N120 Respiratory AQ

The nurse is caring for a patient who has a nasogastric tube. What actions should the nurse perform to prevent aspiration in this patient? Select all that apply. 1 . Monitor gastric residual volumes. 2 . Feed the patient in a reclined position. 3 . Lower the head of the bed to 10 degrees. 4 . Elevate the head of the bed 30 to 45 degrees. 5 . Encourage the patient to sit upright for all meals.

1 . Monitor gastric residual volumes. 4 . Elevate the head of the bed 30 to 45 degrees. 5 . Encourage the patient to sit upright for all meals. Although the nasogastric tubes are small, there is an increased risk for aspiration pneumonia; to prevent it, the head of the bed should be elevated to 30 to 45 degrees, gastric residual volumes should be monitored, and the patient should be made to sit upright for all meals. Lowering the head of the bed and reclining while eating are not advisable because these positions can increase the risk of aspiration.

The nurse is assessing a patient in respiratory distress. The nurse knows that what is one of the two clinical methods to determine the efficiency of air transfer in the lung and tissue oxygenation? 1. Chest x-ray 2. Pulse oximetry 3. Respiratory rate 4. Sputum analysis

2. Pulse oximetry Pulse oximetry and the analysis of arterial blood gases (ABGs) are the two methods used to determine how well air is transferred. A chest x-ray and an analysis of sputum have no direct effect on the transfer of air effectiveness. A patient's respiratory rate does not affect air transfer.

Which structures are located in the lower respiratory tract? Select all that apply. 1 . Alveoli 2 . Larynx 3 . Bronchi 4 . Trachea 5 . Pharynx

1 . Alveoli 3 . Bronchi Alveoli and bronchi are structures found in the lower respiratory tract. With the exception of right and left mainstem bronchi, all lower airway structures are located in the lungs. The larynx, trachea, and pharynx are structures located in the upper respiratory tract.

The nurse is caring for a patient who is a smoker and is diagnosed with chronic obstructive pulmonary disease (COPD). Which sputum characteristics, if present in the patient, may need further evaluation? Select all that apply. 1 . Frothy 2 . Foul odor 3 . Pink tinged 4 . Brown specks 5 . Yellowish color

1 . Frothy 2 . Foul odor 3 . Pink tinged COPD may result in whitish to yellowish sputum, however, any change in the baseline characteristics of the sputum should be reported. Frothy sputum may indicate pulmonary edema and needs further evaluation. A foul odor in the sputum indicates presence of infection and needs immediate medical intervention. Pink-tinged sputum may indicate pulmonary edema and the patient may need further evaluation. Sputum with brown specks is a common finding in a person who smokes. Yellowish sputum is a normal finding in COPD.

On auscultation of a patient's lungs, which breath sounds would the nurse consider normal? Select all that apply. 1 . Loud, high-pitched sounds resembling air blowing through a hollow pipe 2 . Soft, low-pitched, gentle, rustling sounds heard over all lung areas except the major bronchi 3 . Medium-pitched sounds heard anteriorly over the mainstem bronchi on either side of the sternum 4 . The patient repeats the phrase "ninety-nine," and the words are easily understood and are clear and loud through the chest. 5 . The patient whispers "one-two-three," and the almost inaudible voice is transmitted clearly and distinctly.

1 . Loud, high-pitched sounds resembling air blowing through a hollow pipe 2 . Soft, low-pitched, gentle, rustling sounds heard over all lung areas except the major bronchi 3 . Medium-pitched sounds heard anteriorly over the mainstem bronchi on either side of the sternum Bronchial, vesicular, and bronchovesicular sounds are normal breath sounds. Bronchial sounds are loud and high-pitched and resemble air blowing through a hollow pipe. Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over all lung areas except the major bronchi. Bronchovesicular sounds are medium-pitched sounds heard anteriorly over the mainstem bronchi on either side of the sternum. Bronchophony is an abnormal breath sound and is considered positive (abnormal) if the patient repeats the phrase "ninety nine" and the words are easily understood and are clear and loud. Whispered pectoriloquy is also an abnormal breath sound and is considered positive (abnormal) when the patient whispers "one-two-three," and the almost inaudible voice is transmitted clearly and distinctly.

A patient with pleural effusion underwent transthoracic needle aspiration (TTNA). Despite having been given instructions to remain still, the patient moved when the needle was being inserted. To determine if a complication occurred, the nurse expects that which test will be prescribed? 1. Chest x-ray 2. Lung biopsy 3. MRI of lungs 4. CT of the lungs

1. Chest x-ray The most common complication after TTNA is pneumothorax, so an x- ray of the chest will be prescribed to check for air in the pleura. A chest x-ray is sufficient to diagnose pneumothorax, and a lung biopsy, MRI or CT of lungs is not required.

While auscultating the patient's lung fields, the nurse finds abnormal sounds and suspects a pleural friction rub. Which disease processes are associated with this assessment finding? Select all that apply. 1 . Pneumonia 2 . Cystic fibrosis 3 . Bronchospasm 4 . Pulmonary edema 5 . Pulmonary infarction

1 . Pneumonia 5 . Pulmonary infarction Pleural friction, characterized by a creaking or grating sound during inspiration or expiration, is caused by roughened, inflamed pleural surfaces rubbing together. Pneumonia and pulmonary infarction can lead to pleural friction. Cystic fibrosis causes continuous rumbling, snoring, or rattling sounds when rhonchi obstruct large airways. Wheezes are present in the patient with bronchospasm. Pulmonary edema is associated with coarse crackles caused by air passing through the airway when it is intermittently occluded by mucus.

The nurse is conducting an admission assessment on a patient with a history of mental illness who has been experiencing hypoxia. What cognitive changes are characteristic of a patient having hypoxia? Select all that apply. 1 . Restlessness 2 . Apprehension 3 . Improved mood 4 . Memory changes 5 . Pursed-lip breathing 6 . Improved concentration

1 . Restlessness 2 . Apprehension 4 . Memory changes A patient who is hypoxic may have neurologic symptoms that include apprehension, restlessness, memory changes, poor sleep patterns, irritability, and poor concentration. Mood will worsen rather than improve. Pursed lip breathing is not a cognitive symptom.

The nurse is conducting a health history interview with a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which question is appropriate when assessing the patient's nutritional-metabolic pattern? 1. "Have you lost any weight recently?" 2. "Do you have trouble getting to the toilet?" 3. "Does your breathing wake you up in the night?" 4. "Do you have any pain associated with breathing?"

1. "Have you lost any weight recently?" When assessing the effect of COPD on the patient's nutritional-metabolic pattern, the nurse should ask if the patient has experienced any weight loss. Asking about trouble getting to the toilet assesses the effect that COPD has on the patient's elimination patterns. Asking the patient about waking in the middle of the night with breathing issues assesses the patient's sleep-rest pattern. Asking the patient about pain associated with breathing assesses the patient's cognitive-perceptual pattern.

The nurse is caring for the patient with a productive cough. The nurse collects a sputum specimen for an acid-fast bacillus (AFB) smear. What collection time by the nurse is most appropriate? 1. 6 AM 2. 12 noon 3. 6 PM 4. 9 PM

1. 6 AM The correct answer is 6 AM because if the patient has a productive cough, early morning is the ideal time to collect sputum specimens for an AFB smear because secretions collect during the night. Twelve noon, 6 PM, and 9 PM are incorrect because all of these times are afternoon or evening hours and the amount of secretions for the specimen may not be optimal.

The nurse is assessing a patient with a pneumothorax. The nurse expects to note which type of fremitus? 1. Absent fremitus 2. Normal fremitus 3. Increased fremitus 4. Decreased fremitus

1. Absent fremitus In a patient with pneumothorax, the nurse would find absent fremitus. Decreased fremitus may be found in pleural effusion when the hand is farther from the lung, and in barrel chest where the lung is hyperinflated. Increased fremitus is found in pneumonia, in lung tumors, with thick bronchial secretions, and above a pleural effusion. As the patient's voice moves through a dense tissue or fluid-filled lungs, the vibration is increased.

