Kaplan Respiratory Test b
An adult is in a motorcycle accident and sustains three fractured ribs and a pneumothorax. A chest tube is inserted. The nurse should take which of the following actions? a) monitor the fluctuation in the tube b) pin the tubes to the sheets c) clamp the tubes when transferring the patient to bed d) empty the bottles every eight hours (Kaplan Resp Set 21/30)
a) a closed drainage that enables air and blood to drain from the pleural space; cessation of fluctuation may indicate blockage of the tube, or that the lung has re-expanded; fluctuation in the tube should be monitored (Kaplan Resp Set 21/30)
The nurse instructs a group of high school students how to perform the abdominal-thrust maneuver. The nurse determines that teaching is successful if a student makes which comment? a) "the abdominal-thrust maneuver dislodges food or other foreign bodies from the airway." b) "the abdominal-thrust maneuver involves hitting the person on the back several times." c) "the abdominal-thrust maneuver should not be done if the person is pregnant." d) "the abdominal-thrust maneuver should only be done by a well-trained health care professional." (Kaplan Resp Set 17/30)
a) hands crossed at neck is universal sign of chocking; abdominal-thrust maneuver is used to dislodge food or other foreign bodies in the airway (Kaplan Resp Set 17/30)
The nurse assesses a patient receiving isoniazid (INH). It is MOST important for the nurse to observe for which? a) hepatitis b) glomerulonephritis c) photosensitivity d) deafness (Kaplan Resp Set 28/30)
a) hepatitis is a side effect of INH; teach signs of hepatitis and check liver function tests; instruct patient to avoid alcohol; other side effects include peripheral neuritis, rash, and fever (Kaplan Resp Set 28/30)
The nurse performs discharge teaching for a patient diagnosed with chronic obstructive pulmonary disease (COPD). The client asks if the oxygen concentration can be increased during periods of shortness of breath. On what is the nurse's response based? a) high-low oxygen interferes with breathing b) low-flow oxygen will not improve breathing c) high-flow oxygen will stimulate breathing d) low-flow oxygen is more comfortable (Kaplan Resp Set 22/30)
a) patients with COPD are stimulated to breathe not by increasing levels of carbon dioxide, but by a decreased level of oxygen in the blood; if high-flow oxygen is provided to these patients, it eliminates their drive to breathe (Kaplan Resp Set 22/30)
The nurse prepares a patient for a thoracentesis. The nurse should position the patient in which position? a) Semi-Fowler's b) upright c) on the affected side d) prone (Kaplan Resp Set 23/30)
b) a thoracentesis is the aspiration of pleural fluid or air from the pleural space; sitting upright on the edge of the bed allows for the best lung expansion, and allows for good access to the area which will be used for the procedure (Kaplan Resp Set 23/30)
The nurse cares for a patient receiving aminophylline. The nurse identifies which is a common side effect of aminophylline? a) increased respiratory rate b) increased pulse rate c) decreased respiratory rate d) decreased pulse rate (Kaplan Resp Set 30/30)
b) aminyphylline is a therapeutic bronchodilator and a pharmacologic xanthine known to cause tachycardia, nervousness, restlessness, and nausea; must be used cautiously in patients with cardiac impairment (Kaplan Resp Set 30/30)
Which sign or symptom, if observed by the nurse, is MOST important to determine if a patient is hypoxic? a) cool, bluish skin b) abnormal blood gases c) elevated temperature d) increased sputum production (Kaplan Resp Set 20/30)
b) blood gases measure tissue oxygenation, carbon dioxide removal, and acid-base balance; if patient has inadequate exchange of oxygen and carbon dioxide, respiratory acidosis occurs (Kaplan Resp Set 20/30)
The nurse identifies which is the characteristic sound of breathing in a patient experiencing an acute asthma attack? a) murmuring, with "lubb"/"dub" sounds b) high-pitched musical-like squeaky sounds c) high-pitched harsh, loud, blowing sounds d) low-pitched rubbing or grating sounds (Kaplan Resp Set 9/30)
