Ch 20 NCLEX
A patient with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which of the following does the nurse recognize is a deformity of the chest wall that occurs as a result of overinflation of the lungs in this patient population? a) Funnel chest b) Barrel chest c) Pigeon chest d) Kyphoscoliosis
b) Barrel chest Explanation: A barrel chest occurs as a result of over inflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. It occurs with aging and is a hallmark sign of emphysema and chronic obstructive pulmonary disease (COPD). In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. Funnel chest occurs when there is a depression in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.
Which of the following ventilation-perfusion ratios is exhibited when a patient is diagnosed with pulmonary emboli? a) Silent unit b) Dead space c) Normal perfusion to ventilation ratio d) Low ventilation-perfusion ratio
b) Dead space Explanation: When ventilation exceeds perfusion a dead space exists (high ventilation-perfusion ratios). An example of a dead space is pulmonary emboli, pulmonary infarction, and cardiogenic shock. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS.
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? a) Residual volume b) Inspiratory reserve volume c) Tidal volume d) Expiratory reserve volume
b) Inspiratory reserve volume Explanation: The maximum volume of air that can be inhaled after a normal inhalation is termed inspiratory reserve volume. Inspiratory reserve volume is normally 3,000 mL. Tidal volume is the volume of air inhaled and exhaled with each breath. Expiratory reserve volume is the maximum volume of air that can be exhaled forcibly after a normal exhalation. Residual volume is the volume of air remaining in the lungs after a maximum exhalation.
Which of the following is a true statement regarding air pressure variances? a) Air is drawn through the trachea and bronchi into the alveoli during inspiration. b) The diaphragm contracts during inspiration. c) Air flows from a region of lower pressure to a region of higher pressure during inspiration. d) The thoracic cavity becomes smaller during inspiration.
a) Air is drawn through the trachea and bronchi into the alveoli during inspiration. Explanation: During inspiration, movements of the diaphragm and intercostal muscles enlarge the thoracic cavity, thereby lowering the pressure inside the thorax to a level below that of atmospheric pressure. As a result, air is drawn through the trachea and bronchi into the alveoli.
The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following? a) Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax b) Instructing the patient to take a deep breath and hold it while the diaphragm is percussed c) Placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply d) Asking the patient to say "one, two, three" while auscultating the lungs
a) Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax Explanation: While the nurse is assessing for tactile fremitus, the patient is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the patient's thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared. Asking the patient to say "one, two, three" while auscultating the lungs is not the proper technique for assessing for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the patient to take a deep breath and hold it while the diaphragm is percussed.
High or increased compliance occurs in which of the following conditions? a) Emphysema b) Pneumothorax c) Pleural effusion d) ARDS (acute respiratory distress syndrome)
a) Emphysema Explanation: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is over-distended as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and ARDS.
The nurse is caring for a patient with suspected lung cancer. Which of the following imaging studies is more accurate in detecting malignancies than a CT scan? a) PET scan b) MRI c) Gallium scan d) Pulmonary angiography
a) PET scan Explanation: A PET scan is more accurate than a CT scan in detecting malignancies, and it has equivalent accuracy in detecting malignant nodules when compared with invasive procedures such as thorascopy. The gallium scan is used to stage bronchogenic cancer and document tumor regression after chemotherapy or radiation. An MRI is used to characterize pulmonary nodules, to help stage bronchogenic carcinoma, and to evaluate inflammatory activity in interstitial lung disease. Pulmonary angiography is used to investigate thromboembolic disease of the lungs.
In relation to the structure of the larynx, the cricoid cartilage is which of the following? a) The only complete cartilaginous ring in the larynx b) The valve flap of cartilage that covers the opening to the larynx during swallowing c) Used in vocal cord movement with the thyroid cartilage d) The largest of the cartilage structures
a) The only complete cartilaginous ring in the larynx Explanation: The cricoid cartilage is the only complete cartilaginous ring in the larynx (located below the thyroid cartilage). The arytenoid cartilages are used in vocal cord movement with the thyroid cartilage. The thyroid cartilage is the largest of the cartilage structures; part of it forms the Adam's apple. The epiglottis is the valve flap of cartilage that covers the opening to the larynx during swallowing.
The volume of air inhaled and exhaled with each breath is termed which of the following? a) Tidal volume b) Vital capacity c) Vital capacity d) Residual volume
a) Tidal volume Explanation: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does bloody fluid indicate? a) Infection b) Malignancy c) Emphysema d) Trauma
b) Malignancy Explanation: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. The fluid, which may be clear, serous, bloody, or purulent, provides clues to the pathology. Bloody fluid may indicate malignancy, whereas purulent fluid usually indicates an infection. Pneumothorax, tension pneumothorax, subcutaneous emphysema, and pyogenic infection are complications of a thoracentesis. Pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated.
Which of the following terms will the nurse use to document the inability of a patient to breathe easily unless positioned upright? a) Hemoptysis b) Orthopnea c) Hypoxemia d) Dyspnea
b) Orthopnea Explanation: Orthopnea is the term used to describe a patient's inability to breathe easily except in an upright position. Orthopnea may be found in patients with heart disease and, occasionally, in patients with COPD. Patients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.
The clinical finding of pink frothy sputum may be an indication of which of the following? a) Bronchiectasis b) Pulmonary edema c) An infection d) A lung abscess
b) Pulmonary edema Explanation: Profuse, frothy pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath may indicate a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.
The nurse is caring for a patient who is to undergo a thoracentesis. In preparation for the procedure, the nurse will position the patient in which of the following positions? a) Lateral recumbent b) Sitting on the edge of the bed c) Supine d) Prone
b) Sitting on the edge of the bed Explanation: If possible, it is best to place the patient upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the patient could be placed include straddling a chair with arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees if unable to assume a sitting position.