A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? 1. Anxiety 2. Cyanosis 3. Bradycardia 4. Hypercapnia

1. Anxiety An early manifestation during an asthma attack is anxiety, because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH because he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.

A patient with a history of epilepsy is admitted to the hospital for treatment of fever and shortness of breath. The patient is diagnosed with pneumonia. On taking history, the nurse finds that the patient had a seizure four days ago with profuse vomiting. What type of pneumonia does the patient have? 1. Aspiration pneumonia 2. Opportunistic pneumonia 3. Hospital-associated pneumonia 4. Community-acquired pneumonia

1. Aspiration pneumonia A patient who has seizures is at risk of developing aspiration pneumonia. The gastric contents enter the respiratory tract during the seizure and damage the lung tissue. Therefore this is the most probable reason for the patient's symptoms. The history of the patient does not suggest any exposure to pneumonia in the community. The patient has never been in the hospital; therefore, hospital-associated pneumonia is highly unlikely. The patient does not have a history of HIV, intake of immunosuppressive drugs, corticosteroids, or any disorders leading to immunosuppression. Therefore opportunistic pneumonia did not occur in this patient.

Which finding indicates to the nurse that a patient's respiratory status is improving following an acute asthma exacerbation? 1. Audible wheezing 2. Pursed lip breathing 3. Use of intercostal muscles 4. Oxygen saturation 89% of room air

1. Audible wheezing The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Pursed lip breathing does not correlate with asthma improvement. The use of intercostal muscles and an oxygen saturation of 89% are evidence of continued asthma exacerbation.

A patient is prescribed albuterol with a metered dose inhaler (MDI). After taking the cap off and shaking the inhaler, the nurse should instruct the patient to perform the steps of taking the medication in what order? 1. Breathe out completely. 2. Hold the inhaler straight. 3. Press down the inhaler. 4. Breathe slowly through mouth. 5. Hold the breath for 10 seconds. 6. Wait for one minute after every puff.

1. Breathe out completely. 2. Hold the inhaler straight. 4. Breathe slowly through mouth. 3. Press down the inhaler. 5. Hold the breath for 10 seconds. 6. Wait for one minute after every puff. After taking the cap off the medicine and shaking the inhaler, the patient breathes out all the air from the lungs and holds the inhaler as recommended. Then, the patient should start breathing in slowly through the mouth by pressing down the inhaler. With five seconds, the patient should start breathing slowly and deeply. The patient should hold the breath for 10 seconds or more as much as possible. This should be repeated three to four times for better relief. The patient has to wait about one minute between puffs to avoid local irritation caused by the drug.

Which defense mechanism is effective for removing secretions in the main airways? 1. Cough reflex 2. Mucociliary escalator 3. Alveolar macrophages 4. Reflex bronchoconstriction

1. Cough reflex The cough reflex is a protective reflex action that clears the airway by a high pressure, high velocity flow of air. Coughing is effective in removing secretions in the main airways. Below the larynx, movement of mucus is accomplished by the mucociliary clearance system or the mucociliary escalator. Secretions below the subsegmental level must be moved upward by the mucociliary escalator before they can be removed by coughing. Alveolar macrophages rapidly phagocytize foreign particles, such as bacteria. The debris is moved by the cilia in the bronchi for removal. Reflex bronchoconstriction is a protective mechanism, triggered by inhaling irritating substances.

When assessing a patient's sleep-rest pattern related to respiratory health, about what should the nurse ask the patient? Select all that apply. 1. Do you have trouble falling asleep? 2. Do you need to urinate during the night? 3. Do you awaken abruptly during the night? 4. Do you sleep more than eight hours per night? 5. Do you need to sleep with the head elevated?

1. Do you have trouble falling asleep? 3. Do you awaken abruptly during the night? 5. Do you need to sleep with the head elevated? The patient with sleep apnea may have insomnia or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than eight hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

A nurse is caring for a pediatric patient who has experienced a cough, clear and watery sputum, headache, and muscle aches for the past two weeks. The nurse auscultates wheezes during expiration. There is no other abnormality found. The patient's parent asks why an antibiotic has not been prescribed. How should the nurse respond? 1. Explain that antibiotics are not required for the patient. 2. Advise the parent to see another health care provider for a second opinion. 3. Explain that the child needs anticancer treatment and antibiotics will not help. 4. Explain that antibiotics will be prescribed if the cough persists for two more days.

1. Explain that antibiotics are not required for the patient. The symptoms and signs indicate that the patient may have acute bronchitis, which is a viral disorder. Therefore the nurse should explain to the father that antibiotics will not help in viral infections. If they are prescribed, antibiotics may cause side effects and may also lead to antibiotic resistance. It is incorrect to advise the father to see another health care provider who will do the same. It is also inappropriate to tell him that his child needs anticancer treatment. Acute bronchitis is a self-limiting disorder, and cough may last up to three weeks. Informing the father that antibiotics will be prescribed if the cough persists for two more days is not correct.

A patient with pneumonia is being treated at home and has reported fatigue to the nurse. What instructions should the nurse include when teaching the patient about care and recovery at home? Select all that apply. 1. Get adequate rest. 2. Restrict fluid intake. 3. Avoid alcohol and smoking. 4. Resume work to build strength. 5. Take every dose of the prescribed antibiotic.

1. Get adequate rest. 3. Avoid alcohol and smoking. 5. Take every dose of the prescribed antibiotic. To ensure complete recovery after pneumonia, the patient should be advised to rest, avoid alcohol and smoking, and take every dose of the prescribed antibiotic. The patient should not resume work if feeling fatigued and should be encouraged to drink plenty of fluids during the recovery period.

A patient began taking antitubercular drugs a week ago. The nurse reviews the patient's medical record and learns that the patient has a 10-year history of consuming one standard drink of alcohol three times a week. The patient states, "In the last week, my urine turned orange and I am very worried about it." How should the nurse respond? 1. Inform the patient that it is one of the side effects of the antitubercular drug rifampin. 2. Recognize that the tuberculosis may have spread to the liver and further medical consultation is required. 3. Recognize that the liver may be damaged due to alcohol, and so a liver function test should be performed. 4. Instruct the patient to stop taking antitubercular drugs immediately and consult the primary health care provider.

1. Inform the patient that it is one of the side effects of the antitubercular drug rifampin. A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. It may also cause hepatitis. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. However, it is highly unlikely that tuberculosis has spread to the liver. The alcohol intake of the patient is within normal limits, and so it is not correct to say that alcohol may have damaged the liver. It is also inappropriate to advise the patient to stop taking antitubercular drugs.

The nurse is completing a respiratory assessment on a recently admitted patient who uses oxygen at home. What information does the nurse need to obtain and document on the patient? Select all that apply. 1. Liter flow 2. Home safety practices 3. Method of payment for oxygen services 4. What agency supplies the oxygen services 5. Method and effectiveness of administration 6. Fraction of inspired oxygen concentration (FIO2)

1. Liter flow 2. Home safety practices 5. Method and effectiveness of administration 6. Fraction of inspired oxygen concentration (FIO2) How the patient administers the oxygen and its effectiveness, home use, liter flow and FIO2 value need to be determined and documented. It is also important to find out what home safety practices are followed. What oxygen service the patient uses and the patient's method of payment are not necessary to determine in the admission assessment.

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? 1. Monitor the patient for laryngeal edema. 2. Monitor and manage the patient's level of pain. 3. Assess the patient's level of consciousness (LOC). 4. Assess the patient's heart rate and blood pressure.

1. Monitor the patient for laryngeal edema. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of LOC, pain, heart rate, and blood pressure, although the nurse should be assessing these also.

The nurse cares for an immunocompetent patient. Which clinical manifestation is most indicative of pulmonary tuberculosis? 1. Mucopurulent sputum 2. Diarrhea and fatigue 3. Lymph node enlargement 4. Hematuria and dehydration

1. Mucopurulent sputum A cough that progresses in frequency and produces mucoid or mucopurulent sputum is the most common symptom of pulmonary tuberculosis (TB). Diarrhea, hematuria, and dehydration are manifestations not directly associated with pulmonary TB. Fatigue and lymph node enlargement may be seen with TB but are not as indicative as is the production of mucopurulent sputum.

