nur195 exam 2
Q42: which range of water pressure within the endotracheal tube cuff is believed to prevent both injury and aspiration
15-20 mm Hg High cuff pressure (30-35) = tracheal bleeding, ischemia, pressure necrosis Underinflatted (0-15)= increase risk of aspiration pneumonia
Q53: the nurse is caring for a client in the ICU who required emergent endotracheal intubation with mechanical ventilation. The nurse receives an order to obtain ABG after the procedure. The nurse should wait how long to do so
20 min
Q39: a client has recently been diagnosed with malignant lung cancer. The nurse is calculating the clients smoking history in pack years. The client reports smoking 2 packs a day for the past 11 years. The nurse documents the clients pack years as
22
Q51: which is an adverse reaction that would require the process of weaning from a ventilator to be terminated a: blood pressure increase of 20 mm Hg b: Pa02 60 mmHg with an Fi02 <40% c: vital capacity of 12 mL/kg d: heart rate <100 bpm
A
Q58: the nurse is caring for a client following a thoracotomy which finding requires immediate intervention a) moderate amounts of colorless sputum b)chest tube drainage 190 mL/hr c) heart rate 112 bpm d) pain of 5 on 1-10 scale
Chest tube drainage of 190 mL/hr
Xerostomia
Dryness of the mouth caused by reduction of saliva
Q87: 76 Year old client presents to the ED reporting "laryngitis". The triage nurse should ask whether the client has a medical history that includes?
Gastroesophageal reflux disease
Sonorous wheezes
deep, low-pitched rumbling sounds heard primarily during expiration
dyspnea
labored breathing or shortness of breath
Cough in the morning w/ sputum production
may indicate bronchitis
silent unit
occurs in pneumothorax or acute respiratory distress system
vital capacity
the maximum volume of air exhaled from the point of maximum inspiration
expiratory reserve volume
the maximum volume of air that can be exhaled after a normal inhalation
mixed sleep apnea
type of sleep apnea that occurs when central sleep apnea and obstructive sleep apnea occur simultaneously
Examining the posterior pharynx & tonsils
use a tongue blade & light - note any evidence of swelling, inflammation or exudate & changes of mucous membrane colors
Q48: which statements would be considered appropriate interventions for a client with an endotracheal tube? select all that apply
- the cuff is deflated before the tube is removed - cuff pressures should be checked every 6-8 hrs - humidified oxygen should always be introduced through the tube
Q49: which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?
A intermittent mandatory ventilation IMV
Q45: which is the most reliable & accurate method for delivering precise concentrations of oxygen through non-invasive means
A venturi task - allows a constant flow of room air blended with a fixed flow of oxygen
Q65: the herpes simplex virus type 1 (HSV-1) which produces a cold sore (fever blister), has an incubation period of?
A: 2-12 days
Q49: Arterial blood gases should be obtained how often after initiating continuous mechanical ventilation
A: 20 minutes Obtained to measure carbon dioxide partial pressure (PaCO2), ph & Pa02
Q 10: high or increased compliance occurs in which disease process
A: Emphysema the lungs have lost their elasticity and the thorax is overdistended
Q76: a late complication of radiation therapy is
A: Laryngeal necrosis, edema & fibrosis
Q17: which diagnostic imagining modality is more accurate than computed tomography in detecting malignancies
A: PET - it is more accurate in detecting malignancies than CT and it has equlivalent accuracy in detecting malignant nodules when compared w/ invasive procedures such as a thorascopy
Q32: the nurse is caring for a client w/ suspected lung cancer. Which imaging study is more accurate than computed tomography in detecting malignancies?
A: PET scan
Q54: the nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the clients bedside?
A: a bottle of sterile water If the chest tube and drainage system become disconnected, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water
Q 12: which is a true statement regarding air pressure variances?
A: air is drawn through the trachea and bronchi into the alveoli during inspiration - air flows from a region of higher pressure to a region of lower pressure - during inspiration, movement of the diaphragm & other muscles of respiration enlarge the thoracic cavity thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure
Q73: a first-line antibiotic used to treat acute rhino sinusitis is
A: ampicillin - first line also include, amoxicillin, erythromycin - second-line includes; cefuroxime, cefprozil, amoxicilin-clavulanic acid
Q83: the nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?
A: apply an Ice pack & encourage the client to keep the head elevated
Q35: a nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?
A: asking the client to repeat "ninety-nine" as the nurse's hands move down the clients thorax
Q36: the nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?
A: assess the client for a cough reflex - the client must take nothing by mouth until the cough reflex returns
Q40: the nurse is caring for a client reporting chest discomfort. The clients diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use help alleviate the discomfort?
