Respiratory Nclex style questions
5. For a client with COPD who has trouble raising respiratory secretions, which of the following nursing measures would help reduce the tenacity of secretions? A. Ensuring that the client's diet is low in salt. B. Ensuring that the client's oxygen therapy is continuous. C. Helping the client maintain a high fluid intake. D. Keeping the client in a semi-sitting position as much as possible.
5. ANSWER: C A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions. 1 A: A low-salt diet does not help reduce the viscosity of mucus. B: Continuous oxygen therapy does not help reduce the viscosity of mucus. D: Maintaining a semi-sitting position does not help reduce the viscosity of mucus.
51. Which common substances is the client most likely to inhale to become intoxicated? A. Glue, cleaning solutions, insecticides B. Glue, nail polish remover, aerosols C. Paint thinners, insecticides, spray paint D. Cleaning solutions, insecticides, spray paint
51. ANSWER: B Glue, nail polish remover, aerosols, paint thinners, and cleaning solutions are inhalants used for a "high." Insecticides inhalation would likely cause illness, and inhaling a spray paint would color the person's face, an obvious detriment.
31. A client who suffered a cerebrovascular accident has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which of the following interventions would help meet this goal? A. Repositioning the client every 2 hours B. Restricting fluids to 1,000 ml/24 hours C. Administering oxygen by cannula, as ordered D. Keeping the head of the bed at a 30-degree angle
31. ANSWER: A Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle may ease respirations and make them more effective but wouldn't help mobilize secretions.
35. Which of the following interventions is most helpful in determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease? A. Ask the client to tell the nurse when oxygen is needed. B. Assess the client's fatigue level. C. Use a pulse oximeter to determine oxygen saturation. D. Evaluate the client's hemoglobin level daily.
35. ANSWER: C A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy. A: Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need. B: Fatigue may be due to other factors besides oxygenation levels. D: Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need.
1. The client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: A. area of redness is measured in 3 days and determines whether tuberculosis is present. B. skin test doesn't differentiate between active and dormant tuberculosis infection. C. presence of a wheal at the injection site in 2 days indicates active tuberculosis. D. test stimulates a reddened response in some clients and requires a second test in 3 months.
1. ANSWER: B The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.
10. To determine if tissue underlying the lower lobe of a client's right lung is filled with fluid, the nurse should use which of the following methods of physical examination? A. Auscultation B. Inspection C. Palpation D. Percussion
10. ANSWER: D Percussion is the process of striking a client's body surface with short, sharp blows of the fingers to determine the size, position, and density of underlying tissue. Auscultation, inspection, or palpation wouldn't help to attain this result.
100.A nurse has just finished teaching a group of new nursing assistants about the spread of tuberculosis (TB). She knows that her teaching has been effective when one of the assistants states: A. "I could get TB by coming in contact with the client's stool." B. "I could get TB if I become contaminated with the client's blood." C. "I could get TB if I inhale infected droplets when the client coughs." D. "I could get TB if I handle the client's urine without wearing gloves."
100.ANSWER: C TB transmission occurs when an infected person coughs or sneezes, spreading infected droplets. Many other infectious diseases can be transmitted through contact with stool, urine, or blood but not TB.
101.A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. Which of the following is a risk factor for tuberculosis in this client? A. Male sex. B. The infant is in the 95th percentile for height and weight. C. His mother did not receive prenatal care until the second trimester of her pregnancy. D. Age.
101.ANSWER: D Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. A: In later childhood and adolescence, morbidity and mortality are higher in females than males. B: A higher than average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis. C: Prenatal care is unrelated to tuberculosis.
102.Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance? A. Presence of congestion on X-ray B. Breath sounds clear on auscultation C. Continued use of oxygen when necessary D. Respiratory rate of 24 breaths/minute
102.ANSWER: B The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems.
13. During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of data? A. Subjective B. Objective C. Secondary source D. Medical
13. ANSWER: B Physical examination techniques, such as auscultation, provide objective data, which reflect findings without interpretation. Subjective data are reported to the nurse by the client and family. The family and members of the health care team provide secondary source information. Medical data are obtained from the physician and medical record.