The nurse is caring for a patient with a pleural effusion. What nursing interventions are appropriate when preparing this patient for a thoracentesis? Select all that apply. 1. Obtain chest x-ray after the procedure. 2. Ensure that the informed consent was signed. 3. Instruct the patient to cough vigorously during the procedure. 4. Instruct the patient not to eat anything for four hours before the procedure. 5. Position patient upright with elbows on an over bed table with feet supported.

1. Obtain chest x-ray after the procedure. 2. Ensure that the informed consent was signed. 5. Position patient upright with elbows on an over bed table with feet supported. For a thoracentesis, the nurse should ensure that the patient's informed consent was signed. The patient should be positioned upright with elbows on an over-bed table and feet supported. This position gives appropriate access for needle insertion. A chest x-ray is obtained after the procedure to rule out a pneumothorax. The patient should be instructed not to talk or cough during the procedure, because it can cause injury by displacement of the needle. NPO status, or withholding food and drink, is not required for thoracentesis.

Patient A: Enalapril Patient B: Furosemide Patient C: Atenolol Patient D: Metoprolol The nurse reviews the medication records of several patients with hypertension. Which patient is likely to have a severe cough? 1. Patient A 2. Patient B 3. Patient C 4. Patient D

1. Patient A When monitoring patients, the nurse should be aware of the side effects associated with each patient's prescribed medications. Patient A is taking angiotensin-converting enzyme inhibitors, such as enalapril, to treat hypertension, but they may cause coughing in the patient. The medication may have to be changed if the cough is severe. Patient B is taking furosemide, which is a diuretic that can lower blood pressure, but is not known to cause coughing. Patient C is taking atenolol and Patient D is taking metoprolol, which are both beta-blockers that are not known to cause coughing.

The health care provider requests a computed tomography (CT) scan for a patient suspected of having a mediastinal mass. What should the nurse assess prior to the test? Select all that apply. 1. Serum creatinine 2. Blood sugar levels 3. Blood hemoglobin levels 4. Blood urea nitrogen (BUN) 5. Hypersensitivity to shellfish

1. Serum creatinine 4. Blood urea nitrogen (BUN) 5. Hypersensitivity to shellfish The CT scan involves administering a contrast agent; therefore the nurse should assess the renal function to determine the safety of contrast administration. The renal function can be assessed by checking the laboratory values of BUN and serum creatinine. The contrast agent is usually an iodine-based compound; therefore the nurse should also check if the patient is hypersensitive to shellfish, because it contains iodine. Checking blood sugar levels and hemoglobin levels are important, but not necessary prior to a CT.

The nurse is caring for an African patient who is rescued from a fire. As a part of the treatment, the nurse places a pulse oximeter on the patient, and finds the reading to be 78%. Considering it to be an inaccurate reading, the nurse changes the position of the pulse oximeter; however, the reading still is 78%. What factors may cause the pulse oximeter to have an inaccurate reading? Select all that apply. 1. The patient has darker skin. 2. The patient has methemoglobinemia. 3. The patient has an Hgb level of 8.0 mg/dL 4. The patient has soft, pink-colored fingernails. 5. The patient has a blood sugar level 120 mg/dL.

1. The patient has darker skin. 2. The patient has methemoglobinemia. 3. The patient has an Hgb level of 8.0 mg/dL Pulse oximetry helps to measure arterial oxygen saturation (SpO2) through a probe, which can be placed on the finger, toe, ear, or bridge of the nose. SpO2 readings may be inaccurate in a patient with dark skin because the skin color can interfere with transmission of signals from the pulse oximeter to the body tissues. Methemoglobinemia can occur as a result of breathing gases during fire accidents. This form of hemoglobin has less capacity for carrying oxygen and may interfere with the results of the oximeter. An Hgb level of 8.0 mg/dL indicates anemia, which may interfere with the results of pulse oximetry, because there would be lower levels of the hemoglobin protein to carry oxygen. Soft, pink fingernails are a normal finding in patients, regardless of skin tone, and should not interfere with the SpO2 results. Nails with thick acrylic fingernail polish, however, may not yield accurate results. Blood sugar levels do not interfere with SpO2 results.

A patient is diagnosed with a mass on the right side of the neck. What physical change does the nurse find during a physical examination of this patient? 1. The trachea is deviated to the left. 2. The trachea is deviated to the right. 3. The chest expansion is asymmetrical. 4. The diaphragm is unable to contract smoothly.

1. The trachea is deviated to the left. A mass in the neck may cause tracheal diversion to the opposite side of the mass. Therefore if the patient has a neck mass in the right side, the nurse is likely to find tracheal deviation to the left side, away from the mass, during palpation. The tracheal deviation would be to the right side, or toward the mass, in the case of lobar atelectasis. The nurse is not likely to see any effect on the patient's chest expansion or diaphragm movement because a neck mass would be at a higher anatomical level. Chest expansion would be asymmetrical in instances of atelectasis or a collapsed lung. The diaphragm would be dysfunctional in the instance of phrenic nerve injury.

During the respiratory assessment of the older adult, the nurse would expect to find which of these changes? Select all that apply. 1. Thicker mucus 2. Normal PaO2 and SaO2 3. Decreased chest wall movement 4. Increased breath sounds in the lung apices 5. Diminished breath sounds, particularly at lung bases

1. Thicker mucus 3. Decreased chest wall movement 5. Diminished breath sounds, particularly at lung bases Changes in the respiratory system in the older adult include thickened mucus, decreased chest wall movement, and diminished breath sounds, especially at the lung bases. The PaO2 and SaO2 levels are decreased.

Which questions are appropriate when assessing the effects of the patient's respiratory diagnosis on activity-exercise patterns? Select all that apply. 1 . "Are you ever incontinent of urine when you cough?" 2 . "Do you have trouble walking due to shortness of breath?" 3 . "Does your spouse wake you in the middle of the night due to snoring?" 4 . "How many flights of stairs can you walk up before you are short of breath?" 5 . "Do you ever feel full very quickly when eating due to your breathing issues?"

2 . "Do you have trouble walking due to shortness of breath?" 4 . "How many flights of stairs can you walk up before you are short of breath?" When assessing the effects that a respiratory diagnosis has on activity-exercise patterns, the nurse will ask the patient if walking is impacted by dyspnea and how many flights of steps the patient can walk up before dyspnea occurs. Asking the patient about urinary incontinence with coughing is appropriate when assessing elimination patterns. Asking the patient if the spouse wakes him or her up in the middle of the night due to snoring will assess sleep-rest patterns. Asking the patient if he or she feels full quickly when eating assesses the patient's nutritional-metabolic pattern.

A senior nurse is teaching nursing students to auscultate for adventitious sounds. One of the students auscultates a pleural friction rub. What are the common conditions in which a pleural friction rub is present? Select all that apply. 1 . Asthma 2 . Pleurisy 3 . Bronchitis 4 . Pneumonia 5 . Pulmonary infarct

2 . Pleurisy 4 . Pneumonia 5 . Pulmonary infarct The most common conditions presenting with pleural rub are pleurisy, pneumonia, and pulmonary infarct. Pleural rub is caused by the rubbing together of the two layers of the lungs. Asthma and bronchitis present with wheezes and do not manifest as pleural rub.

When assessing the patient with acute respiratory distress, what should the nurse expect to observe? Select all that apply. 1 . Cyanosis 2 . Tripod position 3 . Kussmaul respirations 4 . Accessory muscle use 5 . Increased anterior-posterior (AP) diameter

2 . Tripod position 4 . Accessory muscle use Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disorder (COPD), cystic fibrosis, or with advanced age.