b) describes wheezes, heard primarily during expiration but may also be heard on inspiration; caused by air passing through narrowed airways' auscultated over small airways; heard in cases of acute asthma or chronic emphysema (Kaplan Resp Set 9/30)
A client chokes on food and becomes cyanotic. Which is the best action for the nurse to take? a) the nurse stands behind the client, and with the palm of the hand delivers one quick blow to the middle of the back b) the nurse stands behind the client, wraps arms around the client's waist, and with a fist makes a quick upward thrust into the abdomen c) the nurse stands in front of the client, puts the palm of the hand between the navel and rib cage, and presses firmly upward several times d) the nurse lays the client on the floor and prepares to initiate cardiopulmonary resuscitation (Kaplan Resp Set 13/30)
b) if the person is choking the abdominal-thrust maneuver should be performed; by making quick upward thrusts, the pressure is increased in the thoracic cavity, and the air that is normally trapped in the lungs acts as an upward force to push the obstruction out of the airway (Kaplan Resp Set 13/30)
The nurse identifies which patient is MOST at risk for developing pneumonia? a) a patient with a Foley catheter b) a patient with a nasogastric (NG) tube c) a patient diagnosed with psoriasis d) a patient diagnosed with Paget's disease (Kaplan Resp Set 12/30)
b) nasogastric tube is inserted through the nose and ends in the stomach; used for enteral nutrition to deliver liquid nourishment when GI tract cannot be used; if it is not in proper position before infusion of food, aspiration into the lungs can result, with subsequent chocking and inflammatory process of aspiration pneumonia; tube placement must be verified with aspiration of gastric contents and checking the pH (pH of 0-4 indicates gastric placement, pH of approximately 6 or more indicates placement in lungs); X-ray may also be used to verify placement; in addition, if NG tube becomes obstructed and patient vomits, gastric acid and stomach contents can enter the lungs (Kaplan Resp Set 12/30)
The nurse cares for a client diagnosed wit tuberculosis. The client asks, "Why do I have to take vitamin B6 (pyroxidine)?" What explanation does the nurse provide? a) promote the absorption of isoniazid (an antibiotic) b) prevent neuritis c) alleviate gastrointestinal symptoms d) prevent kidney damage (Kaplan Resp Set B 4/30)
b) neuritis is a potential complication of isoniazid treatment; vitamin B6 (pyridoxine) is given along with the isoniazid to help prevent neuritis (Kaplan Resp Set B 4/30)
A patient is admitted to the hospital with a diagnosis of acute right upper lobe pneumonia. The patient has a history of chronic bronchitis and type 1 diabetes. Which symptom would the nurse expect to see? a) moist, cool skin b) rust-colored sputum c) bradycardia d) decreased respiratory rate (Kaplan Resp Set B 2/30)
b) purulent, blood-tinged or rust-colored sputum due to inflammation; increased respirations, dyspnea, pleuritic pain; treatment includes antibiotics, chest physiotherapy, cough and deep breathe every two hours; encourage fluids; assess breath sounds (Kaplan Resp Set B 2/30)
A patient is diagnosed with a tension pneumothorax resulting from the chest hitting the steering wheel in an automobile accident. The emergency department nurse knows that highest priority is given to which? a) oxygenation b) chest tube insertion c) arterial blood gas (ABG) determination d) attaching a cardiac monitor (Kaplan Resp Set 16/30)
b) tension pneumothorax is an extremely serious emergency, even more than an open pneumothorax; motor vehicle accidents and blunt chest trauma are two potential causes; tension pneumothorax results from air moving into the pleural space and not being able to move back out; pressure builds up in the chest and if it is untreated, the heart, trachea, esophagus, and great vessels are shifted toward the unaffected side due to the lung on the affected side collapsing; further compromise of respiratory and circulatory function ensues; immediate intervention is to insert chest tubes with suction drainage in order to convert the tension pneumothorax into an open pneumothorax; thoracentesis to remove air may be used if chest tube insertion is delated (Kaplan Resp Set 16/30)
The nurse cares for the client needing a tracheostomy. The client's daughter asks the nurse, "Why does my father need a tracheostomy?" The nurse understands that which is the primary reason for performing a tracheostomy? a) promotes pulmonary function b) improves breathing capabilities c) prevents respiratory infections d) decreases respiratory tract secretions (Kaplan Resp Set 7/30)
b) the main purpose of a tracheostomy is to provide and maintain an airway, which permits the removal of tracheobronchial secretions when the patient is unable to cough productively; also permits the use of positive pressure for ventilation, and prevents aspiration of secretions in the unconscious or paralyzed patient (Kaplan Resp Set 7/30)
A patient with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is the MOST appropriate? a) "it's supposed to do that." b) "it shows your lung has not yet re-expanded." c) "why don't you ask your doctor?" d) "what do you think it means?" (Kaplan Resp Set B 5/30)
b) this response provides a true, factual answer (Kaplan Resp Set B 5/30)
The nurse identifies it is MOST important to observe for hyperventilation in a patient receiving which mode of mechanical ventilation? a) control ventilation (CV) b) assist-control ventilation (AC) c) synchronous intermittent mandatory ventilation d) continuous positive airway pressure (CPAP) (Kaplan Resp Set B 1/30)
b) tidal volume and ventilatory rate are pre-set; oxygen is delivered without patient effort, but if patient does inspire it will respond to that effort; if patient respiratory rate increases spontaneously, such as because of pain, anxiety or neurological causes, the machine continues to deliver the pre-set tidal volume with each breath; hyperventilation and respiratory alkalosis result; cause of hyperventilation must be corrected; machine sensitivity may be adjusted (Kaplan Resp Set B 1/30)
The nurse identifies which group of equipment is essential to have at the bedside of a patient with a closed-chest chest tube drainage system in place? a) tape measure, portable scale, Sengstaken-Blakemore tube b) penlight, reflex hammer, safety pin c) sterile connector, sterile petrolatum gauze pad, padded clamp d) nasogastric tube, blood glucose monitor, sputum jar (Kaplan Resp Set 10/30)
c) all are related to management of chest tubes, particularly emergencies; sterile connector is used to reestablish drainage system if tubing disconnects from the drainage equipment; gauze pad is used if chest tube dislodges from body of patient, forming a seal so atmospheric air cannot get into the negative pressure thoracic cavity; padded clamp is used, briefly and with extreme caution, to assess for possible air leaks and also prior to removing chest tube (Kaplan Resp Set 10/30)
The nurse cares for a patient after rhinosplasty and observes bright red blood on the external dressing. Which action should the nurse take FIRST? a) return the patient to the operating room b) contact the physician c) examine the patient's throat d) perform nasopharyngeal suctioning (Kaplan Resp Set B 3/30)
c) assessment is the first step of the nursing process; nurse should observe for bloody drainage in the throat; hemorrhage is an emergency situation that requires the physician to repack internal dressings (Kaplan Resp Set B 3/30)
The patient diagnosed with cholecystitis is blind. In preparation for surgery, the nurse teaches the patient diaphragmatic breathing. Which is the MOST effective teaching method for the nurse to use? a) the nurse demonstrates diaphragmatic breathing and then asks the patient do a return demonstration b) the nurse discusses the rationale behind postoperative abdominal breathing, outlines the steps, and answers questions c) the nurse asks the patient to put both hands on the abdomen and breathe in and out while keeping the chest still d) the nurse asks the patient to tighten and release muscles, progressing from the toes to the head (Kaplan Resp Set 19/30)
c) diaphragmatic or abdominal breathing requires the chest to remain still while the abdominal muscles do the work of breathing; a book on the abdomen with the hands of the patient resting on top of it, or just the hands themselves, provides some resistance and also something a patient can see (or in the case of this patient who is blind-sense or feel) that indicates they are breathing deeply and correctly enough as the abdomen rises and falls (Kaplan Resp Set 19/30)
