the development of active TB, the client should
be treated with isonaizid, 300mg daily, for how long?
1. 10 to 14 days
2. 2 to 4 weeks
3. 3 to 6 months
4. 9 to 12 months
17. A client with a productive cough, chills, and night sweats is suspected
of having active TB. The physician should take which of the following
actions?

7. 1. Admit him to the hospital in respiratory isolation
2. Prescribe isoniazid and tell him to go home and rest
3. Give a tuberculin test and tell him to come back in 48 hours and
have it read.
4. Give a prescription for isoniazid, 300mg daily for 2 weeks, and
send him home.
18. A client is diagnosed with active TB and started on triple antibiotic
therapy. What signs and symptoms would the client show if therapy is
inadequate?
1. Decreased shortness of breath
2. Improved chest x-ray
3. Nonproductive cough
4. Positive acid-fast bacilli in a sputum sample after 2 months of
treatment.
19. A client diagnosed with active TB would be hospitalized primarily for
which of the following reasons?
1. To evaluate his condition
2. To determine his compliance
3. to prevent spread of the disease
4. To determine the need for antibiotic therapy.

8. 20. A high level of oxygen exerts which of the following effects on the
lung?
1. Improves oxygen uptake
2. Increases carbon dioxide levels
3. Stabilizes carbon dioxide levels
4. Reduces amount of functional alveolar surface area
21. A 24-year-old client comes into the clinic complaining of right-sided
chest pain and shortness of breath. He reports that it started suddenly.
The assessment should include which of the following interventions?
1. Auscultation of breath sounds
2. Chest x-ray
3. Echocardiogram
4. Electrocardiogram (ECG)
22. A client with shortness of breath has decreased to absent breath
sounds on the right side, from the apex to the base. Which of the
following conditions would best explain this?
1. Acute asthma
2. Chronic bronchitis
3. Pneumonia
4. Spontaneous pneumothorax

9. 23. Which of the following treatments would the nurse expect for a
client with a spontaneous pneumothorax?
1. Antibiotics
2. Bronchodilators
3. Chest tube placement
4. Hyperbaric chamber
24. Which of the following methods is the best way to confirm the
diagnosis of a pneumothorax?
1. Auscultate breath sounds
2. Have the client use an incentive spirometer
3. Take a chest x-ray
4. stick a needle in the area of decreased breath sounds
25. A pulse oximetry gives what type of information about the client?
1. Amount of carbon dioxide in the blood
2. Amount of oxygen in the blood
3. Percentage of hemoglobin carrying oxygen
4. Respiratory rate
26. What effect does hemoglobin amount have on oxygenation status?
1. No effect

10. 2. More hemoglobin reduces the client’s respiratory rate
3. Low hemoglobin levels cause reduces oxygen-carrying capacity
4. Low hemoglobin levels cause increased oxygen-carrying capacity.
27. Which of the following statements best explains how opening up
collapsed alveoli improves oxygenation?
1. Alveoli need oxygen to live
2. Alveoli have no effect on oxygenation
3. Collapsed alveoli increase oxygen demand
4. Gaseous exchange occurs in the alveolar membrane.
28. Continuous positive airway pressure (CPAP) can be provided
through an oxygen mask to improve oxygenation in hypoxic patients by
which of the following methods?
1. The mask provides 100% oxygen to the client.
2. The mask provides continuous air that the client can breathe.
3. The mask provides pressurized oxygen so the client can breathe
more easily.
4. The mask provides pressurized at the end of expiration to open
collapsed alveoli.
29. Which of the following best describes pleural effusion?
1. The collapse of alveoli

11. 2. The collapse of bronchiole
3. The fluid in the alveolar space
4. The accumulation of fluid between the linings of the pleural space.
30. If a pleural effusion develops, which of the following actions best
describes how the fluid can be removed from the pleural space and
proper lung status restored?
1. Inserting a chest tube
2. Performing thoracentesis
3. Performing paracentesis
4. Allowing the pleural effusion to drain by itself.
31. A comatose client needs a nasopharyngeal airway for suctioning.
After the airway is inserted, he gags and coughs. Which action should the
nurse take?
1. Remove the airway and insert a shorter one.
2. Reposition the airway.
3. Leave the airway in place until the client gets used to it.
4. Remove the airway and attempt suctioning without it.
32. An 87-year-old client requires long term ventilator therapy. He has a
tracheostomy in place and requires frequent suctioning. Which of the
following techniques is correct?