A patient had an intradermal tuberculin skin test (Mantoux) administered 48 hours ago. The nurse assesses the injection site and identifies a 12-mm area of palpable induration. How should the nurse interpret this result? 1. Definitive evidence that the patient does not have tuberculosis 2. A significant indication that the patient has been exposed to tuberculosis 3. Delayed hypersensitivity with a high likelihood of infection with tuberculosis 4. A negative test that cannot be interpreted as ruling out the presence of tuberculosis

2. A significant indication that the patient has been exposed to tuberculosis An area of 12 mm of induration at the injection site 48 hours after a Mantoux test is considered significant for a past or current tuberculin infection. An induration of less than 5 mm is considered a negative result. The other answer options are incorrect conclusions related to the findings.

A patient presents to the emergency department with sudden-onset wheezing and coughing with progressive respiratory distress. What condition or diagnosis does the nurse recognize? 1. Acute bronchitis 2. An asthma attack 3. Pulmonary edema 4. Congestive heart failure

2. An asthma attack A sudden onset of coughing and wheezing are the initial and most obvious symptoms of an acute asthma attack. An asthma attack may begin mildly but progress to respiratory distress and arrest if it goes untreated. Acute bronchitis is irritation and inflammation of the mucous-membrane lining of the respiratory tract, usually caused by an infectious agent. Pulmonary edema is fluid accumulation in the lungs due to heart failure or lung injury. The fluid collection impairs gas exchange and may result in respiratory failure. Congestive heart failure, or heart failure, is a condition in which the heart cannot pump effectively. Fluid may accumulate in the lungs. Edema may develop in the lower extremities, and shortness of breath may also occur with increasing frequency and severity.

A patient presents with a lung abscess. What treatment option would be the most appropriate? 1. Postural drainage 2. Antibiotic treatment 3. Chest physiotherapy 4. Reduction of fluid intake

2. Antibiotic treatment Because there are mixed bacteria in a lung abscess, starting a broad spectrum antibiotic is the appropriate treatment option. Postural drainage and chest physiotherapy are not recommended because they may cause spillage of infection to other bronchi and spread the infection. Reducing fluid intake is not advisable; instead, adequate fluid intake is recommended.

A patient with asthma who has undergone a total hip replacement complains on the third postoperative day of shortness of breath and slight chest pain and notes that "something is wrong." Temperature is 98.8° F, blood pressure 168/98 mm Hg, pulse 96, respirations 32, and oxygen saturation is 89% on room air. What is the priority nursing action? 1. Notify the health care provider and document the vital signs. 2. Apply oxygen and place the patient in a semi-Fowler's position. 3. Obtain an electrocardiogram (ECG) and administer albuterol nebulizers. 4. Administer the prescribed antihypertensive medication and reassess in 15 minutes.

2. Apply oxygen and place the patient in a semi-Fowler's position. The patient's clinical picture is consistent with pulmonary embolus, and the first action the nurse should take is to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the health care provider. An antihypertensive or an ECG may be prescribed at a later time; however, the priority is airway, breathing, and circulation. The health care provider should be notified after the nurse has assessed the patient.

The nurse is performing a pulmonary function test on a patient. Which nursing intervention is beneficial to the patient? 1. Scheduling the test after a meal 2. Assessing for respiratory distress 3. Providing rest before the procedure 4. Administering an inhaled bronchodilator six hours before the procedure

2. Assessing for respiratory distress It is appropriate to assess patients for respiratory distress during pulmonary function tests. The nurse would avoid scheduling the procedure after a meal. It is important that the nurse provide rest for the patient after the procedure, but not necessarily before. Similarly, the nurse would avoid administering an inhaled bronchodilator for six hours before, not after, the procedure.

The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be because of what occurring? 1. Pain 2. Atelectasis 3. Pneumonia 4. Pleural effusion

2. Atelectasis Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case

The nurse is preparing the patient for a diagnostic procedure to remove a mucus plug. The nurse would prepare the patient for which test? 1. Thoracentesis 2. Bronchoscopy 3. Pulmonary angiography 4. Sputum culture and sensitivity

2. Bronchoscopy Bronchoscopy is a procedure in which the bronchi are visualized through a fiberoptic tube. Bronchoscopy may be used for diagnostic purposes to obtain biopsy specimens and assess results of treatment, and also is used for treatment, such as removing mucus plugs or foreign bodies. Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Pulmonary angiography is performed to visualize pulmonary vasculature and locate obstruction or pathologic conditions (e.g., pulmonary embolus). Sputum culture and sensitivity tests are done to identify infectious organisms and the appropriate drug treatment.

The patient is calling the clinic complaining of a cough. What assessment should be made first before the nurse advises the patient? 1. Weight loss, activity tolerance, and orthopnea 2. Cough sound, sputum production, and pattern 3. Frequency, a family history, and hematemesis 4. Smoking, medications, and residence location

2. Cough sound, sputum production, and pattern The sound of the cough, sputum production, and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and is not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive lung disease (COPD) and lung cancer and may cause a cough. Medications may or may not contribute to a cough as well as residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.

The nurse is taking a health history of a patient with respiratory distress. The nurse knows that which respiratory problem has a strong genetic link? 1. Tuberculosis 2. Cystic fibrosis 3. Multiple sclerosis 4. Pulmonary fibrosis

2. Cystic fibrosis Respiratory problems that have a strong genetic link include cystic fibrosis, chronic obstructive pulmonary disease (COPD) resulting from α1-antitrypsin deficiency, and asthma. If people have a family history of these respiratory problems, they have a much greater risk of developing them. A family history of tuberculosis, pulmonary fibrosis, and multiple sclerosis indicates no increased risk for a person to develop one of those diseases.

The nurse is conducting a respiratory assessment on a patient diagnosed with asthma. Which assessment finding indicates the patient is experiencing airway irritation? 1. Hemoptysis 2. Dry, hacking cough 3. Harsh, barky cough 4. Loose-sounding cough

2. Dry, hacking cough A dry, hacking cough indicates the patient is experiencing airway irritation or obstruction. Hemoptysis often occurs with tuberculosis and does not indicate airway irritation. A harsh, barky cough suggests upper airway obstruction. A loose-sounding cough indicates secretions.

A patient with asthma experiences anaphylaxis. Which medication should the nurse prepare to administer? 1. Timolol 2. Epinephrine 3. Magnesium sulfate 4. Sodium bicarbonate

2. Epinephrine Epinephrine helps to resolve anaphylactic reactions in the patient with asthma. Administer epinephrine either subcutaneously or intramuscularly to treat the patient. The nurse should monitor the blood pressure and electrocardiogram of the patient closely after administration of the drug. Timolol is a beta-blocker that may trigger the symptoms of asthma in the patient. Magnesium sulfate helps to treat the patient with severe or life threatening asthma. Sodium bicarbonate helps to treat severe metabolic or respiratory acidosis.

The nurse is assessing a patient diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1. Wheezing 2. Hemoptysis 3. Gray sputum 4. Slightly whitish sputum

2. Hemoptysis Tuberculosis is characterized by hemoptysis, which is the act of coughing up blood or blood-tinged sputum from the respiratory tract. Wheezing is the term used to describe the musical sounds auscultated during assessment; it indicates some degree of airway obstruction that occurs with asthma and emphysema. Grey sputum often occurs in patients who smoke cigarettes. Clear sputum, slightly whitish sputum, and viscous sputum are often normal findings.

After the inhalation of puffs of mometasone, a patient develops oropharyngeal candidiasis, hoarseness and dry cough. What action should the nurse take to reduce the symptoms? 1. Recommend that the patient pauses between the puffs 2. Instruct the patient to rinse the mouth with water after inhalation 3. Assist the patient in obtaining a spacer or holding device for inhalation 4. Wait until the cough subsides before administering the patient's next dose

2. Instruct the patient to rinse the mouth with water after inhalation Upon inhalation into the pharynx, mometasone may cause local irritation such as oropharyngeal candidiasis, hoarseness, and dry cough. Hence the patient should rinse the mouth either with water or with mouthwash after inhalation. The patient may not be benefit by pausing between the puffs. Asking the patient to use a spacer or holding device for inhalation of corticosteroids can be helpful in getting more medication into the lungs. However, it does not reduce the symptoms of candidiasis. The next dose is given to the patient only upon further advice from the practitioner.