The nurse monitors a patient receiving oxygen per face mask. The nurse is MOST concerned if which is observed? a) there is condensation in the tubing of the humidifier container b) the pulse oximetry reading is 92% c) the patient has a nonproductive cough d) the skin under the elastic band is reddened (Kaplan Resp Set 8/30)
c) nonproductive cough is an early symptom of oxygen toxicity; other early symptoms include nasal congestion, sore throat, substernal discomfort or pain, GI upset, dyspnea; later symptoms include decreased vital capacity, increased dyspnea, crackles, hypoxemia; atelectasis or structural damage to the lungs, along with pulmonary edema and hemorrhage and stiffness of lung tissue can occur; this syndrome is known as Adult Respiratory Distress Syndrome (ARDS); treatment of the toxic effects is very difficult, and prevention is a priority (Kaplan Resp Set 8/30)
The home care nurse visits a client diagnosed with chronic bronchitis. The nurse notes the client is weak and congested. It is MOST important for the nurse to make which assessment? a) "Cough as much as you can. The secretions have to come out." b) "If you hold a pillow against your abdomen, the coughing would be easier." c) "Take 3 or 4 deep breaths, and as you exhale the last breath, cough 3 times." d) "It does not matter when you cough. Just do it>" (Kaplan Resp Set 25/30)
c) the client should sit with feet on the floor, lean slightly forward, and take several slow deep breaths through the nose; exhalations should be slow through pursed lips; during exhalation of the last breath the client should cough several times; mucus is moved up the respiratory tree more effectively with several consecutive coughs than with a single one (Kaplan Resp Set 25/30)
The nurse instructs a patient about how to use an incentive spirometer. The nurse determines that teaching is effective if the patient makes which statement? a) "I should take a deep breath and blow into the mouthpiece." b) "I'm glad that I only have to do it twice a day." c) "I should ask for pain medication prior to using the spirometer." d) "I should take lie down to use the incentive spirometer." (Kaplan Resp Set 29/30)
c) the incentive spirometer is used after thoracic and abdominal surgery to prevent atelectasis, to encourage deep inspirations; nursing responsibilities include assessing the patient's level of pain and administering the pain medication as ordered (Kaplan Resp Set 29/30)
Blood gas results on a patient with emphysema indicate severe hypoxia. Oxygen therapy is ordered. Which method of oxygen administration will MOST likely be used? a) face mask with reservoir b) face mask without reservoir c) nasal cannula d) venturi mask (Kaplan Resp Set 6/30)
d) Venturi masks provide oxygen at specified percentages, which is how oxygen should be administered to patients with COPD or emphysema; keep tubing free of kinks (Kaplan Resp Set 6/30)
The client arrives in the emergency room with an acute asthma attack. Epinephrine is given subcutaneously. Which observation by the nurse BEST indicates the treatment is effective? a) an increase in the client's alertness b) an increase in the client's pulse rate c) a decrease in the client's blood pressure and pulse d) a decrease in the client's inspiratory difficulty (Kaplan Resp Set 27/30)
d) asthma is a chronic inflammatory disease of the airways that causes reversible airflow obstruction, airway inflammation, and airway hyper-responsiveness; symptoms include cough, chest tightness, wheezing, and dyspnea; is reversible; decreased inspiratory difficulty indicates effective treatment; epinephrine is a bronchodilator, which relaxes the smooth muscles and decreases difficulty in inspiration (Kaplan Resp Set 27/30)
The nurse performs teaching for a patient diagnosed with tuberculosis. The nurse explains that tuberculosis is caused by which? a) a virus b) poor sanitation c) poor nutrition d) a bacterium (Kaplan Resp Set 24/30)
d) caused by the bacterium Mycobacterium tuberculosis, transmitted via the aerosol route (coughing, laughing, sneezing, or singing); (Kaplan Resp Set 24/30)