12. 1. Using intermittent suction while advancing the catheter.
2. Using continuous suction while withdrawing the catheter.
3. Using intermittent suction while withdrawing the catheter.
4. Using continuous suction while advancing the catheter.
33. A client’s ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of
77 mm Hg, and HCO3
- of 24 mEq/L. What do these values indicate?
1. Metabolic acidosis
2. Respiratory alkalosis
3. Metabolic alkalosis
4. Respiratory acidosis
34. A police officer brings in a homeless client to the ER. A chest x-ray
suggests he has TB. The physician orders an intradermal injection of 5
tuberculin units/0.1 ml of tuberculin purified derivative. Which needle is
appropriate for this injection?
1. 5/8” to ½” 25G to 27G needle.
2. 1” to 3” 20G to 25G needle.
3. ½” to 3/8” 26 or 27G needle.
4. 1” 20G needle.
35. A 76-year old client is admitted for elective knee surgery. Physical
examination reveals shallow respirations but no signs of respiratory
distress. Which of the following is a normal physiologic change related to
aging?

13. 1. Increased elastic recoil of the lungs
2. Increased number of functional capillaries in the alveoli
3. Decreased residual volume
4. Decreased vital capacity.
36. A 79-year-old client is admitted with pneumonia. Which nursing
diagnosis should take priority?
1. Acute pain related to lung expansion secondary to lung infection
2. Risk for imbalanced fluid volume related to increased insensible
fluid losses secondary to fever.
3. Anxiety related to dyspnea and chest pain.
4. Ineffective airway clearance related to retained secretions.
37. A community health nurse is conducting an educational session with
community members regarding TB. The nurse tells the group that one of
the first symptoms associated with TB is:
1. A bloody, productive cough
2. A cough with the expectoration of mucoid sputum
3. Chest pain
4. Dyspnea
38. A nurse evaluates the blood theophylline level of a client receiving
aminophylline (theophylline) by intravenous infusion. The nurse would

14. determine that a therapeutic blood level exists if which of the following
were noted in the laboratory report?
1. 5 mcg/mL
2. 15 mcg/mL
3. 25 mcg/mL
4. 30 mcg/mL
39. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a
client with TB. A nurse reviews the medical record of the client. Which of
the following, if noted in the client’s history, would require physician
notification?
1. Heart disease
2. Allergy to penicillin
3. Hepatitis B
4. Rheumatic fever
40. A client is experiencing confusion and tremors is admitted to a
nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm
Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client
is most likely experiencing:
1. Carbon monoxide poisoning
2. Carbon dioxide narcosis
3. Respiratory alkalosis
4. Metabolic acidosis

15. 41. 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:
1. Positive
2. Negative
3. Inconclusive
4. The need for repeat testing.
42. 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?
1. Nonproductive or productive cough
2. Anorexia and weight loss
3. Chills and night sweats
4. High-grade fever
43. 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:
1. Meats and citrus fruits
2. Grains and broccoli
3. Eggs and spinach
4. Potatoes and fish

16. 44. Which of the following would be priority assessment data to gather
from a client who has been diagnosed with pneumonia? Select all that
apply.
1. Auscultation of breath sounds
2. Auscultation of bowel sounds
3. Presence of chest pain.
4. Presence of peripheral edema
5. Color of nail beds
45. 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?
1. Position changes q4h
2. Nasotracheal suctioning to clear secretions
3. Frequent linen changes
4. Frequent offering of a bedpan.
46. The cyanosis that accompanies bacterial pneumonia is primarily
caused by which of the following?
1. Decreased cardiac output
2. Pleural effusion
3. Inadequate peripheral circulation

17. 4. Decreased oxygenation of the blood.
47. Which of the following mental status changes may occur when a
client with pneumonia is first experiencing hypoxia?
1. Coma
2. Apathy
3. Irritability
4. Depression
48. 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?
1. Maintain complete bedrest
2. Administer oxygen therapy
3. Provide frequent linen changes.
4. Provide fluid intake of 3 L/day
49. Which of the following would be an appropriate expected outcome
for an elderly client recovering from bacterial pneumonia?
1. A respiratory rate of 25 to 30 breaths per minute
2. The ability to perform ADL’s without dyspnea
3. A maximum loss of 5 to 10 pounds of body weight
4. Chest pain that is minimized by splinting the ribcage.