103.Following a laryngectomy, a client, who is being discharged, exhibits concern that the laryngectomy tube may become dislodged. The nurse should teach the client to first: A. Notify the physician at once B. Reinsert another tube immediately C. Keep calm because there is no immediate emergency D. Recognize that prompt closure of the tracheal opening may occur
103.ANSWER: C The client's concerns will be reduced if he or she knows the stoma will stay open long enough so that another tube can easily be inserted. A: The client is in no immediate danger and it is not imperative to notify the physician at once. B: A permanent opening into the trachea is formed after 2 or 3 weeks, and a tube need not be promptly reinserted. D: A permanent opening into the trachea is formed after 2 to 3 weeks and will not close quickly.
104.On the first day following a right pneumonectomy a male client suddenly sits straight up in bed. His respirations are labored, and he is making a crowing sound. His skin is pale, cool, and moist. Immediately the nurse should: A. Notify the physician B. Auscultate the left lung C. Inspect the incision for bleeding D. Check the chest tube for patency
104.ANSWER: B "This is unsafe; the client needs immediate intervention; the airway is the priority. ","A mediastinal shift with airway obstruction may occur because pressure builds up on the operative side, causing the trachea to deviate toward the unoperative side; assessment of the airway takes priority. ","This is unsafe; the client needs immediate intervention; the airway is the priority. ","There is no need for a chest tube when a pneumonectomy is performed.
105.After a thoracentesis for pleural effusion a client returns to the physician's office for a follow-up visit. The nurse would suspect a recurrence of pleural effusion when the client says: A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes have a fever and chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up larger amounts of thicker mucus for the last 2 days."
105.ANSWER: C Tension is placed on the pleura at the height of inspiration and causes pain. A: This is typical of congestive heart failure. B: This may indicate pulmonary infection. D: This may indicate pulmonary infection.
106.A client has had thoracic surgery for removal of a benign mediastinal tumor. He has a left chest tube to water seal drainage. The nurse auscultates scattered crackles bilaterally. Which of the following interventions would be most appropriate? A. Check the water-seal system. B. Encourage deep breathing and ambulation as soon as the client is able. C. Perform suctioning once per shift and ask the physician to order an expectorant. D. Reduce the frequency of pain medication and increase the suction in the water-seal bottle.
106.ANSWER: B Crackles occur because of retained secretions and shallow breathing. Shallow breathing is a common problem after thoracic surgery owing to the pain associated with deep inspiration. Assisting the client to deep breathe and ambulate will help expand the lung tissue, clear secretions and improve oxygenation. A: Scattered crackles are indicative of fluid in the airways, not a malfunctioning drainage system. C: The alert, nonintubated client should not be suctioned when coughing and deep breathing can clear the airways. D: Reducing pain medication would make effective deep breathing and ambulating more difficult.
107.A 68-year-old male client has been hospitalized repeatedly for chronic obstructive pulmonary disease (COPD). During this latest admission, he has refused to participate in his self-care. Every time the nurse approaches him, the client states, "I just want to die. I'm no good to anyone anymore." The nurse realizes that he's experiencing: A. self-actualization B. confabulation. C. reaction formation. D. grief.
107.ANSWER: D The client with a chronic illness goes through a grieving process that is related to the loss of his previous level of function. Grief is commonly manifested as loss of motivation and refusal to perform functions of which the client is fully capable. Self-actualization is the process of fulfilling one's potential. Confabulation is a behavioral reaction in which the client creates stories or invents answers to fill in memory gaps in an unconscious attempt to maintain self-esteem. In reaction formation, the client uses behaviors that are the opposite of what he would like to do.
108.A client is diagnosed as having pulmonary tuberculosis, and one of the drugs the physician orders is pyrazinamide (PZA). The nurse evaluates that the teaching concerning the drug was effective when the client says, "I will: A. Drink at least 2 quarts of fluid a day." B. Take the medication 2 hours after each meal." C. Report any changes in vision to the physician." D. Expect a discoloration of urine, sweat, and tears."
108.ANSWER: A This medication causes hyperuricemia, leading to joint swelling and pain; fluids dilute the urine and help remove the uric acid. B: This medication causes GI irritation and should be taken with food. C: This is not a side effect of this medication. D: This is a side effect of rifampin (Rifadin), not pyrazinamide.
