MEDSURG Chapter 49 Care of the Patient with a Respiratory Disorder cooper, Sole Ch 15
The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a) Management and protection of the airway b) Prevention of gastric aspiration c) Prevention of skin breakdown and nerve damage d) Psychological support to patient and family
A All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a) alveolar-capillary membrane b) left ventricle c) mainstem bronchus d) trachea
A Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema.
Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a) PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE b) Bradycardia and hyperventilation are classic symptoms of PE c) Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE d) Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis
A PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases.
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a) Decreasing PaO2 levels despite increased FiO2 administration b) Elevated alveolar surfactant levels c) Increased lung compliance with increased FiO2 administration d) Respiratory acidosis associated with hyperventilation
A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS,hyperventilation may occur along with respiratory alkalosis.
During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a) an optional treatment to improve ventilation b) less of a risk for skin breakdown because the patient is face down c) possible with minimal help from coworkers d) used to provide continuous lateral rotational turning
A Proning is considered to improve ventilation by shifting perfusion from the posterior bases of the lung to the anterior portion. The patient is not responding to treatment, and all options should be considered.
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a) Increases functional residual capacity b) Prevents collapse of unstable alveoli c) Improves arterial oxygenation d) Opens collapsed alveoli e) Improves carbon dioxide retention
A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention.
Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a) Graduated compression stockings b) Heparin or low-molecular weight heparin for patients at risk c) SCDs d) Strict bed rest e) Leg massage
A, B, C Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended.
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a) high Fowler's b) side lying with HOB elevated c) sitting in a chair d) supine w/ bed flat e) Trendelenburg
A, B, C Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler's position are all appropriate ways to position the patient to facilitate gas exchange and comfort.
Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a) Interrupt sedation each day to assess readiness to extubate b) Maintain head of bed at least 30 degrees of elevation c) Provide deep vein thrombosis prophylaxis d) Provide prophylaxis for peptic ulcer disease e) Swab the mouth with foam swabs every 2 hours
A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a) Airway clearance therapies b) Antibiotic therpy c) Nutritional support d) Tracheostomy e) Lung transplant
A, B, C, E The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF.
The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a) Drain condensate from the ventilator tubing away from the patient b) Elevate HOB 30 to 45 degrees c) Instill normal saline as part of the suctioning procedure d) Perform regular oral care with chlorhexidine e) Awaken the patient daily to determine need for continued ventilation
A, B, D Condensate should be drained away from the patient to avoid drainage back into the patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily "sedation holidays" help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.
Identify diagnostic criteria for ARDS. (Select all that apply.) a) Bilateral infiltrates on chest x-ray study b) Decreased cardiac output c) PaO2/ FiO2 ratio of less than 200 c) Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg d) PAOP less than 18 mm Hg
A, C Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio.
41. The nurse describes the pathophysiologic process of an asthma attack. Place the events in their proper sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Inflammatory process in the mast cells of the lungs b. Increase in edema and mucus production in the bronchioles c. Release of histamine d. Narrowing of the airways e. Exposure to allergen
ANS: E, A, C, B, D The allergen activates the mast cells in the lungs, which release histamine, causing an increase in edema and mucus production that narrows the airways and causes the classic signs of asthma. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1663, Figure 48-14 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation
40. The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. Place the events of reoxygenation in order. (Separate letters by a comma and space as follows: A, B, C, D) a. Pulmonary artery takes blood to capillary system of the alveoli b. Blood enters the left atria via the pulmonary vein c. Blood enter the left ventricle d. Unoxygenated blood enters the right ventricle e. Blood enters the aorta f. CO2 diffused and oxygen infused into the blood in alveoli g. Unoxygenated blood enters the right atrium
ANS: G, D, A, F, B, C, E The unoxygenated blood enters the right atria via the vena cava, then to the right ventricle and out the pulmonary artery into the capillary bed of the alveoli, CO2 and O2 are exchanged in the alveoli, the CO2 being exhaled and the oxygenated blood continues to the right atria via the pulmonary vein, then to the left ventricle and out the aorta to the body. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1613 OBJ: 3 TOP: Reoxygenation of blood KEY: Nursing Process Step: Implementation
38. The nurse recognizes that the reading in an arterial gas report indicates the amount of oxygen dissolved in the plasma.
