questions

The nurse is caring for a client who states, "I am really worried about the thoracentesis. I know I won't be able to sleep tonight." Which statement is most helpful to the client at this time? A) "Tell me what you are worried about." B) "Is there something that I can help you with?" C) "Is there someone that you would like me to call to be with you?" D) "The physician will see you before the procedure and can answer any questions."

Ans: A Feedback: A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client states that he is worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the patient makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.

You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? A) A puncture at the radial artery B) The trachea and bronchi C) The pleural surfaces D) A catheter in the arm vein

Ans: A Feedback: ABGs determine the blood's pH; oxygen-carrying capacity; and levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.

An 18-month-old child is brought to the emergency department by his parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in? A) Right upper lung B) Left upper lung C) Right lower lung D) Left lower lung

Ans: A Feedback: Aspiration of foreign objects is more likely in the right main stem bronchus and right upper lung. The right mainstem bronchus is slightly higher and more vertical than the left,

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation? A) Blood gases B) Complete blood count C) Blood chemistry D) Serum alkaline phosphate

Ans: A Feedback: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.

You are studying for a physiology test over the respiratory system. What should you know about central chemoreceptors in the medulla? A) They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. B) They respond to changes in the O2 levels in the brain. C) They respond to changes in CO2 levels in the brain. D) They respond to changes in O2 levels and bicarbonate levels in the cerebrospinal fluid.

Ans: A Feedback: Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not respond to changes in the O2 levels in the brain, changes in CO2 levels in the brain, changes in O2 levels, and bicarbonate levels in the cerebrospinal fluid.

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion? A) Fluoroscopy B) Chest x-ray C) Magnetic resonance imaging (MRI) D) Computed tomography (CT) scan

Ans: A Feedback: Fluoroscopy enables the physician to view the thoracic cavity with all of its contents in motion. A fluoroscopy more precisely diagnoses the location of a tumor or lesion. An x-ray shows the size, shape, and position of the lungs. An MRI and CT produce axial views of the lungs.

The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that the patient's body is working to stabilize? A) Respirations are increasing. B) Urine output is decreased. C) Heart rate is regular. D) WBC count is within normal limits.

Ans: A Feedback: Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid, causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3- of 28 mEq/L. The nurse reports to the physician which finding? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic acidosis D) Metabolic alkalosis

Ans: A Feedback: Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2 above the normal range of 30 to 40 mm Hg. The HCO3 - is slightly elevated because the normal level is 22 to 26 mEq/L.

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? A) Develop an alternate method of communication. B) Encourage oral nutrition on the second postoperative day. C) Maintain the client in a low-Fowler's position. D) Assess the tracheostomy cuff for leaks.

Ans: A Feedback: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.

You are caring for a client who is status post nasal polypectomy. What would you instruct this client to report? A) Excessive swallowing B) Nasal stuffiness C) Diarrhea D) Coughing

Ans: A Feedback: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Options B, C, and D are incorrect. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds.

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? A) Airway patency B) Level of consciousness C) Psychological status D) Pain level

Ans: A Feedback: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? A) The pons B) The frontal lobe C) Central sulcus D) Wernicke's area

Ans: A Feedback: The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? A) Administer an over-the-counter decongestant. B) Use an anti-allergy medication to decrease rhinitis. C) Place a warm cloth over the sinus area of the forehead. D) Gently blow the nose to eliminate nasal secretions.

Ans: A Feedback: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.

A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document? A) The client has a funnel chest. B) The client has chronic respiratory disease. C) The client has pneumonia in the bases. D) The client needs a cough suppressant.

Ans: A Feedback: The question asks for a documentation based on inspection. A funnel chest, known as pectus excavatum, has the sternum depressed from the second intercostal space, and it is more pronounced on inspiration. The nurse would not diagnose chronic respiratory disease or pneumonia. The client would also not prescribe a cough suppressant.