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following? a) Ensure the patient remains moderately sedated to decrease anxiety. b) Offer the patient ice chips. c) Assess the patient for a cough reflex. d) Instruct the patient that bed rest must be maintained for 2 hours.
c) Assess the patient for a cough reflex. Explanation: After the procedure, the patient must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The patient is sedated during the procedure, not afterward. The patient is not required to maintain bed rest following the procedure.
Which of the following is an age-related change associated with the respiratory system? a) Decreased thickening of alveolar membranes b) Increased elasticity of alveolar sacs c) Decreased size of the airway d) Increased chest muscle mass
c) Decreased size of the airway Explanation: Age-related changes that occur in the respiratory system are a decrease in the size of the airway, decreased chest muscle mass, increased thickening of the alveolar membranes, and decreased elasticity of the alveolar sacs.
The nurse is caring for a patient who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a patient with a respiratory disorder in order to do which of the following? a) Manage respiratory distress b) Aid the caregivers of the patient c) Manage decreased energy levels d) Ensure adequate rest periods
c) Manage decreased energy levels Explanation: In addition to the nursing management of individual tests, patients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these patients, breathing may in some way be compromised and energy levels may be decreased. For that reason, 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 and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.
The nurse auscultates the lung sounds of a patient during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as which of the following? a) Crackles b) Sibilant wheezes c) Pleural friction rub d) Sonorous wheezes
c) Pleural friction rub Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration.
The nurse is calculating the patient's smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient's pack-years as which of the following? a) 5 b) 11 c) 10 d) 22
d) 22 Explanation: Smoking history is usually expressed in pack-years, which is the number of packs of cigarettes smoked per day times the number of years the patient smoked. It is important to find out if the patient is still smoking or when the patient quit smoking. In this situation, the patient's pack years is 22 (2 × 11).
The nurse is caring for a patient with extensive respiratory disease. Which of the following is a late sign of hypoxia in the patient? a) Somnolence b) Hypotension c) Restlessness d) Cyanosis
d) Cyanosis Explanation: Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
The nurse is completing a physical assessment of a patient's trachea. The nurse inspects and palpates the trachea for which of the following? a) Evidence of exudate b) Evidence of muscle weakness c) Color of the mucous membranes d) Deviation from the midline
d) Deviation from the midline Explanation: During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The trachea is normally in the midline as it enters the thoracic inlet behind the sternum, but it may be deviated by masses in the neck or mediastinum. Pulmonary disorders, such as a pneumothorax or pleural effusion, may also displace the trachea. The nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.
The nurse is caring for a critically ill patient in the ICU). The nurse documents the patient's respiratory rate as bradypnea. The nurse recognizes bradypnea is associated with which of the following conditions? a) Pneumonia b) Pulmonary edema c) Metabolic acidosis d) Increased intracranial pressure
d) Increased intracranial pressure Explanation: Bradypnea is associated with increased intracranial pressure, brain injury, and drug overdose. Respirations are slower than normal rate (<10 breaths/min), with normal depth and regular rhythm. Tachypnea is commonly seen in patients with pneumonia, pulmonary edema, and metabolic acidosis.
A patient presents to the ED complaining of severe coughing episodes. The patient states the "episodes are more intense at night." The nurse should suspect which of the following conditions based on the patient's primary complaint? a) Chronic obstructive pulmonary disorder (COPD) b) Bronchitis c) Emphysema d) Left-sided heart failure
d) Left-sided heart failure Explanation: Coughing at night may indicate the onset of left-sided heart failure or bronchial asthma. A cough in the morning with sputum production may indicate bronchitis. A cough that worsens when the patient is supine suggests postnasal drip (rhinosinusitis). Coughing after food intake may indicate aspiration of material into the tracheobronchial tree. A cough of recent onset is usually from an acute infection. A cough that occurs more frequently at night is not associated with COPD, emphysema, or bronchitis.
The nurse is caring for a patient complaining of chest discomfort. The patient's admitting diagnosis is left lower lobe pneumonia. Which of the following strategies will the nurse instruct the patient to use to help alleviate the discomfort? a) Assume a left side-lying position while in bed b) Complete deep breathing exercises when chest discomfort occurs c) Request narcotic medication when pain is experienced d) Lying on the right side
d) Lying on the right side Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration; patients often describe it as being "like the stabbing of a knife." Patients are more comfortable when they lay 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. Pain associated with cough may be reduced manually by splinting the rib cage. The nurse would instruct the patient to lie on the left side, not the right, to decrease the pain. While pain medication may be administered, nonpharmacological therapies and non-narcotic interventions should be implemented first. Deep breathing exercises would not aid in decreasing the pain, but rather slowing the patient's breathing and expanding the lungs.
Which of the following results in decreased gas exchange in older adults? a) The number of alveoli decreases with age. b) The alveolar walls become thicker. c) The elasticity of the lungs increases with age. d) The alveolar walls contain fewer capillaries.
d) The alveolar walls contain fewer capillaries. Explanation: Although the number of alveoli remains stable with age, the alveolar walls become thinner and contain fewer capillaries, resulting in decreased gas exchange. The lungs also lose elasticity and become stiffer. Lungs elasticity does not increase with age, and number of alveoli does not decrease with age.
The nurse answers the call light of a male patient. The patient is complaining of 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 the blood is likely from which of the following? a) The rectum b) The stomach c) The nose d) The lungs
d) The lungs Explanation: Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the patient tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; often referred to as "coffee ground emesis." This blood has an acid pH (<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing