Review Questions Resp
What is the primary problem for the health care team in identifying respiratory disorders such as Legionnaires' disease, severe acute re- spiratory syndrome, and anthrax? (1632-1634) 1.They are agents used in global germ warfare. 2.The percentage of morbidity and mortality is high. 3.They require isolation because transmis- sion is airborne. 4. At first symptoms are similar to other respiratory disorders
Answer 4: The symptoms will mimic other respiratory disorders; thus, diagnosis is delayed because more common causes will be investigated first. During this delay, the infection will become more entrenched. Legionnaires' and SARS can be transmitted via droplets in air, so many people could be exposed before the diagnosis is made. Anthrax has been identified as a possible bioterrorism agent. Morbidity is high for all three disorders. For Legionnaires' disease, 15-20% have died in localized epidemics. For SARS, 10-20% require intubation and risk for death is high. Anthrax responds to antibiotics once diagnosis is made.
16. What is true about activities such as walking for the patient with emphysema? a. Repair dilated alveoli b. Increase capacity to use oxygen c. Lessen the oxygen needs d. Lessen metabolic oxygen needs
ANS: B Aerobic exercises such as walking will increase the body's ability to use oxygen through sustained rhythmic contractions of large muscles. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1559 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
3. A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention? a. Complete care quickly b. Provide a pad and pencil or magic slate c. Refrain from conversations with the patient to reduce stress level d. Offer books or jigsaw puzzles for entertainment
ANS: B Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation. PTS: 1 DIF: Cognitive Level: Application REF: Page 1534 OBJ: 10 TOP: Laryngectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
1. What is the purpose of the cilia? a. Warm and moisturize inhaled air b. Sweep debris toward nasal cavity c. Stimulate cough reflex d. Produce mucus
ANS: B The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Secretions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
18. What is a major advantage of video assisted thoracoscopic surgery (VATS)? a. The surgeon can record entire surgical procedure on a video. b. The surgeon can remove tumors of the lung through a small keyhole incision. c. The surgeon can x-ray and excise tumor in the same procedure. d. The surgeon can avoid the use of a closed chest drainage system after surgery.
ANS: B The video assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1650 OBJ: 19 TOP: VATS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
20. What is inspiratory capacity? a. The amount of air in the lung after a maximal inhalation b. The amount of air moved with each normal inhalation and expiration c. The amount of air that can be inhaled in one breath from the resting expiratory level d. The amount of air that can be forcefully exhaled after maximum inhalation
ANS: C Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting expiratory level. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ: 7 TOP: Inspiratory capacity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
The nursing student uses an automatic blood blood pressure cuff to take vital signs. to be efficient the student simultaneously attaches the pulse oximeter to the patient's same hand. The pulse oximeter reading is below 90%. What should the student do first(1618) 1. Report the findings immediately 2. Redo the pulse oximeter reading on the other hand. 3. Assess the patient for shortness of breath.
Answer 2: The student remembers that the automatic blood pressure cuff occludes blood flow to the distal portions of the extremity, so the first pulse oximeter reading is likely to be falsely low.
21. The patient had a permanent tracheostomy placed several months ago. The nurse will de- sign interventions for the patient's inability to: (1625) 1. breathe independently and safely. 2 secrete adequate amounts of mucus. 3.physiologically produce normal speech. 4.swallow without choking or gagging.
Answer 3: Air cannot pass over the vocal cords, so normal speech is impossible. The patient can breathe through the tracheostomy opening. Secretions will be produced, but interventions relate to keeping the skin around the opening clean and dry. The esophagus and trachea do not communicate, so choking is not anticipated.
For a patient with newly diagnosed asthma, what is the rationale for conducting an assess- ment of the home environment? (1666) 1. Determine if the patient will have activity intolerance related to design of house 2. Assess the safety of the environment related to the use of home oxygen 3. Identify stimulants or allergens that are triggering the asthma attacks 4. Evaluate the need for home health care to accomplish activities of daily living
Answer 3: For newly diagnosed asthma patients, identification of allergens in the home environment will help them to control/avoid exposure and will decrease episodes of acute attacks. These patients should be able to resume normal activities after treatment for an acute episode.
The nurse is reviewing the admission orders for a patient who was stabilized in the emer- gency department and then admitted for a diagnosis of pulmonary edema. Which order is the nurse most likely to question? (1653) 1. Oxygen 2 liters per nasal cannula 2. Notify provider with all blood gas results 3. IV normal saline at 250 mL per hour 4. Place on telemetry monitor
Answer 3: IV fluids are usually withheld to prevent adding fluids to the overloaded patient. (An IV saline lock would be the expected order.) The other orders are appropriate for patients with pulmonary edema.
