1Ignatavicius: Medical-Surgical Nursing, 9th Edition

Chapter 31: Care of Patients With Infectious Respiratory Problems

Answer Key – NCLEXÒ Examination Challenges and Clinical Judgment Challenges

Answer Key – NCLEXÒ Examination Challenges

NCLEXÒ Examination Challenge 31-1

1. A nurse is providing community education on seasonal influenza. What information will the
nurse include in this presentation? (Select all that apply.)

a. Adults older than 65 years should get the Prevnar-13 vaccination yearly.
b. All adults older than 49 years should receive a Fluzone immunization annually.
c. Sneeze into a disposable tissue or into your sleeve instead of your hand.
d. Avoid large crowds during spring and summer to limit the change for getting the flu.
e. Wash your hands frequently and after blowing your nose, coughing, or sneezing.
f. Call your provider for an antiviral prescription within 3 days of getting symptoms.

ANS: B, C, E

A is incorrect because Prevnar-13 is a pneumonia vaccine (not for influenza) and is only given
once.
B is correct because this is the injectable form of the influenza vaccine that is recommended for
adults 49 and older to receive as an immunization yearly.
C is correct because this technique is the one recommended by the CDC to limit infection spread.
D is incorrect because influenza season in North America is in the fall and winter.
E is correct because this action can limit infection spread.
F is incorrect because these drugs are effective only if taken within 24 to 48 hours after
symptoms begin.
Cognitive Level: Applying
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation

NCLEXÒ Examination Challenge 31-2

1. A nursing is caring for a client who suddenly developed acute respiratory distress after
returning home from an extended business trip in a foreign country. What actions by the nurse
are most appropriate before the cause of the problem is identified? (Select all that apply.)

a. Ask the client where the travel specifically occurred and whether he or she was exposed to
anyone who was ill.
b. Use Contact Precautions with this client and use gloves and gown for care.

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Answer Key 31-2

c. Prepare to administer isoniazide (INH) as soon as the first dose is available.

d. Monitor the results of the client’s blood urea nitrogen (BUN, creatinine, and liver function
studies.
e. Collaborate with the interprofessional team to obtain arterial blood gases and prepare to
intubate the client.
f. Assist with obtaining sputum cultures for acid-fast bacilli to send to the laboratory for analysis.

ANS: A, D, E

A is correct. This client has recently traveled and perhaps been exposed to MERS. It is critical to
determine the geographic area(s) the client has been in.
B is not completely correct. Although Contact Precautions should be used, Airborne Precautions
must also be instituted.
C is not correct. Isoniazide is used only for tuberculosis. The sudden and rapid onset of this
client’s respiratory distress is not consistent with tuberculosis.
D is correct because MERS can rapidly be complicated with sepsis and multi-organ dysfunction
syndrome.
E is correct because any client with acute respiratory distress can have progression to complete
respiratory failure. Arterial blood gas results help determine the adequacy of gas exchange and
the need for oxygen therapy and/or mechanical ventilation.
F is incorrect. This test is only for tuberculosis. The sudden and rapid onset of this client’s
respiratory distress is not consistent with tuberculosis.
Cognitive Level: Applying
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessing and Implementation

NCLEXÒ Examination Challenge 31-3

1. When reviewing the laboratory values for a client admitted with pneumonia, which result
would cause the nurse to collaborate quickly with the health care provider?

a. White blood cell (WBC) count of 14,526 mm3

b. PaO2 68 mm Hg
c. PaCO2 46 mm Hg
d. Blood glucose 146 mg/dL

ANS: B

Although all values are abnormal (PaCO2 is only slightly elevated), they are expected findings in
clients with pneumonia or any other severe infection. The very low PaO2 level indicates severe
hypoxemia and great risk for death without immediate intervention.
Cognitive Level: Applying
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluating

NCLEXÒ Examination Challenge 33-4

Answer Key 31-3

1. What information is most important for a nurse to include when teaching a client with
tuberculosis about the prescribed first-line drug therapy?

a. “Report darkening or reddening of the urine while taking Rifampin.”

b. “Do not drink alcohol in any quantity while taking Isoniazid.”
c. “Restrict fluid intake to 2 quarts of liquid a day on pyrazinamide.”
d. “Temporary visual changes while taking ethambutol are not serious.”