The nurse understands the primary mechanism of action of synchronized intermittent mandatory ventilation (SIMV) for a patient requiring respiratory support is which? a) the delivery of breaths is synchronized with the R wave of the patient b) a set tidal volume is delivered at a set rate regardless of the breathing efforts of the patient c) positive pressure is intermittently exerted at the end of ventilator breaths d) ventilator breaths are correlated with patient breathing and patient can breathe naturally in between (Kaplan Resp Set 26/30)
d) describes synchronized intermittent mandatory ventilation (SIMV); preset tidal volume and rate are established; delivery to patient is synchronized with patient inspiration; patient can breathe spontaneously at own tidal volume and rate in between ventilator breaths, using an oxygen reservoir attached to the machine; SIMV is used both as a primary ventilation mode for a wide variety of clinical conditions, as well as as a weaning modality (Kaplan Resp Set 26/30)
The outer cannula of a patient's tracheostomy tube is accidentally expelled 36 hours after surgery. Which action should the nurse take FIRST? a) contact the physician immediately b) cut the tracheostomy neck ties c) insert the emergency outer tube that is taped to the head of the bed d) ventilate the chest using a manual resuscitation bag (Kaplan Resp Set 18/30)
d) nurse should use a manual resuscitation bag to ventilate the patient while another staff member contacts the resuscitation team; if nurse tries to insert a tube in a new (under 72 hours) tracheostomy, may cause tissue damage because the tract is not matured (Kaplan Resp Set 18/30)
The nurse cares for a patient with a new tracheostomy immediately postop. It is MOST important for the nurse to take which action? a) place the patient supine until vital signs are stable b) ask the patient which position makes the patient most comfortable c) place the patient with head elevated and neck hyperextended d) elevate the patient's head and turn the head to one side until consciousness returns (Kaplan Resp Set 11/30)
d) semi-Fowler's position facilitates respiration, promotes drainage, prevents edema, and prevents strain on the suture line (Kaplan Resp Set 11/30)
Albbuterol (Proventil) and beclomethasone (Vanceril) by metered dose inhaler (MDI) are ordered for a patient recently diagnosed with asthma. The patient asks the nurse, "Why do I have to be concerned about which medication I take first and waiting in between medications?" Which is the BEST response by the nurse? a) "that is how your physician wrote the order." b) "you do not have to be concerned. you can take them in whatever way works best for you as long as you take them both." c) "that is the standard way these medications are administered." d) "the proventil will open up the airway so the vanceril can be better absorbed. you want to allow the proventil to have its full effect." (Kaplan Resp Set 15/30)
d) the albuterol (Proventil) is a bronchodilator; it will open the airway so the beclomethasone (Vanceril), which is a steroid, will be absorbed; the 5 minute wait allows for this airway opening to occur; the steroid functions to directly affect smooth muscle relaxation to enhance the effect of some bronchodilators and also to inhibit inflammation that could result in bronchoconstriction (Kaplan Resp Set 15/30)
The nurse on the neurologic unit knows that which is the primary reason for having a patient diagnosed with a cardiovascular accident (CVA) position the head flexed slightly forward when sitting upright to eat? a) to increase the ease of swallowing b) to decrease the musculature effort of maintaining the head erect c) to decrease anxiety from seeing feeding utensils coming directly at them d) to prevent aspiration (Kaplan Resp Set 14/30)
d) when the head is flexed slightly forward when the patient is seated erect it closes the epiglottis, thus preventing aspiration; the epiglottis is a cartilaginous structure hanging over the larynx like a lid; when it closes, food or secretions cannot enter the larynx of the trachea; the trachea extends from the larynx to the mainstem bronchi; this flexed positioning is also used for any patient during nasogastric (NG) tube insertion to ensure the tube goes into the stomach and not the lungs (Kaplan Resp Set 14/30)