ANS: PaO2 The PaO2 reading indicates the amount of oxygen dissolved in the plasma. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1616 OBJ: 8 TOP: Blood gases KEY: Nursing Process Step: Assessment
35. The are the structures of the lung in which gas exchange occurs.
ANS: alveoli The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Lower respiratory tract KEY: Nursing Process Step: Assessment
37. The nurse explains that the opening between the vocal cords is the .
ANS: glottis The glottis is the opening between the vocal cords. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1608 OBJ: 2 TOP: Glottis KEY: Nursing Process Step: Implementation
39. The nurse explains that the diagnostic test that can scan the chest and the abdomen in less than 30 seconds is the .
ANS: spiral CT scan helical CT scan The spiral or helical CT scan can scan the chest and the abdomen in less than 30 seconds. This test is faster and more accurate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ: 7 TOP: Spiral or helical CT scan KEY: Nursing Process Step: Implementation
36. The nurse prepares a patient for the procedure of a(n) , which will remove the fluid from around the lung to improve respiration and obtain a specimen.
ANS: thoracentesis Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1615 OBJ: 7 TOP: Thoracentesis KEY: Nursing Process Step: Implementation
17. The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate? a. The patient will present with edema of the lower extremities and extended neck veins due to hypertension of the pulmonary circulation. b. The patient will present with a dry hacking cough and chest pain due to constriction of the pulmonary vein. c. The patient will present with hypertension and a headache related to pulmonary hypertension. d. The patient will present with unlabored respiration and cyanosis around the mouth.
ANS: A COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1658 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation
4. A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding? a. Obtain a blood pressure b. Record the approximate amount of blood lost c. Inquire about a headache d. Record the last episode of epistaxis
ANS: A Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1618 OBJ: 9 TOP: Epistaxis KEY: Nursing Process Step: Implementation
6. How will the kidneys behave in respiratory acidosis? a. Retain bicarbonate to increase the pH b. Excrete more urine to reduce potassium c. Concentrate the urine to conserve circulating fluid in the blood stream d. Lower the pH by excretion of bicarbonate
ANS: A In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Table 48-2 OBJ: 11 TOP: Respiratory acidosis KEY: Nursing Process Step: Assessment
24. The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment? a. Document the tidaling b. Elevate the head of the bed and notify charge nurse of malfunction of drainage system c. Add more sterile water to the water seal chamber d. Turn patient to the affected side
ANS: A Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1646, Box 48-6 OBJ: 14 TOP: Closed chest drainage KEY: Nursing Process Step: Assessment
31. Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.) a. Positioning in orthopneic position b. Suctioning c. Assisting to cough d. Providing hydration e. Starting IV fluids f. Starting mucolytic agents
ANS: A, B, C, D Independent nursing intervention to help a patient to expectorate would include positioning, assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic agent requires a physician's order and is not an independent nursing action.. PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ: 12 TOP: Assisting expectoration KEY: Nursing Process Step: Planning
30. Which preoperative teaching should a nurse include for a person scheduled for a partial laryngectomy? (Select all that apply.) a. Tracheal suction will be frequent b. The presence of a temporary tracheotomy c. That isolation will be required for 24 hours d. The surgery involves removal of a diseased vocal cord e. Some speech will be retained f. The sense of smell and taste will be lost
ANS: A, B, D, E A partial laryngectomy involves the removal of the diseased cord and possible thyroid cartilage. There will be a temporary tracheostomy that will be closed once edema is under control. Tracheal suctioning will be done frequently. There will be some vocal ability retained. Isolation is not required. Sense of smell and taste are lost with a total laryngectomy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1623 OBJ: 10 TOP: Patient teaching KEY: Nursing Process Step: Assessment
32. Identify the purposes of chest drainage. (Select all that apply.) a. Drains air, blood, and fluid from pleural space b. Restores positive pressure in chest cavity c. Restores negative intrapleural pressure d. Allows lung to collapse and rest e. Allows route for medication administration
ANS: A, C A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavity's normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space. PTS: 1 DIF: Cognitive Level: Application REF: Page 1644 OBJ: 14 TOP: Closed chest drainage KEY: Nursing Process Step: Planning
34. The nurse explains to the person with pneumonia in the left lung that being positioned in the "good lung down" offers the advantage of (select all that apply): a. PaO2 rising in the good lung. b. blood flow to "bad lung" being increased. c. the dependent lung being better perfused. d. dyspnea disappearing. e. decreased hypoxia.