The nurse is receiving the post-tonsillectomy and post-adenoidectomy client in the postanesthesia care unit (PACU). The nurse aide is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the nurse aide to place the client? A) On a side B) Supine C) Semi-Fowler's D) High-Fowler's

Ans: A Feedback: Upon receiving the client in the PACU, the client is drowsy and not fully conscious. A standard of care to prevent aspiration is to place the client lying on either side with an emesis basin to catch drainage. Laying the client is a supine position, semi-Fowler's position, or high-Fowler's position does not provide an easy exit for secretions as the client is recovering from the anesthesia.

The nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply. A) Lung fields documented as clear in the bases. B) Palpable vibrations over the chest wall when the client speaks. C) Decreased fremitus when the client speaks "99." D) Dull sounds percussed over the lung tissue. E) Bronchovesicular sounds heard over the upper lung fields.

Ans: A, B, E Feedback: The question asks for resolution or clearing of the infection; thus, normal respiratory status should be assessed. Lungs will return to clear breath sounds. Palpable vibrations will be felt as there is no blockage in the transmission. Bronchovesicular sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks "99." Dull percussed sounds indicate an area of consolidation.

The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply. A) Rest B) Increased fluids C) Antibiotics D) Antiemetics E) Saline gargles F) Antitussives

Ans: A, B, E, F Feedback: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus.

You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply. A) Alcohol B) Age C) Tobacco D) Industrial pollutants E) Region of country you live in

Ans: A, C, D Feedback: Carcinogens, such as tobacco, alcohol, and industrial pollutants, are associated with laryngeal cancer.

The nurse is working on a busy respiratory unit. In caring for a variety of clients, the nurse must be knowledgeable of diagnostic studies. With which diagnostic studies would the nurse screen the client for an allergy to iodine? Select all that apply. A) Lung scan B) Chest x-ray C) Fluoroscopy D) Pulmonary angiography E) Bronchoscopy F) Pulmonary functions test

Ans: A, C, D Feedback: The nurse must be well educated in screening clients before diagnostic procedures which include contrast medium for an allergy to iodine. A lung scan, fluoroscopy and pulmonary angiography all require contrast medium.

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply. A) Oxygen is dissolved. B) High blood pressure disrupts oxygen transport. C) Oxyhemoglobin circulates to the body tissue. D) All systemic oxygen is available for diffusion. E) Adequate red blood cells are needed for oxygen transport.

Ans: A, C, E Feedback: Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.

The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply. A) Ineffective Airway Clearance related to increased secretions B) Risk for Infection related to operative incision and tracheostomy tube placement C) Knowledge Deficit related to care of the tracheostomy tube and surrounding site D) Impaired Gas Exchange related to shallow breathing and anxiousness

Ans: A, D Feedback: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude the airway or plug the airway requiring frequent suctioning. Impaired Gas Exchange is an equally important diagnosis. These are related to airway and breathing and are priorities.

You are caring for a client who is post-sinus surgery. When you assess this client, you ask him how many fingers you are holding up. Why do you assess postoperative visual acuity? A) To assess possible hemorrhage B) To assess damage to the optic nerve C) To assess postoperative infection D) To assess impaired drainage

Ans: B Feedback: A client who has undergone a sinus surgery faces a serious risk of damage to the optic nerve. Therefore, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed. To assess possible hemorrhage, the nurse observes the client for repeated swallowing. The nurse assesses for pain over the involved sinuses and not a postoperative infection or an impaired drainage.

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? A) A ventilator B) A face mask C) A rigid shell D) A nasal cannula

Ans: B Feedback: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.

The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed? A) Lung fields B) Voiding C) Joint pain D) Mentation

Ans: B Feedback: A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria. The most serious bacteria are the group A streptococci, commonly referred to as strep throat. Strep throat can have serious cardiac and renal complications, including sepsis. Assessing voiding can be an indication of renal status. Lung fields, joint pain, and mentation are completed in the head-to-toe assessment.

What happens to the diaphragm during inspiration? A) It relaxes and raises. B) It contracts and flattens. C) It relaxes and flattens. D) It contracts and raises.

Ans: B Feedback: During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.

You are a nurse in the radiology unit of your hospital. You are caring for a client who is scheduled for a lung scan. You know that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? A) Bleeding B) Iodine allergy C) Dysrhythmias D) Inflammation

Ans: B Feedback: During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.