A: assume a left side-lying position clients are more comfortable when laying on the affected side because this splints the chest wall, limits expansion and contraction of the lung and reduces the friction between the injured or diseased pleurae on that side
Q 4: a thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?
A: cancer - serous fluid may be associated with cancer, inflammatory conditions or heart failure *blood fluid typically suggests trauma *purulent fluid is indicative of infection
Q68: when a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for?
A: carotid artery hemorrhage - the carotid artery lies close to the stoma and may rupture from erosion if the wound does no heal properly
Q66: another term for clergyman's sore throat is?
A: chronic granular pharyngitis - the pharynx is characterized by numerous swollen lymph follicles
Q56: the nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the clients risk of developing ventilator associated pneumonia?
A: cleaning the client's mouth with chlorhexidin daily - keep the pt in semi-fowlers position - daily "sedation vacations" - assessment of readiness to extubatne - peptic ulcer disease prophylaxis -deep venous thrombosis prophylaxis
Q 8: which ventilation-perfusion ratio is exhibited by pulmonary embolus?
A: dead space dead space exists when ventilation exceeds perfusion, an example of a dead space is pulmonary embolus
Q 3: while conducting the physical examination during assessment of the respiratory system, which condition does the nurse assess by inspecting and palpating the trachea?
A: deviation from the midline -
Q69: which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
A: ensure mouth breathing - after surgery nasal packing will be in place the nurse would apply an ice pack to reduce pain & swelling not a warm pack the nurse would recommend the use of splint and the application of pressure to the convex portion of the nose in case of a nasal fracture
Q64: the nurse assess a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?
A: epistaxis - epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any are of the nose
Q84: the nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is?
A: epistaxis, pharyngitis, cough, nasal irritation and bronchospasm
Q82: the nurse is assessing a client for OSA (obstructive sleep apnea). Which are the signs & symptoms of OSA
A: excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, corpulmonale, polycythemia, enuresis
Q46: which type of oxygen therapy included the administration of oxygen at a pressure greater than atmospheric pressure?
A: hyperbaric - as a result of this oxygen therapy, the amount of oxygen dissolved in plasma is increased which brings oxygen levels in the tissues
Q16: Bradypnea is associated with which condition
A: increased intracranial pressure, brain injury and drug overdose
Q79: which clinical manifestation of hemorrhage is related to carotid artery rupture?
A: increased pulse rate, decreased blood pressure, rapid & deep respirations, cold & clammy & pale skin
Q 3: which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
A: inspiratory reserve volume - normally 3000 mL
Q37: a client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night". The nurse should suspect which of the following conditions based on the client's primary report?
A: left-sided heart failure coughing at night may indicated the onset of left-sided heart failure or bronchial asthma.
Q38: the nurse answers a clients call light. The client reports an irritating, tickling sensation in the throat, a salty taste and a burning sensation in the chest. Upon further assessment the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of blood is likely from the?
A: lungs
Q41: which oxygen administration device has the advantage of providing a high oxygen concentration
A: nonrebreathing mask provide high oxygen concentrations but usually fit poorly
Q67: which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion
A: obstructive - usually occurs in men, older aged, and overweight
Q20: which term will the nurse use to document the inability of a client to breath easily unless positioned upright?
A: orthopnea - term used to describe a pts inability to breath easily except in an upright position - occurs in clients w/ heart disease & occasionally in clients w COPD. - clients will be placed in high fowlers position to facilitate breathing
Q74: which medication is the treatment choice for bacterial pharyngitis
A: penicillin (robitussin DM may be used as an antitussive. For severe sore throats aspirin or tylenol or tylenol w/ codeine may be give)
Q63: the nurse is assessing a client in the clinic, upon physical assessment the client demonstrated displacement of the sternum. This would be documented as which condition?
A: pigeon chest - pigeon chest occurs in pts w/ rickets, marfan syndrome, or severe kyphoscoliosis
Q18: the nurse auscultates lung sounds that are are harsh & cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
A: pleural friction rub - heard secondary to inflammation & loss of lubricating pleural fluid
Q44: in general, chest drainage tubes are not used for a pt undergoing
A: pneumonectomy lobectomy= two chest tubes wedge resection= pleural cavity chest tube segmentectomy = chest tube
Q14: pink frothy sputum may be an indication of
A: pulmonary edema
Q80: a client has an altered level of consciousness is receiving a tube feeding. CLients receiving tube feeding should be placed in which position?
A: semi-flowers or higher and left in that position for 30 - 45 min after the feeding
Q72: which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?
A: sinus aspirates
Q85: the nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing
A: sinus infection
q 9: the term for the volume of air inhaled & exhaled with each breath is
A: tidal volume - the volume of air inhaled & exhaled with each breath
Q71: which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?