ANS: A, C, E The "good lung down" position increases the PaO2 in the good lung and also allows for better perfusion, consequently decreasing hypoxia, although dyspnea may still be evident. PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ: 11 TOP: Pneumonia KEY: Nursing Process Step: Implementation
19. How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound? a. Sonorous wheeze b. Friction rub c. Coarse crackles d. Crackles
ANS: B A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub. PTS: 1 DIF: Cognitive Level: Application REF: Page 1612, Table 48-1 OBJ: 6 TOP: Adventitious sounds KEY: Nursing Process Step: Assessment
16. What is true about activities such as walking for the patient with emphysema? a. Repair dilated alveoli b. Increase capacity to use oxygen c. Lessen the oxygen needs d. Lessen metabolic oxygen needs
ANS: B Aerobic exercises such as walking will increase the body's ability to use oxygen through sustained rhythmic contractions of large muscles. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1559 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Implementation
11. A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this? a. Only 82% of the red blood cells are able to use oxygen. b. There is only 82% of oxygen bound to the hemoglobin compared with the amount available. c. Eighteen percent of oxygen is not dissolved in the blood. d. The muscular respiratory effort is only 18% effective.
ANS: B An SaO2 indicates that only 82% of the available oxygen is bound to the hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1616 OBJ: 8 TOP: SaO2 KEY: Nursing Process Step: Assessment
13. How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised? a. Report redness and swelling of extremities b. Accept that the therapy is long term c. Monitor renal function every several months d. Rise slowly to avoid dizziness
ANS: B INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities. PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-2 OBJ: 13 TOP: INH KEY: Nursing Process Step: Planning
12. What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis? a. Place the patient in drainage and secretion precautions b. Place the patient in acid-fast bacillus (AFB) Isolation Precautions c. Maintain the patient in enteric isolation d. Place the patient in any Isolation Precautions
ANS: B If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation Precautions should be requested immediately. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1636 OBJ: 13 TOP: Tuberculosis KEY: Nursing Process Step: Implementation
26. How do leukotriene modifiers reduce the symptoms of asthma? a. By drying up mucus b. By causing bronchodilation and anti-inflammation effects c. By suppressing cough d. By liquefying mucus
ANS: B Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-3 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Planning
3. A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention? a. Complete care quickly b. Provide a pad and pencil or magic slate c. Refrain from conversations with the patient to reduce stress level d. Offer books or jigsaw puzzles for entertainment
ANS: B Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation. PTS: 1 DIF: Cognitive Level: Application REF: Page 1534 OBJ: 10 TOP: Laryngectomy KEY: Nursing Process Step: Implementation
21. The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what condition? a. Pulmonary embolus b. Spontaneous pneumothorax c. Early signs of unilateral pneumonia d. An attack of asthma
ANS: B Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger. PTS: 1 DIF: Cognitive Level: Application REF: Page 1648, Figure 48-13 OBJ: 11 TOP: Postoperative complications KEY: Nursing Process Step: Assessment
1. What is the purpose of the cilia? a. Warm and moisturize inhaled air b. Sweep debris toward nasal cavity c. Stimulate cough reflex d. Produce mucus
ANS: B The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Secretions KEY: Nursing Process Step: Planning
5. The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of: a. friction rub. b. sibilant wheezes. c. crackles. d. sonorous wheezes.