A patient comes to the clinic and reports de- creased appetite, generalized malaise, and a decreased sense of smell. Gentle palpation over the sinus area elicits pain. Which piece of equipment should the nurse prepare so the health care provider can do some diagnostic testing during the physical examination? (1630) 1. Tongue blade 2. Percussion hammer 3. Penlight 4. Cotton-tippedapplicator
Answer 3: The patient has symptoms of sinusitis. Transillumination involves shining a light in the mouth with the lips closed around it; infected sinuses will look dark, whereas normal sinuses will transilluminate.
The nurse is eating in a restaurant. At a nearby table, several men are talking, laughing, drink- ing alcohol, and eating steak. Suddenly, the nurse hears, "Heh! Are you all right?" Which behavior signals a need to intervene for chok- ing? (1623) 1. Vigorous coughing 2. Running from the room 3. Hand over throat 4. Waving hands frantically
Answer 3: The universal sign for choking is hand over the throat. People who are vigorously coughing should be encouraged to continue coughing. While running out of the room is not an obvious signal, people have been known to leave out of embarrassment. Waving hands frantically is a signal, but cause would have to be assessed.
The nurse hears in change of shift report that 1500mL of fluid was removed during the therapeutic thoracentesis procedure. What is the most important intervention that the nurse will plan to do? (1616) 1. Perform routine postprocedure assessments. 2. increase fluid intake to compenstate for the loss. 3. Watch for signs and symptoms of pulmo- nary edema. 4. follow up to get the results of the fluid specimen.
Answer 3: Usually no more than 1300 mL of fluid is removed at one time because there is a risk of intravascular fluid shifting that will result in pulmonary edema. Because of the risk for pulmonary edema, the nurse is likely to increase the frequency of assessment. Giving the patient extra fluid could worsen fluid shifting. If the purpose was therapeutic, the fluid may or may not have been sent to the laboratory for analysis.
A patient was treated for epistaxis with nasal packing saturated with 1:1000 epinephrine. During the postprocedure assessment, the nurse notices that the patient swallows fre- quently. Which question should the nurse ask? (1619) 1.Does your throat feel swollen or painful? 2. Would you like cool liquids to drink 3.Is blood running down the back of your throat? 4. Do you taste the epinephrine in the back ofthe throat?
Answer 3: With epistaxis, frequent swallowing suggests that the blood is running down the back of the throat. This could either be rebleeding or posterior bleeding. Posterior bleeding is not always resolved with anterior packing.
A patient being treated for atelectasis has been prescribed acetylcysteine (Mucomyst). What is the purpose of this medication? (1648) 1. Reduce the risk of infection 2. Dilate the bronchioles 3. Enhance the cough relfex 4. Reduce viscosity of secretions
Answer 4: Acetylcysteine (Mucomyst) is used to reduce the viscosity of secretions. This makes expectoration easier and more effective.
A patient is diagnosed with acute bronchitis. Although the patient is instructed to increase fluid intake to 3-4L a day which beverage would not improve their respiratory condition? (1632) 1. Coffee 2. Soda 3. Orange juice 4. Milk
Answer 4: Dairy products thicken secretions, so they become more tenacious and harder to expectorate.
23. Which of these are regarded as a late sign of respiratory distress? (1613) 1. Shows increased respiratory rate 2. Has adventitious breath sounds 3. Assumes orthopneic position 4. Demonstrates flaring of nostrils
Answer 4: Flaring of the nostrils is usually considered a late sign. Increased respiratory rate is associated with many conditions. Some are serious (e.g., pulmonary edema), and others are benign (aerobic exercise). Adventitious breath sounds can be present and the patient may not be aware that there is a problem (e.g., immobile patients can have crackles). The orthopneic position does signal respiratory distress, but is also used by many patients who have chronic respiratory disorders.
What is the biggest problem for patients who are being treated for tuberculosis? (1640) 1. All the patient's contacts have to be identified and treated 2. Infection control measures are complex and expensive. 3. Many have rapid disease progression with mortality rates up to 89%. 4. Drug therapy lasts 6 to 9 months and about 50% are noncompliant.
Answer 4: The drug regimen is prolonged and for various reasons, many will fail to complete the therapy. This has contributed to multidrug-resistant TB strains. Family and friends are generally not at high risk for contracting TB. Hand hygiene and covering the mouth while coughing are encouraged as the main infection control measures. Mortality rates of 72-89% are noted among HIV-infected people with multidrug-resistant TB strains.
In general, infants and young children with pulmonary tuberculosis (TB) do not require isolation precautions because they rarely cough and their bronchial secretions contain few acid-fast bacilli (AFB) compared with adults with pulmonary TB. (1637) t/f
True
Oxymetazoline (Afrin)
a
Epinephrine(adrenaline)
b
theophylline(Theo-Dur)
c
11. Carbon dioxide and oxygen diffuse between blood and lung ___________________________ and alveolar air. (1612)
capillaries
15. ___________________________ are tissue growths on the nasal tissues that are frequently caused by pro- ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣(1620)
Nasal polyps
40. The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. Place the events of reoxygenation in order. (Separate letters by a comma and space as follows: A, B, C, D) a. Pulmonary artery takes blood to capillary system of the alveoli b. Blood enters the left atria via the pulmonary vein c. Blood enter the left ventricle d. Unoxygenated blood enters the right ventricle e. Blood enters the aorta f. CO2 diffused and oxygen infused into the blood in alveoli g. Unoxygenated blood enters the right atrium
ANS: G, D, A, F, B, C, E The unoxygenated blood enters the right atria via the vena cava, then to the right ventricle and out the pulmonary artery into the capillary bed of the alveoli, CO2 and O2 are exchanged in the alveoli, the CO2 being exhaled and the oxygenated blood continues to the right atria via the pulmonary vein, then to the left ventricle and out the aorta to the body. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1613 OBJ: 3 TOP: Reoxygenation of blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
38. The nurse recognizes that the _______ reading in an arterial gas report indicates the amount of oxygen dissolved in the plasma.
ANS: PaO2 The PaO2 reading indicates the amount of oxygen dissolved in the plasma. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1616 OBJ: 8 TOP: Blood gases KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
37. The nurse explains that the opening between the vocal cords is the __________.
ANS: glottis The glottis is the opening between the vocal cords. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1608 OBJ: 2 TOP: Glottis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
39. The nurse explains that the diagnostic test that can scan the chest and the abdomen in less than 30 seconds is the _____________ _____.
ANS: spiral CT scan helical CT scan The spiral or helical CT scan can scan the chest and the abdomen in less than 30 seconds. This test is faster and more accurate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ: 7 TOP: Spiral or helical CT scan KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
36. The nurse prepares a patient for the procedure of a(n) __________, which will remove the fluid from around the lung to improve respiration and obtain a specimen.
ANS: thoracentesis Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1615 OBJ: 7 TOP: Thoracentesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
34. The nurse explains to the person with pneumonia in the left lung that being positioned in the "good lung down" offers the advantage of (select all that apply): a. PaO2 rising in the good lung. b. blood flow to "bad lung" being increased. c. the dependent lung being better perfused. d. dyspnea disappearing. e. decreased hypoxia.
ANS: A, C, E The "good lung down" position increases the PaO2 in the good lung and also allows for better perfusion, consequently decreasing hypoxia, although dyspnea may still be evident. PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ: 11 TOP: Pneumonia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Acetylcysteine (Mucomyst)
d
9. A 45-year-old, second-day postoperative patient is recovering from thoracic surgery. Which therapeutic nursing intervention would the nurse carry out first? 1. Help the patient cough and deep breathe by splinting the anterior and posterior chest 2. Splint the anterior chest for coughing 3. Place the patient in a supine position 4. Allow the patient to sleep uninterrupted for 8 hours
1 Answers from back of book
11. A 52-year-old patient had a laryngectomy due to cancer of the larynx. Discharge instructions are given to the patient and his family. Which response, by written communication from the patient or verbal response by the family, indicates that the instructions need to be clarified? 1. Report swelling, pain, or excessive drainage. 2. The suctioning at home must be a clean procedure, not sterile. 3. Cleanse skin around stoma twice daily (bid), using hydrogen peroxide; rinse with water; pat dry. 4. It is acceptable to take over-the-counter medications now that the condition is stable.
1 Answers from back of book
4. A 73-year-old patient is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breathe. What is the name of this abnormal condition, in which there is discomfort in breathing in any but an erect sitting position? 1. Orthopnea 2. Dyspnea 3. Orthopsia 4. Cheyne-Stokes
1 Answers from back of book
1. When are rapid and deeper respirations stimulated by the respiratory center of the brain? 1. When oxygen saturation levels are greater than 90% 2. When carbon dioxide levels increase 3. When the alveoli contract 4. When the diaphragm contracts and lowers its dome
2 Answers from back of book
10. Which nursing diagnosis for a patient with an acute asthma attack has the highest priority? 1. Anxiety related to difficulty in breathing. 2. Ineffective airway clearance related to bronchoconstriction and increased mucus production. 3. Ineffective breathing pattern related to anxiety. 4. Ineffective health maintenance related to lack of knowledge about attack triggers and appropriate use of medications.