109.The physician has ordered O2 at 3 liters/minute via nasal cannula. O2 amounts greater than this are contraindicated in the client with COPD because: A. Higher concentrations result in severe headache. B. Hypercapnic drive is necessary for breathing. C. Higher levels will be required later for pO2. D. Hypoxic drive is needed for breathing.
109.ANSWER: D Respiratory effort is stimulated in client's with COPD by hypoxemia. Answer A and C are incorrect because higher levels would rob the client of the drive to breathe. Answer B is an incorrect statement.
11. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care? A. Putting on a mask when entering the client's room B. Instructing the client to wear a mask at all times C. Wearing a gown and gloves when providing direct care D. Keeping the door to the client's room open to observe the client
11. ANSWER: A Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client's blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.
110.A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? A. "I'll have to take the medication for up to a year." B. "This disease may come back later if I'm under stress." C. "I'll stay in isolation for at least 6 weeks." D. "I'll always have a positive test for tuberculosis."
110.ANSWER: C The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. If he's sick or under some stress he could have a relapse of the disease. He'll be positive when tested.
111.When teaching a client with tuberculosis about recovery after discharge from the hospital, the nurse should reinforce that the treatment measure with the highest priority is: A. Having sufficient rest B. Getting plenty of fresh air C. Changing the current life-style D. Consistently taking prescribed medication
111.ANSWER: D A: Although this is important, the microorganisms must be eliminated by the use of medication. B: Although this is important, the microorganisms must be eliminated by the use of medication. C: Although this is important, the microorganisms must be eliminated by the use of medication. D: Tubercle bacilli are particularly resistant to treatment and can remain dormant for prolonged periods; medication must be taken consistently as ordered for prolonged periods.
112.For a client with a sucking stab wound in the chest wall, the nurse should first: A. Start administering oxygen. B. Cover the wound with a petroleum-impregnated dressing. C. Prepare to do a tracheostomy. D. Prepare for endotracheal intubation.
112.ANSWER: B The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound. A: Starting oxygen therapy may be necessary later but does not have the same priority on admission as closing the wound. C: The data provided do not support the need for a tracheostomy. D: Preparing for endotracheal intubation may be necessary later but does not have the same priority on admission as closing the wound.
113.The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: A. suctioning the tracheostomy tube frequently. B. using a cuffed tracheostomy tube. C. using the minimal air leak technique with cuff pressure less than 25 cm H2O. D. keeping the tracheostomy tube plugged.
113.ANSWER: C To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
114.A client with chronic obstructive lung disease tells the nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, "I have several more percussions to do on the unit where I am now. As soon as I'm done, I'll come assess the client." The nurse's most appropriate action is to: A. notify the primary physician immediately. B. stay with the client until the therapist arrives. C. administer the treatment by metered-dose inhaler. D. give the nebulizer treatment herself.
114.ANSWER: D The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment so the nurse can't change the route without a new order from the physician.
115.A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client's arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Prepare to assist with ventilation. B. Monitor the client's heart rhythm. C. Prepare to begin gastric lavage. D. Obtain urine for drug screening.
115.ANSWER: A Respiratory acidosis is associated with hypoventilation, which in this client suggests intake of a drug that suppresses the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening.
116.A client's chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A. cardiogenic pulmonary edema. B. respiratory alkalosis. C. increased pulmonary capillary permeability. D. renal failure.
116.ANSWER: C ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it doesn't cause ARDS. Renal failure also doesn't cause ARDS.
117.A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should: A. Turn the client every 2 hours. B. Elevate the head of the bed 30 degrees. C. Encourage increased fluid intake. D. Maintain a cool room temperature.
117.ANSWER: C Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.
118.The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? A. 15-mm induration B. Reddened area C. 10-mm bruise D. Blister
118.ANSWER: A A 10-mm induration strongly suggests a positive response in this tuberculosis screening test — so, a 15-mm induration clearly requires further evaluation. The remaining options aren't positive reactions to the test and require no further evaluation.
119.Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with COPD. Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? A. The oxygen will be lost at the client's nostrils if given at a higher level with a nasal cannula. B. The client's long history of respiratory problems indicates that he would be unable to absorb oxygen given at a higher rate. C. The cells in the alveoli are so damaged by the client's long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst. D. The client's respiratory center is so accustomed to high carbon dioxide and low blood oxygen concentrations that changing these concentrations with oxygen therapy may eliminate his stimulus for breathing.