A patient with lung cancer reports chest pain. The nurse assesses the patient and finds the pain to be related to pleural effusion. What could be the reason for the development of pleural effusion in this patient? 1. Allergic reaction to chemotherapy 2. Lymphatic drainage blocked by malignant cells 3. Bacterial infection due to compromised immunity 4. Increased blood pressure (BP) due to malignancy

2. Lymphatic drainage blocked by malignant cells The most common cause for the development of pleural effusion in the patient suffering from malignancy is lymphatic drainage blocked by malignant cells. Bacterial infection is unlikely in the absence of other signs. An allergic reaction may not lead to pleural effusion. Malignancy is not the cause of raised BP.

Which assessment finding does the nurse expect when caring for a patient with asthma? 1. pH of 5.11 2. PaCO2 of 30 mm Hg 3. Blood pressure of 110/60 mm Hg 4. Respiratory rate of 25 breaths/minute

2. PaCO2 of 30 mm Hg The patient with acute asthma may reveal signs of hypoxemia and hyperventilation due to air flow limitation, indicated by a low level of partial pressure of carbon dioxide in blood (PaCO2), such as 30 mmHg. This condition leads to a rise in pH leading to respiratory alkalosis; however, a pH of 5.11 is low. The respiratory rate of the asthmatic patient increases to more than 30 breaths/minute due to the use of accessory muscles. The patient with anxiety due to breathlessness has an increase in pulse and blood pressure.

Which interconnected structure allows the movement of air between the alveoli? 1. Bronchioles 2. Pores of Kohn 3. Visceral pleura 4. Parietal pleura

2. Pores of Kohn The alveoli are interconnected by the pores of Kohn, which allow the passage of air from alveolus to alveolus. The main stem bronchi subdivide to form the lobar, segmental, and subsegmental bronchi. Further divisions form bronchioles, which cause bronchoconstriction and bronchodilation. Lungs are lined by a membrane called the visceral pleura. The chest cavity is lined with a membrane called the parietal pleura.

The nurse is monitoring a patient who is having a thoracentesis for recurrent pleural effusion. Which of these assessment findings would be of most concern? 1. Removal of 1000 mL of pleural fluid 2. Restlessness and sudden complaint of dyspnea 3. SpO2 reading of 96% while on 2 L/minute of oxygen 4. Patient complaint of pressure at the needle insertion site

2. Restlessness and sudden complaint of dyspnea During and after a thoracentesis, monitor the patient's vital signs and pulse oximetry and observe the patient for any manifestations of respiratory distress, which may indicate a possible complication, such as pneumothorax or pulmonary edema. It is not unusual to remove up to 1000 to 1200 mL of pleural fluid at one time. The SpO2 reading of 96% and patient complaint of pressure at the needle insertion site are not abnormal findings.

A patient undergoes bronchoscopy. Before allowing the patient to begin oral intake of food and fluids, for what should the nurse assess the patient? 1. Stable vital signs 2. Return of gag reflex 3. Brisk pupil reaction to light 4. Clear bilateral breath sounds

2. Return of gag reflex A patient who is given food or fluid before the gag reflex returns may aspirate food or drink and possibly experience respiratory distress as a result. Vital signs, pupil reaction, and breath sounds are routine assessments after a procedure such as a bronchoscopy, but they are secondary to assessing the patient for the return of the gag reflex.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, the nurse will verify that which health care provider prescriptions have been completed before administering a dose of cefuroxime to the patient? 1. Pulmonary function evaluation 2. Sputum culture and sensitivity 3. Orthostatic blood pressures (BP) 4. Serum laboratory studies prescribed for the morning

2. Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime, because this is community-acquired pneumonia. It is important that the organisms are identified correctly (by the culture) before the antibiotic takes effect. The test also will determine whether the proper antibiotic has been prescribed (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

A patient is admitted to the hospital with cyanosis, dyspnea, and tachycardia. On examination, the nurse finds that the patient is sweating and has cold, clammy skin. What is the priority nursing action? 1. Start a glucose drip. 2. Start oxygen therapy. 3. Administer IV mannitol. 4. Administer antihistamines.

2. Start oxygen therapy. The patient is showing signs and symptoms of inadequate oxygenation. Therefore the first thing that the nurse must do is start oxygen therapy immediately. All the other actions are secondary and performed only if required. Mannitol should be administered if the intracranial pressure (ICT) is raised. Glucose drips are given to increase the intravascular volume. Antihistamines are administered if there is an allergy.

What is the cause of atelectasis? 1. Platelet deficiency 2. Surfactant deficiency 3. Red blood cell deficiency 4. White blood cell deficiency

2. Surfactant deficiency Surfactant is a lipoprotein that lowers the surface tension in the alveoli and reduces the amount of pressure needed to inflate the alveoli, making them less likely to collapse. Therefore the primary reason that atelectasis occurs is due to a surfactant deficiency. Deficiencies in platelets, red blood cells, and white blood cells do not cause atelectasis.

A nurse is caring for a patient with a diagnosis of pulmonary edema. On admission, the patient's arterial blood gas (ABG) analysis revealed a PaO2 of 50 mm Hg, and a PaCO2 of 25 mm Hg. The patient has been in the hospital for 15 days. A recent ABG analysis reveals a PaO2 of 90 mm Hg, a PaCO2 of 42 mm Hg, and a pH of 7.4. What do these measurements indicate? 1. The patient's health is deteriorating. 2. The patient has shown improvement. 3. The patient will develop respiratory failure. 4. The patient has shown no signs of improvement.

2. The patient has shown improvement. The patient has shown improvement, because the observed values of pH of 7.4, PaO2 of 90 mm of Hg, and PaCO2 of 42 mm Hg are normal values. Because they are normal values, they do not indicate that the patient is deteriorating in health or developing respiratory failure. They also do not indicate that the patient has shown no improvement.

Which diagnostic procedure is used to remove pleural fluid for analysis? 1. Lung biopsy 2. Thoracentesis 3. Bronchoscopy 4. Sputum studies

2. Thoracentesis Thoracentesis is a diagnostic procedure used to remove pleural fluid for analysis or to instill medication. A lung biopsy is used to obtain specimens for laboratory analysis. A bronchoscopy involves the use of a flexible fiberoptic scope for diagnosis, biopsy, or specimen collection. Samples for sputum studies are obtained by expectoration and tracheal suction.

A patient who was injured playing football presents to the emergency department (ED). During the assessment, the nurse is palpating the patient's chest. Which finding is a medical emergency? 1. Increased tactile fremitus 2. Trachea moved to the left 3. Decreased tactile fremitus 4. Diminished chest movement

2. Trachea moved to the left Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.

Which would the nurse assess when using palpation during a respiratory assessment? 1. Lung density 2. Tracheal position 3. Adventitious sounds 4. Bronchovesicular sounds

2. Tracheal position Palpation is used to determine tracheal position. Auscultation is used to determine breath sounds, both normal (bronchovesicular) and adventitious. Percussion is used to assess lung density.

A patient has been admitted to the emergency department after complaining of having difficulty breathing for several days. To detect late manifestations of inadequate oxygenation, the nurse would examine the patient for which of these? Select all that apply. 1. Mild hypertension 2. Use of accessory muscles 3. Apprehension and restlessness 4. Cyanosis and cool, clammy skin 5. Pausing for breath between sentences and words

2. Use of accessory muscles 4. Cyanosis and cool, clammy skin 5. Pausing for breath between sentences and words Late manifestations of inadequate oxygenation include use of accessory muscles; cyanosis and cool, clammy skin; and pausing for breath between sentences and words. Mild hypertension, apprehension, and restlessness are early manifestations of inadequate oxygenation.

A patient admitted with respiratory problems is scheduled for a positron emission tomography (PET) scan. The patient asks the nurse what this test is for. What is the most appropriate answer given by the nurse? 1. Used to assess ventilation and perfusion of lungs. 2. Used to distinguish benign and malignant nodules. 3. Used to visualize pulmonary vasculature and locate obstruction. 4. Used to diagnose lesions difficult to see by computed tomography (CT) scan.