2 Answers from back of book
5. A 45-year-old patient is being evaluated to rule out pulmonary tuberculosis (TB). Which finding is most closely associated with TB? 1. Leg cramps 2. Night sweats 3. Skin discoloration 4. Green-colored sputum
2 Answers from back of book
7. The health care provider ordered a blood culture and sputum specimen for a patient who has pneumonia. When should the nurse collect these specimens? (Select all that apply.) 1. After initiation of antibiotic therapy 2. The morning after admission 3. Before initiation of antibiotic therapy 4. At the first sign of elevated temperature 5. After the patient has had breakfast
2,3 Answers from back of book
12. At rest, the normal inspiration lasts about _______ seconds and expiration about _______ seconds. (1612)
2; 3
6. The health care workers caring for a patient with active TB are instructed in methods of protecting themselves from contracting TB. What does the Centers for Disease Control and Prevention currently recommend for health care workers who care for TB-infected patients? 1. Ask the patient to wear a mask while in isolation. 2. Wear a surgical mask. 3. Wear a small-micron, fitted filtration mask. 4. Receive the BCG vaccine.
3 Answers from back of book
8. A 62-year-old patient has just returned to her room after a bronchoscopy. No food or fluids shall be given after the examination until which event has occurred? 1. There is a total absence of blood-streaked sputum. 2. The head nurse gives the order. 3. The patient's gag reflex returns. 4. The patient is up and about and steady on her feet.
3 Answers from back of book
2. What is the most appropriate nursing intervention for a patient requiring finger probe pulse oximetry? 1. Apply a sensor probe over a finger and cover lightly with gauze to prevent skin breakdown. 2. Set alarms on the oximeter to at least 100%. 3. Identify if the patient has had a recent diagnostic test using intravenous dye. 4. Remove the sensor between oxygen saturation readings.
4 Answers from back of book
3. The walls of the thoracic cavity are lined with a serous membrane composed of tough endothelial cells; what is this membrane called? 1. Visceral pleura 2. Apneustic serosa 3. Pneumotaxic serosa 4. Parietal pleura
4 Answers from back of book
41. The nurse describes the pathophysiologic process of an asthma attack. Place the events in their proper sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Inflammatory process in the mast cells of the lungs b. Increase in edema and mucus production in the bronchioles c. Release of histamine d. Narrowing of the airways e. Exposure to allergen
ANS: E, A, C, B, D The allergen activates the mast cells in the lungs, which release histamine, causing an increase in edema and mucus production that narrows the airways and causes the classic signs of asthma. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1663, Figure 48-14 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
17. The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate? a. The patient will present with edema of the lower extremities and extended neck veins due to hypertension of the pulmonary circulation. b. The patient will present with a dry hacking cough and chest pain due to constriction of the pulmonary vein. c. The patient will present with hypertension and a headache related to pulmonary hypertension. d. The patient will present with unlabored respiration and cyanosis around the mouth.
ANS: A COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1658 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
4. A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding? a. Obtain a blood pressure b. Record the approximate amount of blood lost c. Inquire about a headache d. Record the last episode of epistaxis
ANS: A Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1618 OBJ: 9 TOP: Epistaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
6. How will the kidneys behave in respiratory acidosis? a. Retain bicarbonate to increase the pH b. Excrete more urine to reduce potassium c. Concentrate the urine to conserve circulating fluid in the blood stream d. Lower the pH by excretion of bicarbonate
ANS: A In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Table 48-2 OBJ: 11 TOP: Respiratory acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
24. The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment? a. Document the tidaling b. Elevate the head of the bed and notify charge nurse of malfunction of drainage system c. Add more sterile water to the water seal chamber d. Turn patient to the affected side
ANS: A Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1646, Box 48-6 OBJ: 14 TOP: Closed chest drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
31. Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.) a. Positioning in orthopneic position b. Suctioning c. Assisting to cough d. Providing hydration e. Starting IV fluids f. Starting mucolytic agents
ANS: A, B, C, D Independent nursing intervention to help a patient to expectorate would include positioning, assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic agent requires a physician's order and is not an independent nursing action.. PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ: 12 TOP: Assisting expectoration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
30. Which preoperative teaching should a nurse include for a person scheduled for a partial laryngectomy? (Select all that apply.) a. Tracheal suction will be frequent b. The presence of a temporary tracheotomy c. That isolation will be required for 24 hours d. The surgery involves removal of a diseased vocal cord e. Some speech will be retained f. The sense of smell and taste will be lost
ANS: A, B, D, E A partial laryngectomy involves the removal of the diseased cord and possible thyroid cartilage. There will be a temporary tracheostomy that will be closed once edema is under control. Tracheal suctioning will be done frequently. There will be some vocal ability retained. Isolation is not required. Sense of smell and taste are lost with a total laryngectomy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1623 OBJ: 10 TOP: Patient teaching KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
32. Identify the purposes of chest drainage. (Select all that apply.) a. Drains air, blood, and fluid from pleural space b. Restores positive pressure in chest cavity c. Restores negative intrapleural pressure d. Allows lung to collapse and rest e. Allows route for medication administration
ANS: A, C A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavity's normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space. PTS: 1 DIF: Cognitive Level: Application REF: Page 1644 OBJ: 14 TOP: Closed chest drainage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
19. How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound? a. Sonorous wheeze b. Friction rub c. Coarse crackles d. Crackles
ANS: B A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub. PTS: 1 DIF: Cognitive Level: Application REF: Page 1612, Table 48-1 OBJ: 6 TOP: Adventitious sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this? a. Only 82% of the red blood cells are able to use oxygen. b. There is only 82% of oxygen bound to the hemoglobin compared with the amount available. c. Eighteen percent of oxygen is not dissolved in the blood. d. The muscular respiratory effort is only 18% effective.