119.ANSWER: D Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide, they may stop breathing. A: Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. B: The client's ability to absorb oxygen administered at a higher level is not affected. C: Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst.
12. The physician orders oxygen given in low concentration, rather than in high concentration and continuously, for a client with COPD to prevent: A. A decrease in red cell formation B. Rupture of emphysematous bullae C. Depression of the respiratory center D. An excessive drying of the respiratory mucosa
12. ANSWER: C Clients with chronic obstructive pulmonary disease (COPD) must be given only low concentrations of oxygen; a decreased oxygen blood level is the only stimulus for breathing for these clients. A: Prolonged hypoxia will stimulate erythrocyte production; the goal of therapy is to relieve hypoxia. B: The pressure, rather than the concentration, at which oxygen is administered increases this risk. D: To prevent its drying effects on secretions and the mucosa, oxygen should be humidified.
120.When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which of the following problems? A. Hypotension, hyperoxemia, and hypercapnia B. Hyperventilation, hypertension, and hypocapnia C. Hyperoxemia, hypocapnia, and hyperventilation D. Hypercapnia, hypoventilation, and hypoxemia
120.ANSWER: D The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
121.The nurse's assignment for the day includes a 3-day postoperative thoracotomy client with two chest tubes in place. When making the morning assessments on this client, the nurse notes the fluid in the water-seal chamber isn't fluctuating. Which of the following provides the most likely explanation? A. The chest tubes aren't positioned correctly. B. The lung has reexpanded. C. The water-seal chamber needs more sterile water. D. The suction needs to be increased.
121.ANSWER: B Fluctuations of fluid in the water-seal chamber will stop when the lung has expanded, the tubing is occluded, or the suction apparatus malfunctions.
122.The nurse caring for a patient in pre-term labor should be aware that the patient may exhibit which of the following side effects when administered intravenous terbutaline sulfate (Brethine)? A. Uterine hypertonia B. Epistaxis C. Tachycardia D. Dysuria
122.ANSWER: C Tachycardia is listed as one of the primary side effects of Brethine. The mother may report feeling like "her heart is beating out of her chest." The fetal and maternal heart rates should be monitored. Usually, the tachycardia is mild in nature. A: The action of the Brethine is to relax smooth muscles. The uterine muscle is smooth in nature. B: Epistaxis or nosebleeds are not associated with Brethine administration. D: Dysuria or painfUl urination is associated with urinary tract infections and not with the use of Brethine.
123.A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than: A. 0.21. B. 0.35. C. 0.5. D. 0.7.
123.ANSWER: C An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.18 to 0.21.
124.The nurse is planning care for a patient with pneumonia. The patient is to be suctioned PRN. Which of the following techniques, if used by the nurse, MOST accurately describes proper suctioning? A. Apply suction, for no more than 20 seconds, as the catheter is inserted. B. Apply suction, for no more than 10 seconds, as the catheter is both inserted and withdrawn. C. Apply suction, for no more than 10 seconds, as the catheter is withdrawn. D. Apply suction each time the patient inhales.
124.ANSWER: C Gently rotate 360 degree; too long can cause hypoxia, dysrhythmias; hyperoxygenate before, during and after A: not done B: no suction when inserted D: not involved with breathing pattern ADDITIONAL INFO: Pneumonia: infection of the lungs due to viruses/bacteria, aspiration of food/fluids or inhalation of toxic chemicals. S/S: fever, chills, hemoptysis, dyspnea, fatigue. Treatment: antibiotics. Nursing responsibilities: T, C, DB, Fowler's position. Suction to remove secretions and provide open airway. Complications: infection, trauma, hypoxemia, dysrhythmias. Use 12 - 14 French catheter. Suction pressure less than 120 mmHg.
125.To help control pain during coughing for a client who has had a lobectomy, the nurse should: A. Place the bed in slight Trendelenburg's position and help the client turn onto her operative side to splint the incision. B. Raise the bed to semi-Fowler's position and place one hand on the client's back, on the left side, and one hand under the incision. C. Keep the bed flat and tell the client to place her hands over the incision before taking a deep breath. D. Raise the bed to complete Fowler's position and help the client turn onto her operative side to splint the incision.
