Pneumonia on a med-surg unit is a story about oxygenation and prevention. These questions cover the assessment findings that matter, oxygen and positioning, why the timing of cultures and antibiotics is not negotiable, mobilising the patient, and the aspiration precautions that keep the next case from happening.
Question 1
A nursing assistant is delegated to feed a patient with advanced Parkinson's disease and dysphagia. Which observed action by the assistant necessitates immediate redirection by the RN?
- A) A) Offering small bites with chin tuck technique
- B) B) Providing thickened liquids between meals
- C) C) Encouraging rapid eating to prevent fatigue✓
- D) D) Documenting intake percentage consumed
Show rationale
Encouraging rapid eating increases aspiration risk in dysphagia, contravening safety protocols. Small bites (A) and thickened liquids (B) are appropriate compensatory techniques. Intake documentation (D) is within assistant scope. Cues (Parkinson's, dysphagia) require strict adherence to aspiration precautions, mandating RN intervention for unsafe practices.
Question 2
A 68-year-old patient with COPD is admitted for pneumonia. During shift handoff, the nurse learns the patient reported moderate pain during morning vital checks. The nurse reviews CMS Value-Based Purchasing metrics for this facility. Which documentation approach best aligns with value-based reimbursement priorities while addressing this patient’s needs?
- A) A) Documenting pain assessment using a 0-10 scale and administering PRN analgesics per protocol✓
- B) B) Recording pain score in flowsheets and updating the care plan during end-of-shift charting
- C) C) Using descriptive pain notes and collaborating with respiratory therapy for non-pharmacological relief
- D) D) Delaying analgesic administration until after obtaining a full pain history from the patient
Show rationale
Value-Based Purchasing ties reimbursement to HCAHPS patient experience metrics, including pain management responsiveness. Option A uses standardized assessment (discriminating cue: numeric scale) and timely intervention, meeting core measures for pain documentation and treatment. Option B delays care plan updates, risking non-compliance. Option C omits pharmacological intervention despite protocol availability. Option D delays treatment, contradicting pain management standards. All options address pain, but only A combines immediate evidence-based action with required documentation for quality reporting.
Question 3
An elderly Navajo patient with pneumonia requests to leave against medical advice for a healing ceremony. Vital signs are stable, but oxygen saturation is 92% on room air. How should the nurse advocate for this patient?
- A) A) Initiate discharge planning with arrangements for portable oxygen during ceremony✓
- B) B) Explain that leaving would compromise recovery and require liability documentation
- C) C) Consult hospital chaplain services to conduct a ceremony in the facility
- D) D) Negotiate delayed departure until completing intravenous antibiotics
Show rationale
This honors cultural needs while addressing medical safety with oxygen support. Option B prioritizes institutional concerns over cultural practices. Option C imposes non-Navajo spiritual support. Option D disregards ceremonial timing significance. The AMSN Code of Ethics requires respecting cultural practices; CMS discharge standards support culturally safe transitions.
Question 4
A nursing assistant reports a dementia patient's "good appetite" after pureed meals. The nurse discovers unchewed meat in the patient's mouth during oral care. Which evaluation step is most urgent?
- A) A) Assessing the assistant's understanding of aspiration precautions
- B) B) Requesting a speech-language pathology swallow evaluation✓
- C) C) Observing the next meal for safe feeding techniques
- D) D) Reviewing dietary orders for texture consistency appropriateness
Show rationale
Retained food indicates silent aspiration risk in dementia. Option B initiates expert assessment per dysphagia guidelines. Option A evaluates knowledge but doesn't address immediate safety. Option C observes technique but delays diagnostics. Option D checks orders but misses functional impairment.
Question 5
A 78-year-old patient with Parkinson's disease, orthostatic hypotension, and a Morse Fall Scale score of 60 is admitted for pneumonia. The nurse notes they attempt to ambulate unassisted despite weakness. Which intervention best addresses both intrinsic and extrinsic fall risks?
- A) A) Place a low-height bed with floor mats and schedule toileting every 90 minutes
- B) B) Apply a chair alarm and administer PRN antihypertensives before ambulation
- C) C) Install bilateral bed rails and provide non-skid footwear during daytime hours
- D) D) Implement a bed exit alarm and assist with ambulation using a walker✓
Show rationale
The bed exit alarm addresses extrinsic risks by alerting staff to unscheduled mobility attempts. Walker assistance combats intrinsic risks of weakness and postural instability from Parkinson's and orthostatic hypotension. Option A's floor mats don't prevent falls during ambulation attempts. Option B's chair alarm is less relevant than bed exit monitoring, and antihypertensives may worsen hypotension. Option C's bed rails increase injury risk and don't address gait instability. CMSRN guidelines prioritize alarm systems for high-risk patients (Morse >45) and assistive devices for neurological impairment.
Question 6
A 68-year-old patient with COPD and generalized anxiety disorder is admitted for pneumonia. The patient reports acute dyspnea (RR 28/min) and states, "I feel like I'm suffocating." SpO2 is 92% on 2L NC. Which breathing technique should the nurse implement first to reduce air trapping and anxiety?