The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed? A) In the supine position B) Lying on the unaffected side C) In the high Fowler's position D) Prone with a pillow under the head

Ans: B Feedback: Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.

A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first? A) Call for the registered nurse to reinsert the tube. B) Place a dilator in the stoma to maintain the opening. C) Cover the tracheostomy site with a sterile gauze to prevent infection. D) Call for an ambulance and transfer the client to the emergency department.

Ans: B Feedback: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy site with gauze can obstruct the stoma, decreasing ventilation. If needed, an ambulance may be called to transport the client to the emergency department but not until the airway is stabilized.

fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates? A) Cancer B) Infection C) Inflammation D) Heart failure

Ans: B Feedback: Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic acidosis D) Metabolic alkalosis

Ans: B Feedback: Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis/alkalosis are disorders that affect the bicarbonate.

The nurse is caring for a client with an upper respiratory disorder. The client states he have a hacky, nonproductive cough, which wakens him during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night? A) Benadryl B) Robitussin C) Pseudoephedrine D) Flonase

Ans: B Feedback: Robitussin acts on the central nervous system to raise the cough threshold and dampen the cough reflex. Benadryl is an antihistamine which relieves symptoms associated with allergies. Pseudoephedrine relieves nasal congestion associated with sinusitis, colds, and www.testbanktank.com allergies. Flonase reduces tissue edema

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? A) Copious mucous secretions B) Sudden restlessness C) Harsh cough D) Rhonchi in lung fields

Ans: B Feedback: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions.

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated? A) Rhonchi in the bronchial region B) Audible stridor without using a stethoscope C) Crackles in the bases of the lungs D) Diminished breath sounds throughout

Ans: B Feedback: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling.

A client presents to the emergency department in respiratory compromise. The client's temperature is 102.4° F, heart rate 88 beats/minute and regular, and blood pressure 138/76 mm Hg. The client is dyspneic, pale, and expectorating green-tinged sputum. The physician orders medications including antibiotics, antipyretics, nebulizer treatments, and IV fluids. A chest x-ray and sputum culture are to be completed. Which physician order would the nurse complete before beginning antibiotic therapy? A) Chest x-ray B) Sputum culture C) Nebulizer treatments D) Initiating IV fluids

Ans: B Feedback: The nurse would obtain a sputum culture for sensitivity before beginning antibiotic therapy. Obtaining a sputum culture after beginning antibiotics can skew results. Once the sputum culture results are returned, the antibiotic can be closely aligned to kill the organism, if present. The other orders can be prioritized according to client needs.

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? A) CBC with differential B) Transillumination of the sinus C) Nasal culture D) Magnetic resonance imaging (MRI)

Ans: B Feedback: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity.

A client, experiencing respiratory distress, is ordered blood to be drawn for arterial blood gases (ABGs) via the radial artery. Before the blood is drawn, which circulation is assessed? A) Carotid circulation B) Ulnar circulation C) Femoral circulation D) Temporal circulation

Ans: B Feedback: Ulnar circulation is assessed using the Allen's test. The Allen's test is completed to assess blood supply through the ulnar and radial arteries. Noting both circulations is helpful when using an artery for the ABG draw. It is important to ensure adequate secondary blood flow to the hand other than through the radial artery in case the artery were to be damaged. No other circulation is assessed.

What is the difference between respiration and ventilation? A) Ventilation is the process of gas exchange. B) Ventilation is the movement of air in and out of the respiratory tract. C) Ventilation is the process of getting oxygen to the cells. D) Ventilation is the exchange of gases in the lung.

Ans: B Feedback: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells. Therefore, options A, C, and D are incorrect.

The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct? A) Laser surgery is a possibility with limited side effects. B) The physician removes lymph nodes, muscles and tissue. C) Once the tissue is removed, no further treatment is necessary. D) You will be able to speak normally once the swelling subsides.

Ans: B Feedback: When the physician prescribes a radical neck dissection, the disease has extended beyond the larynx. The physician removes lymph nodes, muscle, and tissue. Laser surgery is completed for early lesions and does not have the ability to remove all of the structure needed. Chemotherapy and radiation is typically administered. The client will lose the ability to speak normally.