18. 50. Which of the following symptoms is common in clients with TB?
1. Weight loss
2. Increased appetite
3. Dyspnea on exertion
4. Mental status changes
51. The nurse obtains a sputum specimen from a client with suspected
TB for laboratory study. Which of the following laboratory techniques is
most commonly used to identify tubercle bacilli in sputum?
1. Acid-fast staining
2. Sensitivity testing
3. Agglunitnation testing
4. Dark-field illumination
52. Which of the following antituberculus drugs can cause damage to the
eighth cranial nerve?
1. Streptomycin
2. Isoniazid
3. Para-aminosalicylic acid
4. Ethambutol hydrochloride

19. 53. The client experiencing eighth cranial nerve damage will most likely
report which of the following symptoms?
1. Vertigo
2. Facial paralysis
3. Impaired vision
4. Difficulty swallowing
54. Which of the following family members exposed to TB would be at
highest risk for contracting the disease?
1. 45-year-old mother
2. 17-year-old daughter
3. 8-year-old son
4. 76-year-old grandmother
55. The nurse is teaching a client who has been diagnosed with TB how
to avoid spreading the disease to family members. Which statement(s)
by the client indicate(s) that he has understood the nurses instructions?
Select all that apply.
1. “I will need to dispose of my old clothing when I return home.”
2. “I should always cover my mouth and nose when sneezing.”
3. “It is important that I isolate myself from family when possible.”
4. “I should use paper tissues to cough in and dispose of them
properly.”
5. “I can use regular plate and utensils whenever I eat.”

20. 56. A client has a positive reaction to the PPD test. The nurse correctly
interprets this reaction to mean that the client has:
1. Active TB
2. Had contact with Mycobacterium tuberculosis
3. Developed a resistance to tubercle bacilli
4. Developed passive immunity to TB.
57. INH treatment is associated with the development of peripheral
neuropathies. Which of the following interventions would the nurse
teach the client to help prevent this complication?
1. Adhere to a low cholesterol diet
2. Supplement the diet with pyridoxine (vitamin B6)
3. Get extra rest
4. Avoid excessive sun exposure.
58. The nurse should include which of the following instructions when
developing a teaching plan for clients receiving INH and rifampin for
treatment for TB?
1. Take the medication with antacids
2. Double the dosage if a drug dose is forgotten
3. Increase intake of dairy products
4. Limit alcohol intake

21. 59. The public health nurse is providing follow-up care to a client with
TB who does not regularly take his medication. Which nursing action
would be most appropriate for this client?
1. Ask the client’s spouse to supervise the daily administration of the
medications.
2. Visit the clinic weekly to ask him whether he is taking his
medications regularly.
3. Notify the physician of the client’s non-compliance and request a
different prescription.
4. Remind the client that TB can be fatal if not taken properly.
1. 2. Clients with chronic illnesses generally have poor immune
systems. Often, residing in group living situations increases the
chance of disease transmission.
2. 4. The common feature of all type of pneumonia is an inflammatory
pulmonary response to the offending organism or agent.
Atelectasis and bronchiecrasis indicate a collapse of a portion of
the airway that doesn’t occur in pneumonia. An effusion is an
accumulation of excess pleural fluid in the pleural space, which
may be a secondary response to pneumonia.