ANS: B An SaO2 indicates that only 82% of the available oxygen is bound to the hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1616 OBJ: 8 TOP: SaO2 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised? a. Report redness and swelling of extremities b. Accept that the therapy is long term c. Monitor renal function every several months d. Rise slowly to avoid dizziness
ANS: B INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities. PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-2 OBJ: 13 TOP: INH KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
12. What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis? a. Place the patient in drainage and secretion precautions b. Place the patient in acid-fast bacillus (AFB) Isolation Precautions c. Maintain the patient in enteric isolation d. Place the patient in any Isolation Precautions
ANS: B If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation Precautions should be requested immediately. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1636 OBJ: 13 TOP: Tuberculosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
26. How do leukotriene modifiers reduce the symptoms of asthma? a. By drying up mucus b. By causing bronchodilation and anti-inflammation effects c. By suppressing cough d. By liquefying mucus
ANS: B Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-3 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
21. The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what condition? a. Pulmonary embolus b. Spontaneous pneumothorax c. Early signs of unilateral pneumonia d. An attack of asthma
ANS: B Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger. PTS: 1 DIF: Cognitive Level: Application REF: Page 1648, Figure 48-13 OBJ: 11 TOP: Postoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of: a. friction rub. b. sibilant wheezes. c. crackles. d. sonorous wheezes.
ANS: B The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes, which are high-pitched whistling sounds. PTS: 1 DIF: Cognitive Level: Application REF: Page 1612 OBJ: 16 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
10. A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a "barrel chest." What does this pathology result from? a. An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi b. An increased anteroposterior diameter caused by overinflation of the alveoli c. A decrease in anteroposterior diameter caused by chronic dilation of the bronchi d. A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the airways leading to bronchospasms
ANS: B The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1658, Figure 48-16 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
28. What should the nurse do to keep the chest tubes from becoming occluded? a. Irrigate tubes as needed b. Prevent dependent loops c. Loop the tube over the bed rail d. "Milk" the tube frequently
ANS: B To keep the tubes patent, the tubes should be kept straight without dependent loops. These tubes are not irrigated and should not be milked frequently. PTS: 1 DIF: Cognitive Level: Application REF: Page 1645 OBJ: 1 | 14 TOP: Closed chest drainage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
15. A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse's initial intervention? a. Report signs to the charge nurse. b. Elevate head of bed and administer oxygen. c. Prevent patient from excessive coughing. d. Increase IV flow rate.
ANS: B When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the physician should be notified, but only after the patient is stabilized and oxygenated. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1654, 1655 OBJ: 15 TOP: Pulmonary embolism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
33. What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.) a. Moist mucous membranes b. Kyphosis c. Decrease in pulmonary blood flow d. Stasis pooling of secretions e. Reduced number of cilia
ANS: B, C, D, E Age-related changes that affect the respiratory system are dryer mucous membranes, which reduce ability to humidify inspired air, kyphosis, which restricts the expansion of the lung, stasis pooling of respiratory secretions, and reduced number of cilia, which make infection of the upper and lower airway more likely. PTS: 1 DIF: Cognitive Level: Application REF: Page 1641, Lifespan OBJ: 9 TOP: Pneumonia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
27. How should a patient be positioned after a thoracentesis is completed and the dressing applied? a. High Fowler b. Semi-Fowler c. Side lying on unaffected side d. Prone
ANS: C After a thoracentesis the patient is placed in a side-lying position on the unaffected side. PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ: 11 TOP: Pleural Effusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
8. Which instruction by the nurse is inappropriate for teaching the proper technique for collection of a sputum specimen? a. Bring the sputum up from the lungs b. Rinse mouth with water before expectorating in specimen cup c. Collect specimens before meals d. Send specimen to the lab without delay
ANS: C Collecting specimens before meals will avoid possible emesis from coughing after eating. PTS: 1 DIF: Cognitive Level: Application REF: Page 1615, Box 48-2 OBJ: 12 TOP: Diagnostic procedures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
14. The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related to an imbalance between the oxygen supply and demand? a. Direct patient in vigorous independent ROM. b. Allow to exercise until respirations are over 20 breaths/min over baseline. c. Plan care to provide optimum rest. d. Provide frequent cool showers.