You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply. A) Absence of secretions B) Aspiration C) Infection D) Injury to the laryngeal nerve E) Penetration of the anterior tracheal wall

Ans: B, C, D Feedback: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.

The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply. A) Postoperative bleeding most frequently occurs in the hours after surgery. B) Avoid carbonated fluids. C) Gradually increase fluids then add soft foods. D) Apply an ice collar to the neck area. E) Gargle with warm saline water. F) Limit pain medications to the nighttime.

Ans: B, C, D, E Feedback: A client may be at risk for postoperative bleeding for several days following the surgical procedure as the scab may be removed from the surgical site early causing the bleeding. Clients should avoid carbonated beverages and citrus fluids or foods because these agents are caustic to the suture line. The client should gradually increase fluids from thin liquids to thick liquids then soft foods through the recovery process. Applying an ice collar and gargling with saline decreases swelling and aids in preventing infection. Pain medication would be appropriate throughout the day, not just at night.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply. A) A decreased respiratory rate B) Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 C) Nasal flaring with abdominal retractions D) Administration of a corticosteroid inhaler for quick relief E) Lung sounds of stridor F) Increased respiratory effort

Ans: B, C, E, F Feedback: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time.

A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks through the wall of the trachea with a device. The nurse is correct to provide teaching on which method? A) Esophageal speech B) An electric larynx C) A tracheoesophageal puncture D) An artificial voice box

Ans: C Feedback: A tracheoesophageal puncture is the method where a client speaks through a surgical opening in the posterior wall of the trachea with the assistance of a device. Esophageal speech occurs from swallowing air and forming words with the lips. An electronic larynx is a throat vibrator. There is no electronic voice box on the market.

Your client has just had an invasive procedure to assess the respiratory system. What do you know should be assessed on this client? A) Watery sputum B) Loss of consciousness C) Respiratory distress D) Masses in pleural space

Ans: C Feedback: After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space affect fremitus. General examination of overall health and condition includes assessing the consciousness of a client.

The student nurse is learning breath sounds while listening to a client in the physician's office. An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document? A) Abnormal vesicular sounds B) Normal bronchial sounds C) Normal bronchovesicular sounds D) Abnormal bronchial sounds

Ans: C Feedback: Air movement over the trachea and upper lungs is a normal finding for bronchovesicular sounds. The air movement is noted equally on inspiration as expiration. The other choices do not match type of breath sound for the location in question.

You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter his room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect? A) Infection B) Postoperative bleeding C) Edema of the upper airway D) Plugged tracheostomy tube

Ans: C Feedback: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy

The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: 101.2° F, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which afternoon assessment finding suggests the advancement to an infectious process? A) Achiness B) Headache C) Temperature rise D) Increased respiratory rate

Ans: C Feedback: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal? A) The client will have decreased pain. B) The client will remain alert and oriented. C) The client will have decreased edema. D) The client will have increased tissue perfusion.

Ans: C Feedback: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply.

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? A) Obtain vital signs. B) Monitor heart rhythm. C) Auscultate lung sounds. D) Assess capillary refill.

Ans: C Feedback: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.

The nurse is caring for a client in a physician's office whose x-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room? A) Otoscope B) Ophthalmoscope C) Irrigation equipment D) Tuning fork

Ans: C Feedback: Note the keyword as "must". The nurse would have sinus irrigation equipment available for the physician as saline irrigation of the maxillary sinus is done to remove exudate and promote drainage. This is most helpful as a condition which could lead to an infection is documented. An otoscope and tuning fork may be present in the room for further assessment. An ophthalmoscope is typically not needed.

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? A) Epistaxis, twice last week B) Aphonia following a football game C) Hoarseness for 2 weeks D) Laryngitis following a cold

Ans: C Feedback: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? A) Arterial blood gases B) Pulmonary function test C) Pulse oximetry D) Chest x-ray

Ans: C Feedback: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.

You are presenting about upper respiratory infections at an educational event for a local community group. What should you be sure to include regarding cold tablets containing antihistamines? A) They dilute the nasal secretions. B) They lead to frequent sinus drainage. C) They decrease discomfort temporarily. D) They prolong bleeding.