125.ANSWER: B Semi-Fowler's position allows for downward displacement of the diaphragm and relaxation of the abdominal muscles, which are needed for good ventilatory excursion. The hand placement supports the operative area and splints it without causing pain from pressure. A: Trendelenburg's position is contraindicated because abdominal contents pushing against the diaphragm will decrease effective lung volume. C: Keeping the bed flat does not allow the diaphragm to descend. D: Positioning the client on the operative side prevents maximum inflation of the left lung. Placing the hands on the operative area before inhalation can restrict thoracic movement.
14. A client is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care? A. Assessing the client's temperature every 8 hours B. Placing the client in respiratory isolation C. Monitoring the client's fluid intake and output D. Wearing gloves during all client contact
14. ANSWER: B Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances.
15. A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which of the following measures would most likely help liquefy these viscous secretions? A. Performing postural drainage. B. Breathing humidified air. C. Clapping and percussing over the affected lung. D. Performing coughing and deep-breathing exercises.
15. ANSWER: B Breathing humidified air." -- Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. 1 A: Postural drainage may be helpful for respiratory hygiene but will not affect the nature of secretions. C: Vibration and percussion of the chest wall may be helpful for respiratory hygiene but will not affect the nature of secretions. D: Coughing and deep-breathing exercises may be helpful for respiratory hygiene but will not affect the nature of secretions.
16. A few days after a colectomy, a client suddenly develops chest pain, shortness of breath, and air hunger. The nurse knows she must further assess the client's chest pain to determine its origin. When determining whether the chest pain is cardiac or pleuritic in nature, the nurse knows that pleuritic chest pain typically: A. is described as crushing and substernal. B. worsens with deep inspiration. C. is relieved with nitroglycerin. D. is relieved when the client leans forward.
16. ANSWER: B Pleuritic chest pain is typically described as intermittent, sharp, and very painful and is aggravated with deep inspiration or movement. Crushing, substernal chest pain that is relieved by nitroglycerin is usually of cardiac origin. Leaning forward typically relieves pain associated with endocarditis.
17. The nurse auscultates a client's lungs and notes a fine crackling sound in the left lower lung during respiration. If crackles and rhonchi in the left lower lung were charted on the nurse's notes, the notation would be: A. A nursing diagnosis B. A correct nursing notation C. An inaccurate interpretation D. Correct if palpation ruled out crepitus
17. ANSWER: C Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the notation makes it inaccurate. A: Crackles and rhonchi are client adaptations, not a nursing diagnosis. B: It would be incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. D: Crepitus, which indicates subcutaneous emphysema, is a condition unrelated to the breath sounds heard on auscultation.
18. Following a tonic-clonic seizure, a client has snoring respirations. The physician orders a nasopharyngeal airway inserted to protect the client's airway. The nurse is inserting the airway correctly when she: A. depresses the tongue as the airway is inserted. B. lubricates the airway with petroleum jelly. C. inserts the airway with the tip upward. D. gently pushes the airway along the floor of the nostril.
18. ANSWER: D The nurse is inserting the nasopharyngeal airway correctly when she places the client in a supine position, pushes the tip of the client's nose upward, and inserts the airway along the floor of the nostril into the posterior pharynx. The airway should be inserted to a predetermined length (measuring from the tip of the nose to the ear lobe and marking the distance on the tube) or until the flange is flush with the nostril. An oropharyngeal (not nasopharyngeal) airway should be inserted by pointing the tip upward toward the roof of the mouth. Only water-based lubricant, not petroleum jelly, should be used. Because the airway is inserted nasally, the client's tongue is bypassed and doesn't need to be depressed.
19. Which statement is true about crackles? A. They're grating sounds. B. They're high-pitched, musical squeaks. C. They're low-pitched noises that sound like snoring. D. They may be fine, medium, or coarse.
19. ANSWER: D Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They're classified as fine, medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, high-pitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways.