ANS: C Nursing interventions will be directed at attempting to decrease the patient's anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living. PTS: 1 DIF: Cognitive Level: Application REF: Page 1649, Nursing Care Plan OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
29. Which patient assessment indicates the most severe respiratory distress? a. Nasal flaring, symmetrical chest wall expansion, SaO2 88% b. Abdominal breathing, SaO2 97% c. Substernal retraction, SaO2 84% d. Substernal retraction, SaO2 90%
ANS: C Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress. PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ: 5 TOP: Pneumothorax KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. What happens when there is a decrease in the oxygen level in the blood? a. Pituitary stimulates the respiratory system to increase respiratory rate b. The alveoli diffuse more oxygen into the blood c. Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates d. The parietal pleura increases the negative pressure
ANS: C The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations. PTS: 1 DIF: Cognitive Level: Application REF: Page 1611 OBJ: 1 TOP: Respiratory rate modification KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger: a. on the same side as the blood pressure cuff. b. while exercising the arm to stimulate circulation. c. that is a normal temperature. d. on the same side as an arterial catheter.
ANS: C The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Safety Alert OBJ: 9 TOP: Pulse oximeter KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
25. How does pursed lip breathing assist patients with asthma during an attack? a. It distracts the patient with breathing technique to reduce anxiety. b. It gets rid of CO2 faster. c. It opens bronchioles by backflow air pressure. d. It increases PACO2..
ANS: C The resistance or the expiration through the pursed lips causes a backflow of air and helps to open the bronchioles. PTS: 1 DIF: Cognitive Level: Application REF: Page 1664 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
23. The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful? a. In 24 hours, but must take cold liquids for the rest of the day b. If there is no blood in his sputum c. In 8 hours after a period of nothing by mouth d. When the gag reflex returns
ANS: D Following a bronchoscopy, the patient can eat as soon as the gag reflex returns, usually in about 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1614 OBJ: 7 TOP: Bronchoscopy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
7. An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. What is the infected fluid that the physician removes called? a. Emboli b. Emphysema c. Sputum d. Empyema
ANS: D If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1642 OBJ: 11 TOP: Empyema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
22. Which important precaution should the nurse include when instructing an emphysema patient on the use of home oxygen? a. Use oxygen only when extremely short of breath b. Keep the home oxygen regulator set on 6 L c. Use home oxygen at night while sleeping d. Limit to 1 to 2 L oxygen flow
ANS: D Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body's own respiratory regulatory centers and can cause respiratory failure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1659 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
35. The _________ are the structures of the lung in which gas exchange occurs.
ANS: alveoli The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Lower respiratory tract KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
22. A patient with a chronic lung disorder comes to the clinic and tells the nurse, "I feel like I am getting sick again." What questions would the nurse ask? (Select all that apply.) (1612, 1613) 1."How's your breathing? Can you describe it?" 2."Are you coughing? Can you describe the cough?" 3. When did you notice the worsening of symptoms?" 4. "What were your last arterial blood gas results?" 5. "Do you use oxygen at home? If so, does ithelp?" 6. "Have you noticed a change in your ability to do routine activities?"
Answer 1, 2, 3, 5, 6: The nurse would ask the patient to describe symptoms, onset, alleviating factors, and changes in ability to perform activities of daily living (ADLs). Patients with chronic lung disorders are likely to have had abnormal blood gas results (some may keep track of these results), but these findings are not relevant to the current status.
What is likely to be included in the discharge instructions for a patient who was treated for epistaxis? (Select all that apply.) (1620) 1. Use a vaporizer. 2. Use saline nose drops. 3. Apply nasal lubricants. 4. Take aspirin for pain as needed. 5. Vigorously blow to remove clots. 6. Avoid inserting foreign objects into nose.
Answer 1, 2, 3, 6: The goal is to keep the nasal mucous membranes moist, so a vaporizer, saline nose drops and lubricants are recommended. Nose picking and putting other objects into the nose should be avoided; this point is emphasized with pediatric patients. Aspirin is considered an anticoagulant. Blowing vigorously can restart bleeding. (Note to student: The health care provider may have had the patient blow vigorously just prior to examination, so the patient may assume that the action is okay.)