ANS: B

All the drugs for tuberculosis are liver toxic and can cause liver damage. Drinking alcohol
compounds this damage and should be ingested only in small quantities, if at all. The reddened
urine is an expected side effect of Rifampin therapy and, while the patient should be taught about
this side effect, it does not need to be reported. Fluids should be increased, not decreased for a
patient taking pyrazinamide to prevent gout or hyperuricemia. The visual changes associated
with ethambutol are serious and not temporary. If the drug is not stopped when changes occur, it
can cause optic neuritis and lead to blindness.
Cognitive Level: Applying
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementing

Answer Key – Clinical Judgment Challenges

Clinical Judgment Challenge 31-1, Patient-Centered Care, Evidence Based Practice

A patient has been admitted with an obvious problem with GAS EXCHANGE. The patient’s room
air ABGs are: pH 7.12, pO2 62 mm Hg, PCO2 66 mm Hg, HCO3 22 mm Hg. The patient’s
oxygen saturation is 84% and you assess course lung sounds with some wheezing in all fields.
The patient is anxious and reports feeling very short of breath. The patient is febrile at 102.3°F
(39°C); pulse is 148 beats/minute, respirations 38 breaths/minute, and blood pressure is 98/52
mm Hg.

1. What immediate care actions do you anticipate?

2. After addressing the patient’s GAS EXCHANGE needs, what care priorities should you focus on
next?

3. The provider leaves the following prescriptions for the patient. In what order should you
accomplish them?

a. Start gentamycin (Garamycin) 500 mg IVPB now.

b. Obtain sputum and blood cultures.
c. Insert indwelling urinary catheter.
d. Administer acetaminophen 1000 mg p.o. once for rib pain.
e. Increase rate of IV infusion to 150 ml/hour.

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Answer Key 31-4

4. What member of the interprofessional team would be most helpful in this situation and why?

5. What other assessments should you perform?

Suggested Responses:

1. What immediate care actions do you anticipate?

ANS: Provide immediate measures to increase the patient’s GAS EXCHANGE. These can include:
applying supplemental oxygen based on patient’s response, preparing for intubation and
mechanical ventilation, attaching the patient to an oximeter, and allowing the patient to assume
the position that best facilitates work of breathing. Also assess the patient for the presence of any
respiratory secretions that could impair the patient’s airway. If present, ensure that suction is
available.

2. After addressing the patient’s GAS EXCHANGE needs, what care priorities should you focus on
next?

The priorities of care are Airway, Breathing, and Circulation. After attending to airway and
breathing, circulation interventions would include: starting at least 1 large bore IV for fluids
and/or drugs, placing the patient on a cardiac monitor, treating the fever (fever causes
tachycardia), placing the patient on automatic blood pressure readings (often part of the cardiac
monitor capabilities) for frequent blood pressure measurements, and obtaining frequent vital
signs. Also assess for peripheral pulses, color, warmth, and capillary refill. Depending on the
patient’s age and past history, assess for chest pain as tachycardia can lead to myocardial
ischemia.

3. The provider leaves the following prescriptions for the patient. In what order should you
accomplish them?

a. Start gentamycin (Garamycin) 500 mg IVPB now.

b. Obtain sputum and blood cultures.
c. Insert indwelling urinary catheter.
d. Administer acetaminophen 1000 mg p.o. once for rib pain.
e. Increase rate of IV infusion to 150 ml/hour.

Your first action should be to increase the IV fluid rate. This is an action that can be
accomplished rapidly and may help the patient’s blood pressure. Then obtain cultures to send to
lab and start the antibiotic. Cultures should be obtained before starting antibiotics. Because the
patient has rapid fluids infusing and has a low blood pressure, next insert the catheter for
accurate measurements of urine output. Finally treat the patient’s pain.

4. What member of the interprofessional team would be most helpful in this situation and why?

The respiratory therapist (RT) would be most helpful. The RT can administer a bronchodilator
Answer Key 31-5

via nebulizer to treat the patient’s wheezing, can help obtain the sputum specimen, and can titrate
the patient’s oxygen according to response. In many facilities the RT also draws ABGs. All these
measures are important to treat or assess GAS EXCHANGE.

5. What other assessments should you perform?

Perform a pneumonia severity index or scale assessment to help classify the level of
interventions most appropriate for this patient’s condition. Also ask the patient or significant
other about recent travel and exposure to illness to help determine the possible source of
infection.

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