A: use enteral feedings after the procedure - should be used 10 - 14 days after procedure to avoid irritation and reduce the risk of aspiration
Q47:which type of ventilator has a preset volume of air to be delivered with each inspiration
A: volume-controlled ventilation
Q60: when removing the chest tube from a patient what instructions should the nurse give the patient
A: when the chest tube is being removed, take a deep breath, exhale and bear down
Q88: the nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. what info will the nurse include
A: you can use writing or a communication board to communicate - a total laryngectomy will cause the pt to lose all their natural voice
Q55: the nurse is preparing to perform chest physiotherapy on a client. Which statement by the client tells the nurse that the procedure is contraindicated
A:I just finished eating my lunch, i am ready for CPT now
Q43: when performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?
A; 10-15 second >15 seconds= hazardous, may result in development of hypoxia, which can lead to dysrhythmias and ultimately cardiac arrest <10 = not effective for suctioning secretions
Q15: which is a deformity of the chest that occurs as a result of overinflation of the lungs
A; barrel chest - the anteroposterior diameter of the thorax increases
Q 7: for which reason does gas exchange decrease in older adults
A; the alveolar walls contain fewer capillaries The number of alveoli remains stable with age, the alveolar walls become thinner & contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Elasticity of lungs does not increase with age and the number of alveoli does not decrease with age
residual volume
Amount of air remaining in the lungs after a forced exhalation
Q78:which is the priority nursing diagnosis for a client undergoing a laryngectomy? a) impaired verbal communication b)ineffective airway clearance c)anxiety & depression D)imbalanced nutrition : less than body requirements
B - ineffective airway clearence all options are potential nursing diagnosis, but B is the priority
Q61: the nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client a: requiring mechanical ventilation following the surgery b: returing to the nursing unit with two chest tubes C: requiring sedation until the chest tube(s) are removed d: returning from surgery with no drainage tubes
B -returing to the nursing unit with two chest tubes
Q52: constant bubbling in the water seal of a chest drainage system indicates which problem a: tension b: air leak c: tidaling d: increased drainage
B: air leak Tidaling=fluctuation of the water level in the water seal
Q13: which is an age - related change associated with the respiratory system? a) increased chest muscle mass b) decreased size of the airway c)increased elasticity of alveolar sacs d) thinning of the alveolar membranes
B: decreased size of the airway - decrease chest muscle mass - increase thickening of the alveolar membranes - decreased elasticity of the alveolar sacs
Q50: which finding would indicate a decrease in pressure with mechanical ventilation a: kinked tubing b: increase in compliance c:decrease in lung compliance d:plugged airway tube
B: increase in compliance options A,C,D would cause an increase in peak airway pressure
Q70: When the nurse give a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? a) hand-held showers b)swimming c)coughing d)wearing a scarf over the stoma
B: swimming - water should not enter the stoma because it will flow from the trachea to the lungs. the pt should use a hand-held shower device, and the nurse should suggest the client to wear a scarf to make the opening less obvious. the client should cough every 2 hrs to promote effective gas exchange
Q30: a client with a newly diagnosed emphysema is admitted to the medical surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population?
Barrel chest - occurs w/ aging as is a hallmark sign of emphysema and COPD
q 19: which is a late sign of hypoxia a) somnolence b)restlessness c) cyanosis d)hypotension
C) cyanosis Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
Q75: a client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include? a) a sore throat that feels worse in the evening b)moist cough c)hoarseness d)non edematous uvula
C- hoarseness - signs of acute laryngitis include hoarseness or aphonia and severe cough. A dry cough and a sore throat that feels worse in the morning if allergies are present the uvula will be visibly edematous
Q 6: it is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory distress in order to? a: manage decreased respiratory distress b: aid the clients caregivers c: manage decreased energy levels d: ensure adequate rest periods
C: manage decreased energy levels - in addition to the nursing management of individual tests, clients w/ respiratory disorders require informative & appropriate explanations for any diagnostic procedures they will experience. Nurses must remember that for many clients breathing may in some way be compromised and energy levels may be decreased. Explanations should be brief, yet complete, and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before & after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress
sibilant wheezes
Continuous musical, high pitched, whistle like; heard on inspiration and expiration; narrowed by asthma, spasm, or secretions
low-flow systems
Contribute partially to the inspired gas the client breaths. Meaning the client breaths some room air along with the oxygen Ex. Simple mask, nasal cannula
Kyphoscoliosis
Elevation of the scapula and a corresponding S shaped spine. limits lung expansion within the thorax
Q57: the nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy. Which action, if preformed by the nurse, indicated the need for further review of the procedure
Places clean tracheostomy ties then removes soiled ties after the new ties are in place - two people should assist with tie changes
Q 11: In which position should the client be placed for a thoracentesis?