Which patient is most likely to develop acute respiratory distress syndrome (ARDS)? (1657, 1658) 1. Was diagnosed and treated for sepsis 5 days ago ␣␣␣ 2. Had direct trauma to the chest 10 days ago 3. Has a history of chronic obstructive pulmonary disease 4. Has been treated for asthma since early childhood
Answer 1: Sepsis is the most common precursor of ARDS. The window is 5-10 days after onset of sepsis. ARDS due to injury usually manifests in 12-24 hours. COPD or asthma can be factors as underlying respiratory diseases, but many patients who have COPD or asthma never develop ARDS.
For a patient with a chest tube, which task could be delegated to the UAP? (1646) 1.Assist to ambulate with water-seal below the level of the chest. 2. Check to make sure that all connections are secure and intact. 3. Observe for and report hypoventilation or increased dyspnea. 4.Assess quantity and quality of drainage in the collection chamber.
Answer 1: The UAP can help the patient ambulate, but the nurse must give specific instructions about holding the container below the chest and ensure that the UAP and patient do not place undue pressure on the tubes. (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)
25. Which patient has the greatest need for a he- lical computed tomography scan, which is considered a new and improved technology? (1655) 1. A disoriented elderly man who may have a pulmonary embolus 2. A toddler who might have swallowed a metallic foreign body 3. A patient who requires a sample of lymph node tissue for biopsy 4. A patient who was exposed to tuberculosis several decades ago
Answer 1: The advantage of the helical computed tomography scan is that the entire study can be performed in less than 30 seconds. The disoriented patient may have difficulty cooperating for a V-Q scan or pulmonary angiography, as both are much longer procedures. A flat plate of the abdomen is the best exam for ingested foreign bodies. A mediastinoscopy will be performed to obtain lymph tissue. A chest x-ray will be performed for the patient exposed to tuberculosis.
The patient needs a thoracentesis for therapeu- tic reasons. Which position should the nurse help the patient to assume for the procedure? (1616) 1. Seated on the bed; head and arms resting on a pillow placed on an overbed table 2. Placed in a supine position with the anterior-lateral chest draped for ready ac- cess 3. Positioned in a recumbent prone position with head resting on forearms and hands 4. Situated in a side-lying position on affected side and uncovered to the waist
Answer 1: The goal of thoracentesis for therapeutic reasons is to remove fluid from the thoracic cavity. Positioning the patient upright will facilitate the drainage.
What is the nurse's role in allergy testing? (1621) 1. Uses a lancet to prick the skin with differ- ent allergens 2. Evaluates the response to different aller- gens 3. Advises the patient about allergens to avoid 4. Determines schedule for retesting ques- tionable allergens
Answer 1: The nurse can administer the allergens and should mark the sites. The localized reaction should be measured and documented. The health care provider is responsible for evaluating the outcomes of the test, discussing allergens to avoid, and instructing the patient about ambiguous results. The nurse can reinforce what the health care provider tells the patient, but should not initiate discussion of findings. Allergy testing and interpretation of results is not an exact science.
The nurse is performing a rapid strep screen. What is the rationale for obtaining two throat swabs? (1629) 1. the 1st swab is likely contaminated so a backup swab is needed. 2. If the rapid strep test is negative, the sec- ond swab is sent for culture. 3. The second swab is given to the patient, in case the rapid strep is positive. 4 they're grown in different types of culture media.
Answer 2: A rapid strep test is performed to detect the presence of β-hemolytic streptococci, which is a severe form of acute pharyngitis. If those results are negative, then the second swab is used to culture a medium and is allowed to grow so the infecting organism can be identified.
41. A patient recently diagnosed with peripherally located lung cancer reports he is experienc- ing severe chest pain. Based on the nurse's knowledge of the pathophysiology of this pain, which therapy does the nurse anticipate? (1645, 1651) 1. Bronchodilators 2. Thoracentesis 3. Mechanical ventilation 4. Corticosteroids
Answer 2: Severe pain in peripheral lung cancer is likely to be caused by a pleural effusion. The treatment for this is a thoracentesis.
26. The nurse is caring for a patient who had a bronchoscopy. Which task can be delegated to the UAP? (1615) 1. Give clear fluids after checking for the gag reflex 2. Assist the patient to a semi-Fowler's position. 3.Report signs of laryngeal edema, such as stridor. 4. Check sputum for signs of hemorrhage.
Answer 2: The UAP can assist the patient to move and make position changes. The other tasks are nursing responsibilities. (Note to student: The UAP could ordinarily be expected to watch for and report seeing blood in specimens; however, some blood is an expected finding after biopsy and the nurse should do the assessment to determine if bleeding is excessive.) (Note to student: Knowledge of correct nursing action and principles of delegation are combined to decide which action can be assigned or delegated to a UAP. Remember that UAP need specific instructions.)