22. 3. 3. Pneumococcal or streptococcal pneumonia, caused
by streptococcus pneumoniae, is the most common cause of
community-acquired pneumonia. H. influenzae is the most
common cause of infection in children. Klebsiella species is the
most common gram-negative organism found in the hospital
setting. Staphylococcus aureus is the most common cause of
hospital-acquired pneumonia.
4. 1. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest
pain are common symptoms of pneumonia, but elderly clients may
first appear with only an altered mental status and dehydration due
to a blunted immune response.
5. 1. Chest auscultation reveals bronchial breath sounds over areas of
consolidation. Bronchiovesicular are normal over midlobe lung
regions, tubular sounds are commonly heard over large airways,
and vesicular breath sounds are commonly heard in the bases of
the lung fields.
6. 4. Sputum C & S is the best way to identify the organism causing
the pneumonia. Chest x-ray will show the area of lung
consolidation. ABG analysis will determine the extent of hypoxia
present due to the pneumonia, and blood cultures will help
determine if the infection is systemic.
7. 3. The client is having difficulty breathing and is probably
becoming hypoxic. As an emergency measure, the nurse can
provide oxygen without waiting for a physicians order. Antibiotics
may be warranted, but this isn’t a nursing decision. The client
should be maintained on bedrest if he is dyspneic to minimize his
oxygen demands, but providing additional will deal more
immediately with his problem. The client will need nutritional

23. support, but while dyspneic, he may be unable to spare the energy
needed to eat and at the same time maintain adequate oxygenation.
8. 4. If the client still has pneumonia, the breath sounds in the right
base will be bronchial, not the normal vesicular breath sounds. If
the client still has dyspnea, fever, and increased respiratory rate, he
should be examined by the physician before discharge because he
may have another source of infection or still have pneumonia.
9. 3. This test would be classed as negative. A 5mm raised area would
be a positive result if a client was HIV+ or had recent close contact
with someone diagnosed with TB. Indeterminate isn’t a term used
to describe results of a PPD test. If the PPD is reddened and raised
10mm or more, it’s considered positive according to the CDC.
10. 4. A primary TB infection occurs when the bacillus has successfully
invaded the entire body after entering through the lungs. At this point,
the bacilli are walled off and skin tests read positive. However, all but
infants and immunosuppressed people will remain asymptomatic. The
general population has a 10% risk of developing active TB over their
lifetime, in many cases because of a break in the body’s immune
defenses. The active stage shows the classic symptoms of TB: fever,
hemoptysis, and night sweats.
11. 1. Some people carry dormant TB infections that may develop into
active disease. In addition, primary sites of infection containing TB
bacilli may remain inactive for years and then activate when the client’s
resistance is lowered, as when a client is being treated for cancer. There’s
no such thing as tertiary infection, and superinfection doesn’t apply in
this case.

24. 12. 2. Typical signs and symptoms are chills, fever, night sweats, and
hemoptysis. Chest pain may be present from coughing, but isn’t usual.
Clients with TB typically have low-grade fevers, not higher than 102*F.
Nausea, headache, and photophobia aren’t usual TB symptoms.
13. 3. The sputum culture for Myobacterium tuberculosis is the only
method of confirming the diagnosis. Lesions in the lung may not be big
enough to be seen on x-ray. Skin tests may be falsely positive or falsely
negative.
14. 3. If the lesions are large enough, the chest x-ray will show their
presence in the lungs. Sputum culture confirms the diagnosis. There can
be false-positive and false-negative skin test results. A chest x-ray can’t
determine if this is a primary or secondary infection.
15. 4. A tuberculin converter’s skin test will be positive, meaning he has
been exposed to an infected with TB and now has a cell-mediated
immune response to the skin test. The client’s blood and x-ray results
may stay negative. It doesn’t mean the infection has advanced to the
active stage. Because his x-ray is negative, he should be monitored every
6 months to see if he develops changes in his x-ray or pulmonary
examination. Being a seroconverter doesn’t mean the TB has gotten into
his bloodstream; it means it can be detected by a blood test.
16. 4. Because of the increased incidence of resistant strains of TB, the
disease must be treated for up to 24 months in some cases, but treatment
typically lasts for 9-12 months. Isoaizid is the most common medication
used for the treatment of TB, but other antibiotics are added to the
regimen to obtain the best results.