Ans: C Feedback: Some cold tablets contain antihistamines that thicken the nasal secretions. Although this action may temporarily decrease the discomfort of profuse nasal secretions, thickened secretions can block the drainage openings of the sinus cavity, leading to the failure of the sinuses to drain adequately. Aspirin prolongs bleeding.

A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding? A) Ruddy colored drainage on the nasal dressing B) Occasional nonproductive cough C) Frequent swallowing D) Pressure in the nasal cavity

Ans: C Feedback: Standards of postoperative care include assessment for postoperative bleeding with symptoms such as repeated swallowing. Swallowing indicates a slow oozing or dripping down the back of the throat. Ruddy colored drainage indicates old drainage. Occasional nonproductive cough could possibly indicate a problem but is not as definitive as swallowing. Pressure in the nasal cavity is to be expected.

A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which nursing diagnosis would the nurse identify as a priority? A) Acute Pain B) Potential for Infection C) Impaired Gas Exchange D) Ineffective Airway Clearance

Ans: C Feedback: The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis Acute Pain is probable, gas exchange is a higher priority. Ineffective Airway Clearance is the least concern because the problem is with ventilation.

You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements? A) They produce anorexia. B) They impair the immune system. C) They prolong bleeding. D) They lower high-density lipoprotein levels.

Ans: C Feedback: The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy and adenoidectomy. Therefore, the nurse asks the clients about any recent use of herbal supplements. The nurse must ask about the use of these supplements because they may prolong bleeding. A client may experience anorexia because of a diminished sense of taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune system and lowers the levels of high-density lipoproteins. These symptoms are not caused by herbal supplements.

A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis? A) Apply a moustache dressing. B) Provide a nasal splint. C) Apply direct continuous pressure. D) Place the client in a semi-Fowler's position.

Ans: C Feedback: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.

Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion? A) The two methods of perfusion are the bronchial and alveolar circulation. B) The two methods of perfusion are the bronchial and capillary circulation. C) The two methods of perfusion are the bronchial and pulmonary circulation. D) The two methods of perfusion are the alveolar and pulmonary circulation.

Ans: C Feedback: The two methods of perfusion are the bronchial and pulmonary circulation. There is no alveolar circulation. Capillaries are the vessels that performs the perfusion regardless of which area of the lung they are in.

A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection? A) Cilia B) Sinus cavity C) Tonsils D) Turbinates

Ans: C Feedback: Tonsils and adenoids do not contribute to respiration but protect against infection. Palatine tonsils are composed of lymphoid tissue. Cilia are fine hairs that move particles and liquid, preventing irritation and contamination of the airway. Sinuses are nasal cavity structures. Turbinates warm and add moisture to the inspired air.

The nurse is suctioning a client who is unable to expectorate respiratory secretions. At which point does the nurse expect the client to experience coughing? A) When the catheter reaches the back of the pharynx B) When the catheter enters the main bronchus of the lung C) When the catheter reaches the point of the carina D) When the catheter tickles the uvula

Ans: C Feedback: Upon the catheter stimulating the carina, coughing and even bronchospasm may occur. Productive secretions may be loosened and eliminated via the suction catheter. When the catheter reaches the back of the pharynx near the uvula, the gag reflex is initiated. The suction catheter does not reach the entrance of the lung.

The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid? A) A serum CBC B) A Nitrazine paper C) A Dextrostix D) A glucometer check

Ans: C Feedback: When clear drainage is observed from the nares of a client, a Dextrostix is used to determine the presence of glucose which is present in cerebrospinal fluid. A serum CBC would provide information on red and white blood cell count. A low red blood cell count is may be found due to hemorrhage that has occurred. Nitrazine paper is under to assess vaginal secretions for the presence of amniotic fluid. A glucometer check will provide information on serum glucose, not the glucose level in the cerebrospinal fluid.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? A) The nursing assistant is assisting the client to a semi-Fowler's position. B) The nursing assistant is assisting the client to the side of the bed to use a urinal. C) The nursing assistant is pouring a glass of water to wet the client's mouth. D) The nursing assistant is asking a question requiring a verbal response.

