Respiratory Disorders NCLEX questions

A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm? A Kinking of the ventilator tubing B A disconnected ventilator tube C An endotracheal cuff leak D A change in the oxygen concentration without resetting the oxygen level alarm

A. Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would tigger the oxygen alarm.

Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous

A. Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A Dyspnea B Bradypnea C Bradycardia D Decreased respirations

A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? A Stridor B Occasional pink-tinged sputum C A few basilar lung crackles on the right D Respiratory rate 24 breaths/min

A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician.

For a male client with an endotracheal (ET) tube, which nursing action is most essential? A Auscultating the lungs for bilateral breath sounds B Turning the client from side to side every 2 hours C Monitoring serial blood gas values every 4 hours D Providing frequent oral hygiene

A.For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.

The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? A It helps prevent early airway collapse B It increases inspiratory muscle strength C It decreases use of accessory breathing muscles D It prolongs the inspiratory phase of respiration

A.Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: A Resonant sounds B Hyperresonant sounds C Dull sounds D Flat sounds

A.When percussing the chest wall, the nurse expects to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: A Lips B Mucous membranes C Nail beds D Earlobes

B

A male patient has a sucking stab wound to the chest. Which action should the nurse take first? ADrawing blood for a hematocrit and hemoglobin level BApplying a dressing over the wound and taping it on three sides CPreparing a chest tube insertion tray DPreparing to start an I.V. line

B

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? A Simple mask B Non-rebreather mask C Face tent D Nasal cannula

B. A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? A Hypocapnia B A hyperinflated chest noted on the chest x-ray C Increased oxygen saturation with exercise D A widened diaphragm noted on the chest x-ray

B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A Call the physician B Place the tube in bottle of sterile water C Immediately replace the chest tube system D Place a sterile dressing over the disconnection site

B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to: A Call the physician to reinsert the tube B Grasp the retention sutures to spread the opening C Call the respiratory therapy department to reinsert the tracheotomy D Cover the tracheostomy site with a sterile dressing to prevent infection

B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation.

On auscultation, which finding suggests a right pneumothorax? A Bilateral inspiratory and expiratory crackles B Absence of breaths sound in the right thorax C Inspiratory wheezes in the right thorax D Bilateral pleural friction rub

B. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: A15 to 60 seconds B 5 to 20 minutes C30 to 40 minutes D 45 to 60 minutes

B. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: A 1 L/min B 2 L/min C 6 L/min D 10 L/min

B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A Face tent B Venturi mask C Aerosol mask D Tracheostomy collar

B. The Venturi mask delivers the most accurate oxygen concentration

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A Pallor B Low arterial PaO2 C Elevated arterial PaO2 D Decreased respiratory rate

B. The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A Inform the physician B Continue to monitor the client C Reinforce the occlusive dressing D Encourage the client to deep-breathe

B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A A low respiratory rate B Diminished breath sounds C The presence of a barrel chest D A sucking sound at the site of injury

B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen? ALimiting fluid BHaving the client take deep breaths CAsking the client to spit into the collection container DAsking the client to obtain the specimen after eating

B. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis? A Bronchoscopy B Sputum culture C Chest x-ray D Tuberculin skin test

B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase "a" in ABG value present? A Acid-base balance B Arterial Blood C Arterial oxygen saturation D Alveol

B.A lowercase "a" in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase "A" represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli.

A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: A Area of redness is measured in 3 days and determines whether tuberculosis is present. B Skin test doesn't differentiate between active and dormant tuberculosis infection. C Presence of a wheal at the injection site in 2 days indicates active tuberculosis. D Test stimulates a reddened response in some clients and requires a second test in 3 months.

B.The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A Cardiogenic pulmonary edema B Respiratory alkalosis C Increased pulmonary capillary permeability D Renal failure

C. ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? AThe system is functioning normally B The client has a pneumothorax C The system has an air leak D The chest tube is obstructed

C. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? A Impaired color discrimination B Increased urinary frequency C Decreased hearing acuity D Increased appetite

C. Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be prescribed. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus.

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? AContinue to suction BNotify the physician immediately C Stop the procedure and reoxygenate the client DEnsure that the suction is limited to 15 seconds

C. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A1 minute B5 seconds C10 seconds D30 seconds

C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician? A Dry cough B Hermaturia CBronchospasm DBlood-streaked sputum

C. If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: A Pleural effusion B Pulmonary edema C Atelectasis D Oxygen toxicity

C. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? A Encouraging the patient to drink three glasses of fluid daily B Keeping the patient in semi-fowler's position C Using a high-flow venturi mask to deliver oxygen as prescribe D Administering a sedative, as prescribe

C. The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: A Monitor fluctuations in the water-seal chamber B Clamp the chest tube once every shift C Encourage coughing and deep breathing D Milk the chest tube every 2 hours

C. When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage

A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? AActivity intolerance related to fatigue BAnxiety related to actual threat to health status CRisk for infection related to retained secretions DImpaired gas exchange related to airflow obstruction

D

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A pH, 5.0; PaCO2 30 mm Hg B pH, 7.40; PaCO2 35 mm Hg C pH, 7.35; PaCO2 40 mm Hg D pH, 7.25; PaCO2 50 mm Hg

D In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.

Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for: A Patients with an acute asthma attack B Patients with narcolepsy C Patients under age 6 D Elderly patients

D. Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.

Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: A Dyspnea B Chest pain C A bloody, productive cough D A cough with the expectoration of mucoid sputum

D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: A Promote oxygen intake B Strengthen the diaphragm C Strengthen the intercostal muscles D Promote carbon dioxide elimination

D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A Nausea or vomiting BAbdominal pain or diarrhea CHallucinations or tinnitus DLightheadedness or paresthesia

D. The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A Contralateral side in a simple pneumothorax B Affected side in a hemothorax C Affected side in a tension pneumothorax D Contralateral side in hemothorax

D. The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A Exhale slowly B Stay very still C Inhale and exhale quickly D Perform the Valsalva maneuver

D. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.

A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose? A Leg movement B Finger movement C Lip movement D Fighting the ventilator

D.Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

Which phrase is used to describe the volume of air inspired and expired with a normal breath?

Tidal volume