25. 17. 1. The client is showing s/s of active TB and, because of the
productive cough, is highly contagious. He should be admitted to the
hospital, placed in respiratory isolation, and three sputum cultures
should be obtained to confirm the diagnosis. He would most likely be
given isoniazid and two or three other antitubercular antibiotics until the
diagnosis is confirmed, then isolation and treatment would continue if
the cultures were positive for TB. After 7 to 10 days, three more
consecutive sputum cultures will be obtained. If they’re negative, he
would be considered non-contagious and may be sent home, although
he’ll continue to take the antitubercular drugs for 9 to 12 months.
18. 4. Continuing to have acid-fast bacilli in the sputum after 2 months
indicated continued infection.
19. 3. The client with active TB is highly contagious until three
consecutive sputum cultures are negative, so he’s put in respiratory
isolation in the hospital.
20. 4. Oxygen toxicity causes direct pulmonary trauma, reducing the
amount of alveolar surface area available for gaseous exchange, which
results in increased carbon dioxide levels and decreased oxygen uptake.
21. 1. Because the client is short of breath, listening to breath sounds is a
good idea. He may need a chest x-ray and an ECG, but a physician must
order these tests. Unless a cardiac source for the client’s pain is
identified, he won’t need an echocardiogram.
22. 4. A spontaneous pneumothorax occurs when the client’s lung
collapses, causing an acute decrease in the amount of functional lung

26. used in oxygenation. The sudden collapse was the cause of his chest pain
and shortness of breath. An asthma attack would show wheezing breath
sounds, and bronchitis would have rhonchi. Pneumonia would have
bronchial breath sounds over the area of consolidation.
23. 3. The only way to reexpand the lung is to place a chest tube on the
right side so the air in the pleural space can be removed and the lung
reexpanded.
24. 3. A chest x-ray will show the area of collapsed lung if pneumothorax
is present as well as the volume of air in the pleural space. Listening to
breath sounds won’t confirm a diagnosis. An IS is used to encourage
deep breathing. A needle thoracostomy is done only in an emergency and
only by someone trained to do it.
25. 3. The pulse oximeter determines the percentage of hemoglobin
carrying oxygen. This doesn’t ensure that the oxygen being carried
through the bloodstream is actually being taken up by the tissue.
26. 3. Hemoglobin carries oxygen to all tissues in the body. If the
hemoglobin level is low, the amount of oxygen-carrying capacity is also
low. More hemoglobin will increase oxygen-carrying capacity and thus
increase the total amount of oxygen available in the blood. If the client
has been tachypneic during exertion, or even at rest, because oxygen
demand is higher than the available oxygen content, then an increase in
hemoglobin may decrease the respiratory rate to normal levels.
27. 4. Gaseous exchange occurs in the alveolar membrane, so if the
alveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as

27. well as other nutrients, from the bloodstream. Collapsed alveoli have no
effect on oxygen demand, though by decreasing the surface area
available for gas exchange, they decrease oxygenation of the blood.
28. 3. The mask provides pressurized oxygen continuously through both
inspiration and expiration. The mask can be set to deliver any amount of
oxygen needed. By providing the client with pressurized oxygen, the
client has less resistance to overcome in taking his next breath, making it
easier to breathe. Pressurized oxygen delivered at the end of expiration is
positive end-expiratory pressure (PEEP), not continuous positive airway
pressure.
29. 4. The pleural fluid normally seeps continually into the pleural space
from the capillaries lining the parietal pleura and is reabsorbed by the
visceral pleural capillaries and lymphatics. Any condition that interferes
with either the secretion or drainage of this fluid will lead to a pleural
effusion.
30. 2. Performing thoracentesis is used to remove excess pleural fluid.
The fluid is then analyzed to determine if it’s transudative or exudative.
Transudates are substances that have passed through a membrane and
usually occur in low protein states. Exudates are substances that have
escaped from blood vessels. They contain an accumulation of cells and
have a high specific gravity and a high lactate dehydrogenase level.
Exudates usually occur in response to a malignancy, infection, or
inflammatory process. A chest tube is rarely necessary because the
amount of fluid typically isn’t large enough to warrant such a measure.
Pleural effusions can’t drain by themselves.