- A) A) Instruct pursed-lip breathing during exhalation while sitting upright✓
- B) B) Guide diaphragmatic breathing with hand placement on abdomen
- C) C) Initiate paced breathing at 5-second inhale/exhale cycles
- D) D) Teach box breathing with 4-second holds after inhalation
Show rationale
Pursed-lip breathing reduces air trapping in COPD by maintaining positive airway pressure during exhalation, directly addressing dyspnea and anxiety. Upright positioning optimizes lung expansion. Diaphragmatic breathing (B) is less effective during acute dyspnea in COPD due to flattened diaphragms. Paced breathing (C) may increase work of breathing if not matched to individual capacity. Box breathing (D) risks hyperinflation with breath-holds. Current COPD Foundation guidelines prioritize pursed-lip breathing for acute dyspnea management over other techniques.
Question 7
A 68-year-old patient with COPD (FEV1 45% predicted) and BMI 32 is scheduled for elective laparoscopic cholecystectomy. During pre-op education, the patient reports smoking half a pack daily for 50 years. Which education focus is most critical to prevent postoperative complications?
- A) A) Techniques for incentive spirometer use every 2 hours while awake✓
- B) B) Instruction on sequential compression device application overnight
- C) C) Demonstration of proper splinting during cough and ambulation
- D) D) Guidance on protein-rich diet to support surgical wound healing
Show rationale
The COPD severity (FEV1 45%) and smoking history create high risk for atelectasis/pneumonia. Incentive spirometry directly addresses impaired gas exchange by promoting alveolar expansion, aligning with anesthesia/surgical impact on respiratory function in abdominal surgery. Option B is suboptimal as SCDs target DVT risk, not the primary respiratory threat. Option C, while useful, is less proactive than scheduled spirometry for preventing alveolar collapse. Option D is important but secondary; nutrition doesn't address the acute airway clearance need exacerbated by COPD and anesthesia. ATS/ACS guidelines prioritize lung expansion techniques for high-risk pulmonary patients.
Question 8
A 68-year-old with COPD and heart failure (ejection fraction 35%) is admitted for pneumonia. The pneumonia clinical pathway recommends aggressive IV fluids, but the nurse notes bilateral crackles and 3+ pitting edema. Which action aligns with standardized care principles for this patient?
- A) A) Administer IV fluids per pathway and increase oxygen flow rate
- B) B) Initiate IV diuretic therapy and restrict fluids to 1L/day✓
- C) C) Follow the pathway strictly but monitor respiratory status hourly
- D) D) Withhold IV fluids and consult the rapid response team immediately
Show rationale
Standardized pathways require individualization for comorbidities. Aggressive IV fluids (A) would worsen heart failure, evidenced by crackles and edema. Hourly monitoring (C) delays intervention. Rapid response (D) is unnecessary without acute instability. B aligns with HF guidelines: fluid restriction and diuresis address pulmonary congestion while managing pneumonia. COPD isn't contraindicated here. The cues (low EF, edema) prioritize HF management over the pneumonia pathway, demonstrating protocol adaptation for comorbidities.
Question 9
A 72-year-old patient with COPD (FEV1 45%) and osteoporosis is being discharged after pneumonia treatment. The patient lives alone in a split-level home, uses a rolling walker, and reports two falls last month. Which discharge planning action takes priority?
- A) A) Schedule home oxygen therapy delivery and pulse oximetry training
- B) B) Arrange physical therapy for stair negotiation techniques and balance exercises✓
- C) C) Coordinate Meals on Wheels for nutritional support three times weekly
- D) D) Provide written medication schedules for antibiotics and inhalers
Show rationale
The fall history combined with osteoporosis (fracture risk) and split-level home environment creates immediate safety concerns. Physical therapy directly addresses mobility safety, which must precede other interventions. Home oxygen (A) is important for COPD but doesn't address fall risks. Nutritional support (C) is secondary to safety. Medication education (D) is essential but less urgent than preventing falls in a high-risk environment. Safety-focused mobility training aligns with CMSRN standards for discharge planning with fall-prone patients.
Question 10
After administering vancomycin via port, the nurse notes blanching along the vein path and patient discomfort. A 0.5mL blood return is aspirated. Which action aligns with ONS guidelines for suspected extravasation?
- A) A) Stop infusion immediately and apply warm compresses
- B) B) Aspirate residual drug via the port before needle removal✓
- C) C) Continue infusion slowly while assessing for infiltration
- D) D) Administer hyaluronidase subcutaneously near the site
Show rationale
Blanching and pain suggest vesicant extravasation. Aspirating residual drug minimizes tissue damage, per ONS protocols. Option A delays aspiration. Option C risks further injury. Option D is for non-DNA-binding vesicants (e.g., vinca alkaloids), not vancomycin. Blood return doesn’t rule out extravasation due to partial occlusion. Prompt aspiration reduces toxin volume before needle withdrawal and cold application (indicated for vancomycin).
