NCLEX Questions: Respiratory Disorders
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. Do nothing, because this is an expected finding Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous, not intermittent. The bubbling should also be gentle.
A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, & the endotracheal intubation & mechanical ventilator 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. A endotracheal cuff leak D. A change in the oxygen concentration without setting the oxygen level alarm
A. Kinking of the ventilator tubing The high pressure alarm can be triggered by kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water int he tube, coughing or biting on endotracheal tube, or patient being out of breathing rhythm with the ventilator.
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. Stridor The nurse should report stridor to the physical 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.
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assess 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. 2 L/min Oxygen is used cautiously & 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.
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. A hyper-inflated chest noted on the chest x-ray Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion & at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyper-inflated chest & a flattened diaphragm if the disease is advanced.
On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles B. Absence of breath sounds in the right thorax C. Inspiratory wheezes in the right thorax D. Bilateral pleural friction rub
B. Absence of breath sounds in the right thorax With a pneumothorax, the alveoli are deflated and no air exchange occurs. Therefore, breath sounds in the affected lung field are absent. Bilateral crackles may result from pulmonary congestion. Inspiratory wheezes may signal asthma. Pleural friction rub may indicated pleural inflammation.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first? A. Drawing blood for a hematocrit and hemoglobin level B. Applying a dressing over the wound and taping it on three sides C. Preparing a chest tube insertion tray D. Preparing to start an IV line
B. Applying a dressing over the wound and taping it on three sides The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (this is more life threatening than an open chest wound). Everything else should be done once the wound is covered & taped.
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. Alveoli
B. Arterial blood A lowercase "a" in an ABG value represents arterial blood.
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. Continue to monitor the client 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 look exists, if the suction is not working properly, or if the lung has re expanded.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to: A. Encourage oral feeding as soon as possible B. Develop an alternative communication method C. Keep the tracheostomy cuff fully inflated D. Keep the patient flat in bed
B. Develop an alternative communication method This patient will not be able to speak and still needs to be able to communicate. To decrease the swelling, the patient should be in semi-fowler's position.
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. Diminished breath sounds This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax include shortness of breath & chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, & subcutaneous emphysema. Hyper-resonance also may occur on the affected side.
While changing the tapes on a tracheostomy tube, the male client coughs and the 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. Grasp the retention sutures to spread the opening. 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.
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. Low arterial PaO2 The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, & the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals a PaO2 lower than 60 mmHG.
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause: A. Nasal congestion B. Nervousness C. Lethargy D. Hyperkalemia
B. Nervousness Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat. Hypokalemia may occur with high doses. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting, and muscle cramps.
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. Place the tube in bottle of sterile water If the chest drainage system is disconnected, the end of the chest tube is placed in a bottle of sterile water held below the level of the chest.
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. Sputum culture TB is definitively diagnosed through culture & isolation of Mycobacterium tuberculosis.
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. Venturi mask The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration.
Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In a acute rhinitis, nasal drainage normally is: A. Yellow B. Green C. Clear D. Gray
C. Clear Nasal drainage in acute rhinitis is clear. Yellow or green drainage would indicate an infection. Grey drainage would indicate a secondary infection.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this client, the nurse must: A. Report 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. Encourage coughing and deep breathing When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing & deep breathing to prevent pneumonia in the unaffected lung. Since the lung has been removed, the water seal chamber should display no fluctuations.
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
C. Fighting the ventilator Pancuronium is a non depolarizing blocking agent and is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation & paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another dose.
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. Increased pulmonary capillary permeability ARDS results from increased pulmonary capillary permeability, which then leads to noncardiogenic pulmonary edema. Respiratory alkalosis & renal failure do not cause ARDS.
For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A. Restricting fluid intake to 1,000 ml per day B. Enforcing absolute bed rest C. Teaching the patient how to perform controlled coughing D. Administering prescribe sedatives regularly and in large amounts
C. Teaching the patient how to perform controlled coughing Controlled coughing helps maintain a patent airway because it helps mobilize & remove secretions. A moderate fluid intake and moderate activity will help break down secretions.
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 venture mask to deliver oxygen as prescribe D. Administering a sedative, as prescribe
C. Using a high flow venture mask to deliver oxygen as prescribe 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 & accurately. Patients with COPD & respiratory distress should be placed in high fowler's position. They should also not receive sedatives or other drugs that may further cause respiratory depression.
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. A cough with the expectoration of mucoid sputum One of the first pulmonary symptoms are a slight cough with the expectoration of mucoid sputum.
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. Contralateral side in hemothorax The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax & hemothorax, acumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid acumulation, the trachea will not shift.
Before administering ephedrine, Nurse Tony assesses the patient's history. Before 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. Elderly patients Ephedrine is not recommended for elderly patients who are particularly susceptible to CNS reactions (like confusion & anxiety) & to cardiovascular reactions (such as increased systolic blood pressure, coldness in extremities, & angina pain). Ephedrine is used for its bronchodilator effects with acute & chronic asthma & occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 & older.
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? A. Activity intolerance related to fatigue B. Anxiety related to actual threat to health status C. Risk for infection related to retained secretions D. Impaired gas exchange related to airflow obstruction
D. Impaired gas exchange related to airflow obstruction Patient's airway & an adequate breathing pattern are the top priority for any patient, therefore "impaired gas exchange related to airflow obstruction" is the most important.
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 B. Abdominal pain or diarrhea C. Hallucinations or tinnitus D. Lightheadedness or paresthesia
D. Lightheadedness or paresthesia Patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness & tingling in arms and legs). Nausea, vomiting, abdominal pain, & diarrhea may accompany respiratory acidosis. Hallucinations & tinnitus are rarely associated with respiratory alkalosis & any other acid-base imbalance.
A nurse is assisting the physician with the removal of a chest tube. The nurse should instruct the client to: A. Exhale slowly B. Stay very still C. Inhale & exhale quickly D. Perform the Valsalva maneuver
D. Perform the Valsalva maneuver 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, & an airtight dressing is taped in place. An alternate instruction would be to ask the client to take a deep breath and hold the breath while the tube is removed.
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. Promote carbon dioxide elimination 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.