28. 31. 1. If a client gags or coughs after nasopharyngeal airway placement,
the tube may be too long. The nurse should remove it and insert a
shorter one. Simply repositioning the airway won’t solve the problem.
The client won’t get used to the tube because it’s the wrong size.
Suctioning without a nasopharyngeal airway causes trauma to the
natural airway.
32. Intermittent suction should be applied during catheter withdrawal.
To prevent hypoxia, suctioning shouldn’t last more than 10-seconds at a
time. Suction shouldn’t be applied while the catheter is being advanced.
33. 4.
34. 3. Intradermal injections like those used in TN skin tests are
administered in small volumes (usually 0.5 ml or less) into the outer skin
layers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or
27G needle should be inserted about 1/8” below the epidermis.
35. 4. Reduction in VC is a normal physiologic change in the older adult.
Other normal physiologic changes include decreased elastic recoil of the
lungs, fewer functional capillaries in the alveoli, and an increase is
residual volume.
36. 4. Pneumonia is an acute infection of the lung parenchyma. The
inflammatory reaction may cause an outpouring of exudate into the
alveolar spaces, leading to an ineffective airway clearance related to
retained secretions.

29. 37. 2. One of the first pulmonary symptoms includes a slight cough with
the expectoration of mucoid sputum.
38. 2. The therapeutic theophylline blood level range from 10-20
mcg/mL.
39. 3. Isoniazid and rafampin are contraindicated in clients with acute
liver disease or a history of hepatic injury.
40. 2. Carbon dioxide narcosis is a condition that results from extreme
hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The
client experiences symptoms such as confusion and tremors, which may
progress to convulsions and possible coma.
41. 1. 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.
42. 4. 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.
43. 1. The nurse teaches the client with TB to increase intake of protein,
iron, and vitamin C.
44. 1, 3, 5. A respiratory assessment, which includes auscultating breath
sounds and assessing the color of the nail beds, is a priority for clients

30. 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.
45. 3. 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.
46. 4. 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.
47. 3. 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.
48. 4. 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.

31. 49. 2. 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.
50. 1. TB typically produces anorexia and weight loss. Other signs and
symptoms may include fatigue, low-grade fever, and night sweats.
51. 1. The most commonly used technique to identify tubercle bacilli is
acid-fast staining. The bacilli have a waxy surface, which makes them
difficult to stain in the lab. However, once they are stained, the stain is
resistant to removal, even with acids. Therefore, tubercle bacilli are often
called acid-fast bacilli.
52. 1. Streptomycin is an aminoglycoside, and eight cranial nerve
damage (ototoxicity) is a common side effect from amintoglycodsides.
53. 1. The eighth cranial nerve is the vestibulocochlear nerve, which is
responsible for hearing and equilibrium. Streptomycin can damage this
nerve.
54. 4. Elderly persons are believed to be at higher risk for contracting TB
because of decreased immunocompetence. Other high-risk populations
in the US include the urban poor, AIDS, and minority groups.
55. 2, 4, 5.

32. 56. 2. A positive PPD test indicates that the client has been exposed to
tubercle bacilli. Exposure does not necessarily mean that active disease
exists.
57. 2. INH competes with the available vitamin B6 in the body and
leaves the client at risk for development of neuropathies related to
vitamin deficiency. Supplemental vitamin B6 is routinely prescribed.
58. 4. INH and rifampin are hepatoxic drugs. Clients should be warned
to limit intake of alcohol during drug therapy. Both drugs should be
taken on an empty stomach. If antacids are needed for GI distress, they
should be taken 1 hour before or 2 hours after these drugs are
administered. Clients should not double the dosage of these drugs
because of their potential toxicity. Clients taking INH should avoid foods
that are rich in tyramine, such as cheese and dairy products, or they may
develop hypertension.
59. 1. Directly observed therapy (DOT) can be implemented with clients
who are not compliant with drug therapy. In DOT, a responsible person,
who may be a family member or a health care provider, observes the
client taking the medication. Visiting the client, changing the
prescription, or threatening the client will not ensure compliance if the
client will not or cannot follow the prescribed treatment.
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One Response to Airway – Pneumonia and TB
1. soliana says:
February 20, 2013 at 9:58 pm
I love it
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