2. A client hospitalized with a pneumothorax has the following arterial blood gas (ABG) analysis: pH, 7.19; partial pressure of arterial carbon dioxide (PaCO2), 63 mm Hg; and HCO3-, 22 mEq/L. A chest tube was inserted and oxygen administered at 4 L/minute by nasal cannula. One hour after the initiation of treatment, ABG analysis reveals: pH, 7.28; PaCO2, 52 mm Hg; and HCO3-, 22 mEq/L. This change in ABG analysis indicates: A. respiratory alkalosis. B. impending respiratory arrest. C. the need for intubation. D. improved respiratory status.
2. ANSWER: D The original ABG analysis reveals respiratory acidosis commonly seen with a pneumothorax. After chest tube insertion, the client's respiratory status has improved, pH is increasing toward normal, and the PaCO2 is decreasing. ABG analysis in respiratory alkalosis shows an elevated pH and a low PaCO2. Assessment findings are more important than ABG analysis in determining whether the client requires intubation or if respiratory arrest is imminent.
20. Which of the following instructions would the nurse give to the parents of an 8-year-old child with asthma who is being switched from parenteral steroid therapy to a daily dose of oral prednisone? A. Administer the dose before bedtime to minimize side effects. B. Give the medication according to the child's response. C. Have the child take the dose with meals to prevent gastric irritation. D. Make sure the pill is given intact to maintain the enteric coating.
20. ANSWER: C Prednisone causes severe gastric upset. Therefore, it should be given with food. A: It is recommended that the daily dose be given in the morning before 9:00 AM. Given at this time, the medication will suppress adrenal cortex activity less, which may reduce the risk of HPA-axis suppression. B: The drug must be given as ordered and not titrated to response. If the drug has been given over a long period, abrupt cessation can cause serious side effects. D: Because the pills are not enteric-coated, they may be crushed and mixed with food if the child has difficulty swallowing them.
21. After staying several hours with her 10-year-old daughter who is admitted to the hospital with an asthmatic attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings would lead the nurse to make a nursing diagnosis of Anxiety related to respiratory distress? A. Complaints of an inability to get comfortable. B. Frequently requests for someone to stay in the room. C. Inability to remember his exact address. D. Verbalization of a feeling of tightness in his chest.
21. ANSWER: B A 10-year-old should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress at this age suggesting Anxiety. A: The inability to get comfortable is commonly characteristic of child with a diagnosis of Pain. C: Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge. D: Tightness in the chest occurs as a result of bronchial spasms and indicates a diagnosis of Ineffective Airway Clearance.
22. A client's respiratory status necessitates endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for this client at this time would be to: A. Prepare the client for emergency surgery B. Facilitate the client's verbal communication C. Assess the client's response to the equipment D. Maintain sterility of the ventilation system the client is using
22. ANSWER: C Nothing is achieved if the equipment is working and the client is not responding. A: This is presumptive; the data base is incomplete for the assessment that surgery is necessary. B: Endotracheal intubation does not permit verbal communication. D: This is important but not the priority.
23. When discussing the use of cromolyn sodium (Intal) with the parent of a child diagnosed with asthma, the nurse should teach the mother that the medication will be ineffective if it is administered at which of the following? A. Intermittently for short-term use. B. During an asthmatic attack. C. Preparation for going to bed. D. Prior to riding a bicycle for a block.
23. ANSWER: B Cromolyn sodium (Intal) is used as a prophylactic agent to help prevent bronchial asthmatic attacks. The drug inhibits histamine release and acts locally to prevent the release of mediator substances from mast (connective tissue) cells after exposure to allergens. The drug is not an anti-inflammatory, bronchodilator, or antihistamine agent. Therefore, it is of no use during an asthma attack. A: To be effective, cromolyn should be administered consistently over a long period of time. Short-term dosing provides no benefits. C: Cromolyn is used prophylactically and administered routinely several times a day. Although preparation for bed would not affect the effectiveness of cromolyn, it may be one of the scheduled dosing times. D: Although cromolyn is indicated for the prevention of exercise-induced bronchospasm, riding a bicycle one block is usually not considered to be strenuous exercise. Thus, cromolyn would not be helpful in preventing airway narrowing.