2. Used to distinguish benign and malignant nodules. PET scans use an intravenous (IV) radioactive glucose preparation to demonstrate increased uptake of glucose in malignant lung cells. A ventilation/perfusion (VQ) scan is used to assess ventilation and perfusion of lungs, such as with a PET. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction. A magnetic resonance imaging (MRI) test is used to diagnose lesions difficult to assess by CT scan.

A patient is brought to the emergency department with chest tightness and acute dyspnea after an afternoon of gardening. As the nurse auscultates the patient's lungs, which finding would indicate a need for asthma testing? 1. Rhonchi 2. Wheezes 3. Fine crackles 4. Coarse crackles

2. Wheezes Asthma involves bronchospasms, which can be triggered by many factors including pollens inhaled during outdoor activities such as gardening. Wheezes are continuous, high-pitched squeaking or musical sounds caused by the rapid vibration and narrowing of bronchial walls. If the patient has wheezing sounds during auscultation, it indicates the patient may have asthma. Rhonchi sounds are continuous rumbling, snoring, or rattling sounds caused by obstruction of large airways with secretions. This would be seen in instances of cystic fibrosis. Fine crackles are series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration, as seen in cases of pulmonary fibrosis and interstitial edema. Coarse crackles are long-duration, discontinuous, and low-pitched, and they are usually caused by air passing through an airway intermittently occluded by mucus, unstable bronchial walls, or folds of mucosa. Coarse crackles can be heard in conditions such as heart failure and pulmonary edema.

The patient with human immunodeficiency virus (HIV) has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when the patient makes which statement? 1. "I will be given amphotericin B to treat the fungus." 2. "I got this fungus because I am immunocompromised." 3. "I need to be isolated from my family and friends so they won't get it." 4. "The effectiveness of my therapy can be monitored with fungal serology titers."

3. "I need to be isolated from my family and friends so they won't get it." The patient with an opportunistic fungal infection does not need to be isolated because Candida albicans is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with intravenous amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

The nurse determines that additional discharge teaching is needed for a patient with pneumonia when the patient states what? 1. "I will take all medications as prescribed." 2. "Breathing exercises may help prevent future infections." 3. "I should take antibiotics for all upper respiratory infections." 4. "I will seek medical attention if I develop a fever or productive cough."

3. "I should take antibiotics for all upper respiratory infections." Antibiotics are not indicated for all upper respiratory tract infections. It is important for the patient to continue with coughing and deep-breathing exercises for at least six weeks, until all of the infection has cleared from the lungs. The patient should take all medications as prescribed and seek medical attention for signs or symptoms of new infection.

Which is the term used to describe abnormal breath sounds? 1. Vesicular 2. Bronchial 3. Adventitious 4. Bronchovesicular

3. Adventitious Adventitious is the term used to describe abnormal breath sounds such as crackles, rhonchi, wheezes, and a pleural friction rub. The three normal breath sounds are vesicular, bronchovesicular, and bronchial sounds. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched; they resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard anteriorly over the main stem bronchi on either side of the sternum and posteriorly between the scapulae.

When can airborne infection isolation for a patient with pulmonary tuberculosis (TB) be discontinued? 1. Once isoniazid drug therapy has been initiated 2. When two consecutive negative x-ray results are confirmed 3. After three consecutive acid-fast bacillus (AFB) smears are negative 4. After effective instruction on the use of a high-efficiency particulate air (HEPA) mask

3. After three consecutive acid-fast bacillus (AFB) smears are negative Airborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious (defined as effective drug therapy, clinical improvement, and three negative AFB smears). Therapy must be deemed effective. Teaching the patient to properly use the HEPA mask isn't a criterion for terminating isolation. Chest x-rays are not criteria to terminate isolation.

A patient is undergoing a sputum study. Which condition will the study help diagnose? 1. Asthma 2. Lung cancer 3. Bacterial lung infection 4. Chronic obstructive pulmonary disease

3. Bacterial lung infection A sputum study is often used to diagnose bacterial lung infection via culture and sensitivity results. Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive pulmonary disease.

A patient has a history of coughing up blood. How can the nurse differentiate between hemoptysis and hematemesis? 1. By measuring SpO2 2. By asking the history in detail 3. By performing a mucus pH test 4. By performing hematologic tests

3. By performing a mucus pH test Coughing up blood is called hemoptysis. Vomiting blood is known as hematemesis. Both conditions are difficult to differentiate. A pH test of the mucus may show an acidic reaction if the blood is from the stomach. A detailed history may not help the nurse to differentiate between hemoptysis and hematemesis, because the symptoms are similar. Hematologic tests may indicate the levels of hemoglobin but do not help in differentiating between both conditions. SpO2 helps in measuring the oxygen saturation levels but does not help in differentiating between hemoptysis and hematemesis.

The nurse assesses a patient who presents with tachypnea and clubbing of the fingers. Which diagnosis does the nurse anticipate for this patient? 1. Asthma 2. Chest trauma 3. Chronic hypoxemia 4. Chronic pulmonary obstructive disease

3. Chronic hypoxemia Tachypnea and clubbing of the fingers support the diagnosis of chronic hypoxemia. Pursed-lip breathing, inability to lie in a flat position, and use of accessory muscles to assist with breathing are findings observed in patients with asthma and chronic obstructive pulmonary disease. Voluntary decrease in tidal volume to reduce pain on chest expansion is referred to as splinting, which is a common manifestation of chest trauma or pleurisy.

Which radiology study does the nurse anticipate will be beneficial for the patient with a suspected pulmonary embolism? 1. Chest x-ray 2. Pulmonary angiogram 3. Computed tomography 4. Magnetic resonance imaging

3. Computed tomography Computed tomography (CT) is used in the diagnosis of lesions that are difficult to assess by conventional x-ray studies. Common types of CT are helical or spiral. Spiral CT is used to diagnose pulmonary embolism. A chest x-ray is used to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize vasculature and locate obstructions or pathologic conditions. Magnetic resonance imaging is used for diagnosis of lesions that are difficult to assess by CT scan, such as lung apex.

What is the major muscle of respiration? 1. Accessory muscle 2. Intercostal muscle 3. Diaphragm muscle 4. Abdominal muscle

3. Diaphragm muscle The diaphragm is the major muscle of respiration. It is a sheet of internal skeletal muscle. An accessory muscle is a relatively rare anatomic duplication of muscle that may appear anywhere in the muscular system. The intercostal muscles are several groups of muscles that run between the ribs and help form and move the chest wall. The abdominal muscles support the trunk, allow movement, and hold organs in place by regulating internal abdominal pressure. They also assist in expelling air during labored breathing.

A nurse is caring for a patient with pneumonia. The nurse is most likely to auscultate what breath sounds when assessing the patient's lungs? Select all that apply. 1. Stridor 2. Wheezes 3. Egophony 4. Bronchophony 5. Whispering pectoriloquy

3. Egophony 4. Bronchophony 5. Whispering pectoriloquy Pneumonia will present with egophony, bronchophony, and whispering pectoriloquy. Egophony is a test to assess breath sounds. It is positive when the patient is asked to pronounce "E" but instead says "A." In bronchophony, the patient is asked to repeat "ninety-nine" several times in a row. If the words are easily understood and are clear and loud, it indicates an abnormal finding. In pectoriloquy, the patient is asked to whisper "one-two-three." If the whisper is heard clearly and distinctly, it indicates an abnormal finding. Wheezes are heard in asthma when there is bronchoconstriction. Stridor is heard in laryngeal diseases due to the obstruction of the larynx or trachea.