Sitting on the edge of the bed - place the client upright or sitting on the edge of the bed with the feet supported and arm & head on a padded over-the-bed table
Pulmonary edema or cardiac distress can occur:
after a sudden shift in mediastinal contents when large amounts of fluid are aspirated
examining anterior, posterior, lateral chest walls for:
any evidence of muscle weakness
Coughing after food intake may indicate:
aspiration of material into the tracheobronchial tree..
Atrophic pharyngitis
characterized by a membrane that is thin, white, glistening and at times wrinkled
Q81: the nurse knows that there are 3 types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?
chronic granular
Transtracheal Oxygen Delivery
clients achieve adequate oxygenation at lower rates making this method less expensive and more efficient
a cough that occurs more frequently at night is not associated with
copd, emphysema or bronchitis
Synchronized Intermittent Mandatory Ventilation (SIMV)
delivers a present tidal volume and number of breaths per minute. Between ventilator delivered breaths, the client can breath spontaneously with no assistance from the ventilator for those extra breaths
dysphagia
difficulty swallowing
low ventilation perfusion ratio
exists in pneumonia or with a mucus plug
face tent
fairly accurate fraction of inspired oxygen but is bulky and uncomfortable
pleuritic pain
from irritation of the parietal pleura is sharp & seems to "catch" upon inspiration; clients often describe it as "like the stabbing of a knife"
Hypertrophic pharyngitis
general thickening and congestion of the pharyngeal mucous membrane
hypertrophic pharyngitis
general thickening and congestion of the pharyngeal mucous membrane
Q59: the nurse is instructing the client pursed lip breathing what is the purpose of this technique
improve oxygen transport; induce a slow, deep breathing pattern, and assist the client to control breathing
aphonia
inability to use ones voice
Q31: a nurse is caring for a critically ill client in the ICU. The nurse documents the clients respiratory rate as bradypnea. The nurse recognizes that bradypnea is associated w/ which condition?
increased intracranial pressure
high-flow systems
indicated for clients who require a constant precise amount of oxygen -venturi mask -aerosol mask -face tent -tracheostomy collar -t-piece
catheter (oxygen)
inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distension
thyroid cartilage
largest of the cartilage structures and part of it forms the adams apple
foul smelling sputum
lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic oranisms
Q77: stiffness of the neck or inability to bend the neck is referred to as
nuchal rigidity
Q86: the nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon the nurse will
obtain a light, mirror, gauze and curved hemostats
pigeon chest
occurs as a result of displacement of the sternum resulting in an increase in the anteroposterior diameter.
Funnel chest
occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs
tachypnea is commonly seen w/
pneumonia, pulmonary edema, metabolic acidosis
Complications from a thoracentesis include:
pneumothorax & subcutaneous emphysema
Conditions associated w/ decreased compliance
pneumothorax, pleural effusion, acute respiratory distress system (ARDS)
assist control ventilation
provides full ventilator support by delievering a present tidal volume + respiratory rate
venturi mask
provides low levels of supplemental oxygen
central sleep apnea
pt demonstrates simultaneous cessation of both airflow & respiratory movements
rhinorrhea
refers to drainage of a large amount of fluid from the nose
hemoptysis
refers to expectoration of blood from the respiratory tract.
Hypoxemia
refers to low oxygen levels in the
Q62: the nurse is caring for a client with an endotracheal tube. Which of the nursing interventions is contraindicated
routinely deflating the cuff
Crackles
soft high-pitched, discontinuous popping sounds that occur during inspirations
A cough that worsens when the patient is supine:
suggests postnasal drip (rhinosinusitis).
Pressure suppor ventilation
supports SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing
expiratory reserve volume
the maximum volume of air that can be exhaled forcibly after each exhalation
Q 2: In relation to the structure of the larynx the cricoid cartilage is?
the only complete cartilaginous ring in the larynx, located below the thyroid cartilage
client w/ emphysema
the ribs are more widely spaced and the intercostal spaces tend to bulge upon expiration (barrel chest)
epiglottis
the valve flap of cartilage that covers the opening of the larynx during swallowing
tidal volume
the volume of air inhaled and exhaled with each breath
Residual volume
the volume of air remaining in the lungs after a maximum exhalation
MRI
used to characterize pulmonary nodules, stage bronchogenic carcinoma, evaluate inflammatory activity in interstitial lung disease
pulmonary aniography
used to investigate thromboembolic disease of the lungs
gallium scan
used to stage bronchogenic cancer & document tumor regression after chemotherapy or radiation
Arytenoid cartilage
used with the thyroid cartilage in vocal cord movement