Ans: C Feedback: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post procedure period.

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? A) Raised temperature in the affected limb B) Excessive capillary refill C) Absent distal pulses D) Flushed feeling in the client

Ans: C Feedback: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. Absent distal pulses may indicate damage to the artery or a clot. When the contrast medium is infused, the client will sense a warm, flushed feeling.

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated? A) Crackles B) Rhonchi C) Rubs D) Wheezes

Ans: D Feedback: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? A) Tympanic B) Resonant C) Hyperresonant D) Dull

Ans: D Feedback: A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyperresonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis? A) Cool mist humidifier B) Lavender scent C) Ice chips D) Salt water gargle

Ans: D Feedback: A salt water or saline gargle combines moisture from the water with sodium from the salt to treat the infection and aid in associated discomfort. Humidification and ice chips are also acceptable but just aids in soothing moisture to the air aiding in discomfort. A lavender scent is relaxing.

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? A) "I have environmental allergies." B) "I smoke a pack of cigarettes a day." C) "I used my voice in excess over the weekend." D) "I was chewing ice chips all day long."

Ans: D Feedback: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.

The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding? A) "I will feel a dull pain when the catheter is introduced." B) "I will feel light-headed when the contrast medium is introduced." C) "I will feel waves of nausea throughout the procedure." D) "I will feel warm and an urge to cough."

Ans: D Feedback: During a pulmonary angiography a contrast medium is injected into the femoral artery. When the medium is infused, the client will feel a sense of warm and flushed with an urge to cough. The client will feel a pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during the procedure.

The nurse is providing health education on the body's ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement, provided by the nurse, is most correct when asked about diffusion during inspiration? A) During inspiration, the concentration of oxygen is equal in both the alveoli and the capillaries. B) During inspiration, oxygen diffuses from the arterial system through to the alveolar capillary membrane. C) During inspiration, carbon dioxide provides the basis for all diffusion gradients. D) During inspiration, oxygen is greater in the alveoli than in the capillaries.

Ans: D Feedback: During inspiration, oxygen-rich air from the environment enters the pulmonary system. During inspiration, the concentration of inspired oxygen is higher in the alveoli than in the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion from the arterial system after the oxygen diffuses from the alveoli to the capillaries. Carbon dioxide does not provide the basis for all diffusion gradients.

You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? A) Incrusted mucous membranes B) Hardened secretions C) Erosion of the trachea D) Noisy breathing

Ans: D Feedback: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.

A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy? A) "I must carry tissues with me." B) "I must give up my love of pool aerobics." C) "I will not be able to have the tracheostomy removed." D) "Tell my wife about it, I do not want to touch it."

Ans: D Feedback: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration need to be arranged by being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.

The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control? A) Medulla oblongata, cerebellum, and heart rate B) Pons, cerebellum, and oxygen receptors C) Medulla oblongata, mitral valve, and central receptors D) Aortic arch, pons, and CO2 receptor sites

Ans: D Feedback: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.

A client visits the physician's office concerned about possible sleep apnea. The client states he lives alone and fears that he will not awaken from sleep. The client states that he has many symptoms which may indicate sleep apnea. Which symptom, stated by the client, is not a symptom of sleep apnea? A) "I wake myself up by snoring several times each night." B) "I wake up in the morning with a headache." C) "I have trouble concentrating throughout the day." D) "I have pressure in the middle of my chest at night."

Ans: D Feedback: Signs of pressure in the middle of the chest are not indicative of sleep apnea and require further instruction and investigation by the nurse. A cardiac or epigastric cause may be

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? A) Tickle the back of the throat to produce the gag reflex. B) Drink 8 oz of water to thin the secretions for expectoration. C) Use the secretions present in the oral cavity. D) Take deep breaths and cough forcefully.

Ans: D Feedback: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify? A) "My study is scheduled for 10 AM, several hours after I eat." B) "I brought comfortable clothes and shoes for the test." C) "I am ordered a bronchodilator to note lung improvement following use." D) "I will breathe in through my mouth and out through my nose."

Ans: D Feedback: The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.