ANS: B The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes, which are high-pitched whistling sounds. PTS: 1 DIF: Cognitive Level: Application REF: Page 1612 OBJ: 16 TOP: Asthma KEY: Nursing Process Step: Assessment
10. A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a "barrel chest." What does this pathology result from? a. An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi b. An increased anteroposterior diameter caused by overinflation of the alveoli c. A decrease in anteroposterior diameter caused by chronic dilation of the bronchi d. A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the airways leading to bronchospasms
ANS: B The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1658, Figure 48-16 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Assessment
18. What is a major advantage of video assisted thoracoscopic surgery (VATS)? a. The surgeon can record entire surgical procedure on a video. b. The surgeon can remove tumors of the lung through a small keyhole incision. c. The surgeon can x-ray and excise tumor in the same procedure. d. The surgeon can avoid the use of a closed chest drainage system after surgery.
ANS: B The video assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1650 OBJ: 19 TOP: VATS KEY: Nursing Process Step: Implementation
28. What should the nurse do to keep the chest tubes from becoming occluded? a. Irrigate tubes as needed b. Prevent dependent loops c. Loop the tube over the bed rail d. "Milk" the tube frequently
ANS: B To keep the tubes patent, the tubes should be kept straight without dependent loops. These tubes are not irrigated and should not be milked frequently. PTS: 1 DIF: Cognitive Level: Application REF: Page 1645 OBJ: 1 | 14 TOP: Closed chest drainage KEY: Nursing Process Step: Planning
15. A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse's initial intervention? a. Report signs to the charge nurse. b. Elevate head of bed and administer oxygen. c. Prevent patient from excessive coughing. d. Increase IV flow rate.
ANS: B When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the physician should be notified, but only after the patient is stabilized and oxygenated. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1654, 1655 OBJ: 15 TOP: Pulmonary embolism KEY: Nursing Process Step: Implementation
33. What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.) a. Moist mucous membranes b. Kyphosis c. Decrease in pulmonary blood flow d. Stasis pooling of secretions e. Reduced number of cilia
ANS: B, C, D, E Age-related changes that affect the respiratory system are dryer mucous membranes, which reduce ability to humidify inspired air, kyphosis, which restricts the expansion of the lung, stasis pooling of respiratory secretions, and reduced number of cilia, which make infection of the upper and lower airway more likely. PTS: 1 DIF: Cognitive Level: Application REF: Page 1641, Lifespan OBJ: 9 TOP: Pneumonia KEY: Nursing Process Step: Planning
27. How should a patient be positioned after a thoracentesis is completed and the dressing applied? a. High Fowler b. Semi-Fowler c. Side lying on unaffected side d. Prone
ANS: C After a thoracentesis the patient is placed in a side-lying position on the unaffected side. PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ: 11 TOP: Pleural Effusion KEY: Nursing Process Step: Implementation
8. Which instruction by the nurse is inappropriate for teaching the proper technique for collection of a sputum specimen? a. Bring the sputum up from the lungs b. Rinse mouth with water before expectorating in specimen cup c. Collect specimens before meals d. Send specimen to the lab without delay
ANS: C Collecting specimens before meals will avoid possible emesis from coughing after eating. PTS: 1 DIF: Cognitive Level: Application REF: Page 1615, Box 48-2 OBJ: 12 TOP: Diagnostic procedures KEY: Nursing Process Step: Implementation
20. What is inspiratory capacity? a. The amount of air in the lung after a maximal inhalation b. The amount of air moved with each normal inhalation and expiration c. The amount of air that can be inhaled in one breath from the resting expiratory level d. The amount of air that can be forcefully exhaled after maximum inhalation
ANS: C Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting expiratory level. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ: 7 TOP: Inspiratory capacity KEY: Nursing Process Step: Implementation
14. The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related to an imbalance between the oxygen supply and demand? a. Direct patient in vigorous independent ROM. b. Allow to exercise until respirations are over 20 breaths/min over baseline. c. Plan care to provide optimum rest. d. Provide frequent cool showers.