The nurse is assessing a patient with a persistent cough who was diagnosed with pulmonary edema. Which assessment finding supports the patient's diagnosis? 1. Foul-smelling sputum 2. Clear, whitish, or yellow sputum 3. Large amounts of frothy, pink-tinged sputum 4. Clear to gray sputum with occasional specks of brown

3. Large amounts of frothy, pink-tinged sputum Large amounts of frothy, pink-tinged sputum support the diagnosis of pulmonary edema, which is characterized by a persistent cough. Foul-smelling sputum indicates an infection. Clear, whitish, or yellow sputum is often found in patients diagnosed with chronic obstructive pulmonary disease, especially in the early morning hours. Clear to gray sputum with brown specks indicates the patient is a smoker.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to prescribe? 1. Thoracentesis 2. Pulmonary angiogram 3. Positron emission tomography (PET) 4. Computed tomography (CT) scan of the patient's chest

3. Positron emission tomography (PET) PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an intravenous radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

A 46-year-old patient who has undergone total left knee arthroplasty complains of shortness of breath and slight chest pain. Temperature is 98° F, blood pressure 140/86 mmHg, respirations 30, and oxygen saturation 92% on room air. The nurse suspects that the patient is experiencing which condition? 1. Pneumonia 2. Unstable angina 3. Pulmonary embolus 4. Chronic obstructive pulmonary disease (COPD) exacerbation

3. Pulmonary embolus The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain. Unstable angina would present with chest pain occurring at rest; COPD exacerbation would present with wheezing, cough, and shortness of breath. Pneumonia would be evident if the patient had a fever, elevated white blood cell count, and a productive cough with yellow, green, or rust-colored sputum

A patient has been admitted with a suspected lung abscess. During the assessment, the nurse is aware that the most common manifestation of a lung abscess is which of these? 1. Fever 2. Vomiting 3. Purulent sputum that has a foul odor and taste 4. Increased breath sounds on auscultation over the involved segment of lung.

3. Purulent sputum that has a foul odor and taste The most common manifestation of a lung abscess is cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Hemoptysis is common, especially when an abscess ruptures into a bronchus. Other common manifestations are fever, chills, prostration, night sweats, pleuritic pain, dyspnea, anorexia, and weight loss. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of lung. Vomiting is not a manifestation of a lung abscess.

When percussing a patient's lung fields, the nurse notes a moderately low-pitched sound over the chest. Which term does the nurse use to document this finding? 1. Dull 2. Tympany 3. Resonance 4. Hyperresonance

3. Resonance Low-pitched sounds heard over normal lungs during percussion indicate resonance. Tympany is a drum-like, loud, empty quality heard over a gas-filled stomach or intestine. Hyperresonance is a loud, lower-pitched sound heard when percussing hyperinflated lungs, which can occur in patients who are experiencing an acute asthma exacerbation.

A patient in the emergency ward is dyspneic and speaks unclear words. Assessment findings include a respiratory rate of 45 breaths/minute, a pulse of 130 beats/minute, oxygen saturation of 90%, and neck vein distention. Which treatment does the nurse expect will help alleviate the patient's symptoms? 1. Administration of ipratropium orally 2. Three puffs of albuterol every 30 minutes 3. Supplementary oxygen through nasal cannula 4. Obtaining peak flow rate and monitoring the patient continuously

3. Supplementary oxygen through nasal cannula The patient with a severe attack of asthma has an elevated respiratory rate, decreased oxygen saturation and elevated pulse, and the inability to speak, which indicate a severe airway obstruction. The patient may also have neck vein distension. Hence the nurse should anticipate correction of hypoxemia and improve ventilation in the patient with supplementary oxygenation by nasal prongs. This helps to keep oxygen saturation above 90 percent. Administration of ipratropium does not provide additional benefits to the patient. Three puffs of albuterol every 30 minutes help to resolve the symptoms in the patients with mild asthma. Obtaining the peak flow rate and continuous monitoring of the patient is critical during asthma attack, but will not alleviate the patient's symptoms.

Which assessment finding of the respiratory system does the nurse interpret as normal? 1. Positive egophony 2. Fine crackles over the distal lung fields 3. Symmetric chest expansion and contraction 4. Bronchial breath sounds in the lower lung fields

3. Symmetric chest expansion and contraction Symmetric chest expansion and contraction is a normal assessment finding. Positive egophony and fine crackles are not normal findings. Bronchial or bronchovesicular sounds heard in the peripheral lung fields are abnormal breath sounds.

During a routine round on the nursing unit, the nurse notices a patient with an SpO2 of 70%. The nurse recognizes that the finding indicates what? 1. Alkalosis 2. Acidosis 3. Tissue hypoxia 4. Normal oxygenation

3. Tissue hypoxia SpO2 indicates the oxygen saturation value of hemoglobin. A normal level of SpO2 is more than 95%. An SpO2 of 70% in a patient signifies tissue hypoxia. It means that the oxygen delivered to the tissues is less than the actual demand. Alkalosis and acidosis cause change in the pH of blood and do not affect the SpO2. SpO2 of 70% does not indicate normal oxygenation.

Which receptors cause an increase in the partial pressure of arterial carbon dioxide (PaCO2) level and a decrease in pH level? 1. Irritant receptors 2. Stretch receptors 3. Juxtacapillary receptors 4. Central chemoreceptors

4. Central chemoreceptors The central chemoreceptors respond to increased levels of PaCO2 by stimulating an increased respiratory rate in an effort to rid the blood of the increased carbon dioxide. As the lungs inflate, stretch receptors activate the inspiratory center to inhibit further lung expansion. Stimulation of irritant receptors produce a cough to remove foreign material from the respiratory tract. Juxtacapillary receptors cause rapid respiration in response to pulmonary edema.

While auscultating a patient's chest, the nurse notes wheezing. Which diagnosis does the nurse anticipate? 1. Bronchiectasis 2. Pleural effusion 3. Pulmonary edema 4. Chronic obstructive pulmonary disease

4. Chronic obstructive pulmonary disease Wheezes are continuous high-pitched squeaking sounds produced by the rapid vibration of the bronchial walls. The rapid vibration is caused by a blockage in the airways, which often occurs with chronic obstructive pulmonary disease. Diminished breath sounds are observed in pleural effusion. Rhonchi are observed in patients with bronchiectasis. Coarse crackles are observed in patients with pulmonary edema.

A patient presents with a bluish coloration of the lips, which the nurse identifies as cyanosis. What etiology does the nurse suspect? 1. Asthma 2. Lung cancer 3. Bronchiectasis 4. Decreased cardiac output

4. Decreased cardiac output Decreased cardiac output causes bluish coloration of the lips, which is a characteristic feature of cyanosis. Wheezing, shortness of breath, and chest tightness are the clinical manifestations of asthma. Finger clubbing is the clinical manifestation of lung cancer and bronchiectasis.

When administering and reading the tuberculosis (TB) skin test, what measures should the nurse take? 1. Ensure that the injection is given subcutaneously. 2. Do not use a pen around the test area to mark the site. 3. Include the reddened flat areas on the skin when measuring the induration. 4. Draw a diagram of the forearm and hand and label the injection sites in the patient's chart.

4. Draw a diagram of the forearm and hand and label the injection sites in the patient's chart. When a skin test is administered for TB bacilli, the nurse should chart the site of administration by drawing a diagram of the forearm and hand and labeling the injection sites. The nurse should ensure that the injection is given intradermally. The nurse should circle the area with a pen and instruct the patient not to remove the mark. The diameter of the induration should be measured for reading the test. The reddened flat area is not included in the measurement.

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? 1. Chest excursion 2. Spinal curvatures 3. Respiratory pattern 4. Fingernails and their base

4. Fingernails and their base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

The nurse provides education to a patient who is prescribed a metered-dose inhaler. Which actions taken by the patient indicate the need for further teaching? Select all that apply. 1. Waits between puffs 2. Activates the inhaler during inspiration 3. Holds the breath for 10 seconds after a puff 4. Inhales more than one puff with each inspiration 5. Does not shake the metered-dose inhaler before use

4. Inhales more than one puff with each inspiration 5. Does not shake the metered-dose inhaler before use The metered-dose inhaler (MDI) has to be shaken before use, and the patient should only inhale one puff per inspiration. The patient using an MDI should wait between each puff. The MDI should be activated during inspiration. The patient should to hold the breath for 10 seconds after each puff.