A patient is admitted for a deep vein thrombo- sis in the left leg. He is in good spirits during the AM assessment, but later in day he reports feeling mildly short of breath with a sense of impending doom. What should the nurse do ␣␣␣␣␣␣(1655) 1. Obtain an order for an arterial blood gas. 2. Check the vital signs and pulse oximeter reading. 3. Assess the left leg for warmth, redness, or swelling. 4. Alert the RN about possible pulmonary embolus.
Answer 2: The nurse would first check vital signs and a pulse oximeter reading and assess for other signs of respiratory distress or decreased cardiac output. Notifying the RN and health care provider would be the next step. A blood gas is likely to be ordered. Assessing the leg is not helpful once the thrombus becomes an embolus.
24. A patient was brought to the emergency de- partment because he was involved in a motor vehicle accident. The patient shows mild respi- ratory distress and expansion of the right side of the chest is decreased compared to the left. The history and data are indicative of which disorder? (1649) 1. Pleural effusion 2. Pneumothorax 3. Empyema 4. Pulmonary edema
Answer 2: Trauma combined with uneven chest expansion are associated with pneumothorax (collapsed lung).
The patient is diagnosed with pleurisy. During auscultation of the lungs, what is the nurse most likely to hear? (1613) 1. Interrupted crackling or bubbling sounds more common on inspiration 2. Deep, loud, low, coarse sound (like a snore) during inspiration or expiration 3. Dry, creaking, grating, with a machinelike quality loudest over anterior chest 4. High-pitched, musical, whistlelike sound during inspiration or expiration
Answer 3: A pleural friction rub is considered diagnostic for pleurisy. The nurse should hear a dry, creaking, grating, low-pitched sound with a machinelike quality during both inspiration and expiration. Crackles are interrupted crackling or bubbling sounds more common on inspiration. Sonorous wheezes are deep, loud, low, coarse sounds (like a snore) during inspiration or expiration. Sibilant wheezes are high-pitched, musical, whistlelike sounds during inspiration or expiration.
A patient is diagnosed with viral laryngitis. Which discharge instruction is the most important to relive edema and inflammation of the vocal cords? (1629) 1. Use a mild analgesic, such as acetamino- phen for pain. 2. Complete the full course of antibiotics. 3. Rest the voice; communicate with gestures or by writing. 4. Suck on throat lozenges to promote com- fort.
Answer 3: Resting the voice is the most important measure to reduce the inflammation of the vocal cords. The other measures help to promote comfort. Antibiotics are not prescribed for a diagnosis of viral laryngitis.
For a patient with chronic bronchitis, what is the physiologic cause of polycythemia? (1660) 1. Medication side effect 4. Compensation for chronic hypoxemia
Answer 4: An increased number of red blood cells (polycythemia) occurs as the body at tempts to increase the oxygen to tissue. Dehydration could contribute to an elevated red cell count, but is not directly related to chronic bronchitis.
What special consideration is needed for an arterial blood gas for a patient who is taking warfarin (Coumadin)? (1655) 1. The dietary therapy associated with the drug is likely to alter the results. 2. The drug increases fragility of the vessels,so the specimen is hard to obtain. 3. The drug alters the amount of oxygen that hemoglobin can carry. 4. The clotting times are longer than normal,so pressure is held for 20 minutes on the puncture site.
Answer 4: Warfarin is an anticoagulant, so the nurse would hold pressure on the puncture wound for 20 minutes to prevent a hematoma.
Lung cancer is now the leading cause of death from cancer for men only. (1650) t/f
False: Lung cancer is the leading cause of death from cancer for men and women.
Aspirated foreign bodies are more likely to lodge in the left main stem bronchus. (1610) T/F
False: The right mainstem bronchus is larger and more vertical; therefore, foreign bodies are more likely to go to the right.
Cigarette smoking is by far the most common cause of emphysema and chronic bronchitis. (1659) t/f
True
13. When stimulated by increasing levels of blood ___________________________, decreasing levels of blood ___________________________, or increasing blood acidity, the chemoreceptors send nerve impulses to the respiratory centers, which in turn modify respiratory rates. (1612)
carbon dioxide; oxygen
Salmeterol(Serevent)
e
Prednisone (Deltasone)
f
Ethambutol (Myambutol)
g
isoniazid (INH, Nydrazid)
h
Zafirlukast (Accolate)
i
14. The pCO2 level is ___________________________ in primary respiratory acidosis and ___________________________ in primary respiratory alkalosis. (1617)
increased; decreased
Potassium Iodide
j