ANS: C Nursing interventions will be directed at attempting to decrease the patient's anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living. PTS: 1 DIF: Cognitive Level: Application REF: Page 1649, Nursing Care Plan OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Planning
29. Which patient assessment indicates the most severe respiratory distress? a. Nasal flaring, symmetrical chest wall expansion, SaO2 88% b. Abdominal breathing, SaO2 97% c. Substernal retraction, SaO2 84% d. Substernal retraction, SaO2 90%
ANS: C Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress. PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ: 5 TOP: Pneumothorax KEY: Nursing Process Step: Assessment
2. What happens when there is a decrease in the oxygen level in the blood? a. Pituitary stimulates the respiratory system to increase respiratory rate b. The alveoli diffuse more oxygen into the blood c. Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates d. The parietal pleura increases the negative pressure
ANS: C The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations. PTS: 1 DIF: Cognitive Level: Application REF: Page 1611 OBJ: 1 TOP: Respiratory rate modification KEY: Nursing Process Step: Assessment
9. When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger: a. on the same side as the blood pressure cuff. b. while exercising the arm to stimulate circulation. c. that is a normal temperature. d. on the same side as an arterial catheter.
ANS: C The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Safety Alert OBJ: 9 TOP: Pulse oximeter KEY: Nursing Process Step: Assessment
25. How does pursed lip breathing assist patients with asthma during an attack? a. It distracts the patient with breathing technique to reduce anxiety. b. It gets rid of CO2 faster. c. It opens bronchioles by backflow air pressure. d. It increases PACO2..
ANS: C The resistance or the expiration through the pursed lips causes a backflow of air and helps to open the bronchioles. PTS: 1 DIF: Cognitive Level: Application REF: Page 1664 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation
23. The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful? a. In 24 hours, but must take cold liquids for the rest of the day b. If there is no blood in his sputum c. In 8 hours after a period of nothing by mouth d. When the gag reflex returns
ANS: D Following a bronchoscopy, the patient can eat as soon as the gag reflex returns, usually in about 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1614 OBJ: 7 TOP: Bronchoscopy KEY: Nursing Process Step: Implementation
7. An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. What is the infected fluid that the physician removes called? a. Emboli b. Emphysema c. Sputum d. Empyema
ANS: D If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1642 OBJ: 11 TOP: Empyema KEY: Nursing Process Step: Assessment
22. Which important precaution should the nurse include when instructing an emphysema patient on the use of home oxygen? a. Use oxygen only when extremely short of breath b. Keep the home oxygen regulator set on 6 L c. Use home oxygen at night while sleeping d. Limit to 1 to 2 L oxygen flow
ANS: D Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body's own respiratory regulatory centers and can cause respiratory failure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1659 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation
The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a) 46.8; meets criteria for ARDS b) 130; meets criteria for ARDS c) 468; normal lung function d) Not enough data to compute the ratio
B 78/0.60 = 130, which meets the criteria for ARDS.
The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a) cardiac output of 10 L/min and low systemic vascular resistance b) PAOP of 10 mm Hg and PaO2 of 55 c) PAOP of 20 mm Hg and cardiac output of 3 L/min d) PAOP of 5 mm Hg and high systemic vascular resistance
B A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this has been deleted from the most current definition. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a) Bradycardia b) Change in sputum characteristics c) Hypoventilation and respiratory acidosis d) Pursed-lip breathing
B Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD.
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a) "If you get the pneumococcal vaccine, you'll never get pneumonia again." b) "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c) "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d) "Since you have been treated for pneumonia, you now have immunity from getting it in the future."