The nurse assesses a patient who is tachypneic and notes a PaO2 of 56%, a PaCO2 of 50%, and diminished mental status. The patient's medical history reveals a 40-year history of smoking. Which nursing action is the highest priority? 1. Obtaining a detailed history of prior hospitalizations 2. Implementing a plan to teach the patient diaphragmatic and pursed-lip breathing 3. Initiating postural drainage and chest percussion and vibration to remove secretions 4. Initiating the administration of oxygen and continuous pulse oximetry monitoring

4. Initiating the administration of oxygen and continuous pulse oximetry monitoring Increasing hypoxemia and hypercapnia, as evidenced by a change in mental status, necessitate an immediate priority action to improve oxygenation through supplemental delivery of oxygen, as well as monitoring of the results through the use of continuous pulse oximetry. If the patient does not improve with these initial interventions, further care may necessitate endotracheal intubation and mechanical ventilation to improve oxygenation and decrease carbon dioxide retention. The nursing actions in the other answer options are appropriate for this patient, but they are of lower priority in light of the patient's urgent care needs.

The nurse is caring for a patient suspected of having pneumonia. What instructions should the nurse provide to the patient prior to receiving a chest x-ray? 1. Instruct the patient to sign a consent form. 2. Tell the patient to not have food for two hours before the test. 3. Instruct the patient to undress completely and put on a gown. 4. Instruct the patient to remove any metal between neck and waist.

4. Instruct the patient to remove any metal between neck and waist. For the chest x-ray, the nurse should instruct the patient to remove any metal between neck and waist. The patient is not required to undress completely; because it is a chest x-ray, undressing to the waist is sufficient. The test does not require the patient to sign a consent form, and there is no need to avoid food before the test.

A patient who has tuberculosis (TB) is being treated with combination drug therapy. The nurse explains that combination drug therapy is essential because of what reason? 1. It minimizes the required dosage of each of the medications. 2. It helps reduce the unpleasant side effects of the medications. 3. It shortens amount of time that the treatment regimen will be needed. 4. It discourages the development of resistant strains of the TB organism.

4. It discourages the development of resistant strains of the TB organism. Recommendations for the initial treatment of tuberculosis (TB) include a four-drug regimen until drug susceptibility tests are available. After susceptibility is established, the regimen can be altered, but patients should still receive at least two drugs to prevent emergence of drug-resistance organisms. Dosage, side effects, and duration of the regimen are not reasons for combination drug therapy in a patient with TB.

The nurse is assessing a patient who smokes and notes gray-colored sputum with specks of brown. What action would be appropriate for this patient? 1. Inform the health care provider. 2. Administer oxygen therapy to the patient. 3. Assess oxygen saturation through pulse oximetry. 4. No action is required because it is considered normal.

4. No action is required because it is considered normal. Gray-colored sputum with specks of brown is a normal finding in an individual who smokes, so no action is required. Administering oxygen therapy, assessing oxygen saturation, and informing the health care provider are not necessary for this patient.

When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? 1. Vomiting 2. Increased urination 3. Decreased heart rate 4. Rapid respiratory rate

4. Rapid respiratory rate When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every six hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? 1. Chew a hard candy before the first puff of medication. 2. Rinse the mouth with water before each puff of medication. 3. Ask for a breath mint following the second puff of medication. 4. Rinse the mouth with water following the second puff of medication.

4. Rinse the mouth with water following the second puff of medication. Because beclomethasone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection. The mouth should be rinsed after the second puff, not before each puff. Hard candy or breath mints will not prevent oral infection.

A patient suspected of having lung cancer has undergone lung biopsy through transthoracic needle aspiration (TTNA). What is the priority nursing action for this patient immediately following the procedure? 1. Allow the patient to take a rest. 2. Measure oxygen saturation levels. 3. Instruct the patient to do deep breathing. 4. Send the patient for a chest x-ray as prescribed.

4. Send the patient for a chest x-ray as prescribed. Following a lung biopsy through TTNA, the patient should be sent for chest x-ray to rule out a pneumothorax, which is a common complication of the procedure. Only after the chest x-ray is done, can the patient can be told to rest or do deep breathing exercises. Oxygen saturation levels are generally monitored throughout the procedure.

A patient is scheduled for a computed tomography (CT) scan with contrast medium. After reviewing the patient's laboratory reports, the nurse contacts the primary health care provider and the CT scan is cancelled. Which laboratory parameter would have made the diagnostic test unsafe for the patient? 1. Hematocrit 50% 2. PaCO2 40mm Hg 3. Hemoglobin 14.0 g/dL 4. Serum creatinine 3.0 mg/dL

4. Serum creatinine 3.0 mg/dL CT scans may be often performed with contrast medium. These contrast media are excreted through urine; therefore it is important for the patient to have optimal renal function to prevent accumulation of the contrast media in the body. The normal range of serum creatinine level is 0.6 to 1.3 mg/dL; therefore a serum creatinine level of 3.0 mg/dL is very high and indicates renal dysfunction. As a result, the diagnostic test should not be performed on the patient. Hematocrit of 50%, PaCO2 of 40 mm Hg, and hemoglobin of 14.0 g/dL are within normal ranges.

The nurse is assisting the health-care provider (HCP) in performing a diagnostic thoracentesis on a patient. The nurse positions the patient in what position? 1. Lying flat in the fetal position on the unaffected side 2. Sitting in bed with knees slightly flexed and feet flexed 3. Lying flat on the unaffected side with knees slightly flexed 4. Sitting upright with elbows on an over bed table and feet supported

4. Sitting upright with elbows on an over bed table and feet supported To appropriately locate the pleural space, the patient needs to be positioned sitting upright with elbows on an over-bed table with feet supported. Lying flat would not adequately expand the thorax and permit the provider to position the thoracentesis needle in the correct place. Sitting in the bed would also not allow the HCP to visualize the pleural space for needle insertion.

A patient presents with a productive cough and a body temperature of 102° F. The patient's white blood cell (WBC) count is 15,000/mm3. The nurse expects that what diagnostic test will be prescribed? 1. Niox Mino test 2. Allergy skin test 3. Lung function test 4. Sputum culture test

4. Sputum culture test Fever, productive cough, and white blood cells of 15,000/mm3 indicate infection in the patient. Evidence of the sputum culture test helps to rule out bacterial infection from other upper respiratory tract problems. Niox Mino test helps to measure airway inflammation related to asthma and an allergy skin test is helpful for assessment of sensitivity for specific allergen. A lung function test helps to evaluate the lung capacity in the patient with respiratory problems.

A nurse is caring for a patient experiencing a chronic cough with a suspected diagnosis of tuberculosis (TB). Which test will be conducted to confirm the diagnosis? 1. Widal test 2. Lepromin test 3. Benedict's test 4. Tuberculin test

4. Tuberculin test The nurse recommends the tuberculin skin test to check for TB. A Benedict's test is performed to check urine glucose. A lepromin test is done to check for leprosy. A Widal test is useful for diagnosing typhoid infection.

A nurse is interviewing a patient from Asia who reports a chronic cough over the last three months, an evening rise in temperature, and weight loss. The patient will most likely be diagnosed with what? 1. Mycosis 2. Empyema 3. Asbestosis 4. Tuberculosis

4. Tuberculosis The most common condition in patients from Asia who have chronic cough and fever in the evenings is tuberculosis. Mycosis is a fungal infection, which does not present with a chronic cough and weight loss. Asbestosis is noninfective in origin and presents as difficulty in breathing, not as weight loss. Empyema is accumulation of purulent material in the lungs. It does not cause weight loss in the patient.

A patient is prescribed an inhaler for treatment of asthma. The medication canister contains 200 puffs, scheduled to last for 25 days. The nurse should instruct the patient to inhale how many puffs per day to receive the prescribed amount? Record your answer using a whole number. ________

8 A patient who is taking medication from a canister of 200 puffs has to take eight puffs per day to completely administer the medication within 25 days.