B The influenza vaccine reduces the risk of pneumonia by more than 50%.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a) "I'm going to contact the pharmacist to see if you can take this medication by mouth." b) "This injection is being given to prevent blood clots from forming." c) "This medication will dissolve any blood clots you might get." d) "You should not be receiving this medication. I will contact the provider to get it stopped."
B Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.
When fluid is present in the alveoli, a) alveoli collapse and atelectasis occurs b) diffusion of oxygen and carbon dioxide is impaired c) hypoventilation occurs d) the patient is in heart failure
B Fluid prevents the diffusion of gases
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a) Hyperventilation and respiratory acidosis b) Hypoventilation and respiratory acidosis c) Hypoventilation and respiratory alkalosis d) Respiratory acidosis and normal oxygen levels
B Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a) Increased oxygen saturation via pulse oximetry b) Increased peak inspiratory pressure on the ventilator c) Normal chest radiograph with enlarged cardiac structures d) PaO2/FiO2 ratio >300
B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.
An acute exacerbation of asthma is treated with which of the following? a) Corticosteroids and theophylline by mouth b) Inhaled bronchodilators and intravenous corticosteroids c) Prone positioning or continuous lateral rotation d) Sedation and inhaled bronchodilators
B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways.
The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a) amniotic fluid embolus b) deep vein thrombosis from lower extremities c) fat embolus from a long bone fracture d) vegetation that dislodges from an infected CVC
B The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.
Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a) Tooth brushing is performed every 2 hours for the greatest effect b) Implementing a comprehensive oral care program is an intervention for preventing VAP c) Oral care protocols should include oral suctioning and brushing teeth d) Protocols that include chlorhexidine gluconate have been effective in preventing VAP e) Using oral swabs or toothettes are just as effective as brushing the teeth
B, C, D A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle.
A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a) administration of two aspirin tablets every 4 hours b) infusion of thrombolytics c) insertion of a vena cava filter d) SQ heparin administration every 2 hours
C A filter may be inserted as a prevention measure in patients who are at high risk for pulmonary embolism.
The basic underlying pathophysiology of acute respiratory distress syndrome results in a) a decrease in the number of white blood cells available b) damage to the right mainstem bronchus c) damage to the type II pneumocytes, which produce surfactant d) decreased capillary permeability
C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.
The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a) obtaining an appointment for follow-up pulmonary function studies 1 week after discharge b) limiting activity until the patient is able to climb two flights of stairs c) taking all asthma medications as prescribed d) taking medications on a "prn" basis according to symptoms
C Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a) Emergency tracheostomy and mechanical ventilation b) Mechanical ventilation via an endotracheal tube c) Noninvasive positive-pressure ventilation (NPPV) d) Oxygen at 100% via bag-valve-mask device
C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority.
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a) continuous lateral rotation therapy b) guided imagery c) neuromuscular blockade d) prone positioning
C Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation.
Intrapulmonary shunting refers to a) alveoli that are not perfused b) blood that is shunted from the left side of the heart to the right and causes heart failure c) blood that is shunted from the right side of the heart to the left without oxygenation d) shunting of blood supply to only one lung
C Shunting refers to blood that is not oxygenated in the lungs.
A definitive diagnosis of pulmonary embolism can be made by a) ABG analysis b) chest x-ray examination c) pulmonary angiogram d) ventilation-perfusion scanning
C The angiogram is one test that can confirm pulmonary embolism.
In assessing a patient, the nurse understands that an early sign of hypoxemia is a) clubbing of nail beds b) cyanosis c) hypotension d) restlessness
D Central nervous system signs, such as restlessness, are early indications of low oxygen levels.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a) Antiseptic oral care b) Bed rest with HOB elvated c) Coughing and deep breathing d) Mobility
D Mobility helps to prevent deep vein thrombosis and pulmonary embolus.
The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a) elevate the HOB 30 degrees b) obtain an order for VTE prophylaxis c) provide adequate sedation d) reposition the patient q2h
D Repositioning the patient will facilitate mobilization of secretions.
Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a) Aspirin b) Embolectomy c) Heparin d) Thrombolytics
D Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot.