24. The nurse is aware that a client understands the instructions about an appropriate breathing technique for COPD when the client: A. Inhales through the mouth B. Increases the respiratory rate C. Holds each breath for a second at the end of inspiration D. Progressively increases the length of the inspiratory phase
24. ANSWER: C This pause allows added time for gaseous exchange at the alveolar capillary beds. A: Inhalation should be through the nose to moisten, filter, and warm the air. B: This decreases the effectiveness of respirations. D: The expiratory phase should be lengthened, and exhalation should be through pursed lips.
25. A client suffers adult respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A. Kinking of the ventilator tubing B. A disconnected ventilator tube C. An endotracheal cuff leak D. A change in the oxygen concentration without resetting the oxygen level alarm
25. ANSWER: A Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the endotracheal tube, and the client being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.
26. In the early stage of shock, the nurse would expect the results of arterial blood gas (ABG) analysis to indicate: A. Respiratory alkalosis. B. Respiratory acidosis. C. Metabolic alkalosis. D. Metabolic acidosis.
26. ANSWER: A As a compensatory measure in the early stage of shock, the client hyperventilates in response to hypoxemia. Hyperventilation is an attempt to provide more oxygen to the tissues to compensate for decreased circulating volume. It increases minute volume and results in decreased PaCO2), while PaO2 remains normal. This is the classic picture of respiratory alkalosis. B: Respiratory acidosis occurs in the advanced stage of shock. C: Metabolic alkalosis does not develop in shock unless overcorrection of acidosis is a result of administering sodium bicarbonate. D: Metabolic acidosis occurs in the advanced stage of shock.
27. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for? A. Infection of the lung B. Kinked or obstructed chest tube C. Excessive water in the water-seal chamber D. Excessive chest tube drainage
27. ANSWER: B Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage.
28. A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid? A. The tubing from the client to the chamber is blocked. B. There is a leak somewhere in the tubing system. C. The client's affected lung has reexpanded. D. The tubing needs to be cleared of fluid.
28. ANSWER: B Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling to occur during inspiration, but continuous bubbling signifies a leak in the closed system. Absence of bubbling in the second chamber signifies a block in the system. It can also mean that the affected lung has reexpanded.
29. A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty with the chest tube separated from the drainage system. The nurse should: A. Obtain a new sterile drainage system B. Clamp the drainage tubing with two clamps C. Reconnect the client's tube to the drainage system D. Place the client in the high-Fowler's position immediately
29. ANSWER: C To prevent further possibility of pneumothorax, the nurse should immediately reconnect the tube. A: This is unnecessary. B: Clamping is appropriate for changing a broken drainage system or to check for an air leak; it should not be done needlessly. D: The high-Fowler's position is appropriate for a client in respiratory distress, but this does not remedy this problem.
3. A client is admitted to the intensive care unit with pulmonary edema. When performing the admission assessment, the nurse should expect: A. A decreased blood pressure B. Radiating anterior chest pain C. A pulse that is weak and rapid D. Crackles at the base of each lung
3. ANSWER: D Crackles are the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli. A: The blood pressure is usually increased with hypervolemia. B: This would occur with angina or a myocardial infarction. C: The pulse would be bounding with hypervolemia.
30. A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? A. "Clean the tracheostomy tube with alcohol and water." B. "Family members should continue to talk to the client." C. "Oral intake of fluids should be limited for 1 week only." D. "Limit the amount of protein in the diet."
30. ANSWER: B Commonly, family members are reluctant to talk to a client who has had a total laryngectomy and no longer can speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client and family to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
32. Immediately after a thoracentesis a client's right lung collapses. A chest tube is inserted and attached to a three-chamber closed drainage system. The nurse knows that the chest tube is functioning properly when fluid: A. Is bubbling gently in the chest drainage chamber B. Remains constant in the chest drainage chamber C. Is bubbling vigorously in the suction control chamber D. Rises in the tube of the water-seal chamber on inspiration
32. ANSWER: D Increased negative pressure on inspiration causes the fluid to rise; a decrease in the negative intrapleural pressure on expiration causes the fluid to fall. A: This would indicate an air leak. B: This would indicate that there is an obstruction in the drainage tubing or the suction is too low; there should be a slight increase in fluid in this chamber postoperatively. C: The suction is too high; bubbling should be gentle.
33. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review? A. Fluid intake for the last 24 hours B. Baseline arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results
33. ANSWER: B Before weaning a client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
34. The nurse is taking a nursing history on a preoperative client. Which of the following pieces of information would most likely have a significant impact on the client's recovery postoperatively? The client: A. Has smoked 1 pack of cigarettes a day for 12 years. B. Had a cold 6 weeks ago. C. Drinks about two beers a week on a regular basis. D. Is 10 pounds overweight.
34. ANSWER: A A client who smokes is at increased risk for atelectasis postoperatively; thus, smoking is the most significant risk factor listed in this item. B: If the client has completely recovered from the cold he had 6 weeks ago, it would be irrelevant to his postoperative recovery. C: This amount of alcohol intake is minimal and will have no bearing on his postoperative recovery. D: Although an obese client faces increased surgical risks, an excess of 10 pounds is not significant to pose a greater risk than the smoking.
36. A client is brought to the emergency department in acute respiratory distress. After endotracheal intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the endotracheal tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? A. They help prevent subcutaneous emphysema. B. They help prevent pneumothorax. C. They help prevent cardiac arrhythmias. D. They help prevent pulmonary edema.
36. ANSWER: C Endotracheal suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not endotracheal suctioning.
37. A client's chest tube accidentally disconnects from the drainage tube when she turns onto her side. Which of the following actions should the nurse take first? A. Notify the physician. B. Clamp the chest tube. C. Raise the level of the drainage system. D. Reconnect the tube.
37. ANSWER: B When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified. A: First priority must be given to clamping the chest tube. C: To prevent backward flow of drainage, the drainage system should never be raised above chest level. D: To prevent backward flow of drainage, the drainage system should never be raised above chest level.
38. A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? A. Endotracheal suctioning B. Encouragement of coughing C. Use of cooling blanket D. Incentive spirometry
38. ANSWER: A Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
39. Which of the following would be an appropriate nursing diagnosis for a hospitalized client with bacterial pneumonia and shortness of breath? A. Ineffective Cardiopulmonary Tissue Perfusion related to myocardial damage. B. Risk for Self-Care Deficit related to fatigue. C. Deficient Fluid Volume related to nausea and vomiting. D. Disturbed Thought Processes related to inadequate relief of chest pain.
39. ANSWER: B Fatigue is a major problem for the client with pneumonia, making it difficult to perform self-care activities. Fatigue is due to reduced oxygenation and inability to sleep and rest because of coughing. The hospital environment further contributes to interrupted sleep patterns. A: Myocardial damage is not typically associated with pneumonia. C: Deficient Fluid Volume might occur with the client with pneumonia; however, it would most likely be related to fever and increased insensible fluid loss from respiratory secretions, not nausea and vomiting. 4 D: Disturbed Thought Processes, which is characterized by cognitive dissonance, memory problems, and inappropriate or non-reality-based thinking
40. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority for this client? A. Impaired gas exchange B. Impaired oral mucous membranes C. Imbalanced nutrition: Less than body requirements D. Activity intolerance
40. ANSWER: A While all these nursing diagnoses are appropriate for the client with AIDS, Impaired gas exchange is the priority nursing diagnosis for the client with P. carinii pneumonia. Airway, breathing, and circulation take top priority with any client.
41. A client abruptly sits up in bed, reports having difficulty breathing, and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? A. Simple mask B. Nonrebreather mask C. Face tent D. Nasal cannula
41. ANSWER: B A nonrebreather mask can deliver levels of oxygen concentration as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of oxygen concentration.
42. The morning weight for a client indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD? A. Polycythemia B. Cor pulmonale C. Left ventricular failure D. Compensated acidosis
42. ANSWER: B Answer 1 and 4 do not cause weight gain, so they're incorrect. And answer 3 would be reflected in pulmonary edema, so it's incorrect.
43. Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which of the following? A. Poor ability to concentrate urine. B. Little skin pigment to prevent sunburn. C. Poorly functioning temperature control center. D. Abnormally high salt loss through perspiration.
43. ANSWER: D One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual. A: In the child with cystic fibrosis, the functioning of the sweat glands is the problem, causing abnormal amounts of salt to be lost with perspiration. The ability to concentrate urine is not the problem. B: Little skin pigment is not a condition associated with cystic fibrosis. C: A poorly functioning temperature control center is not a condition related to cystic fibrosis.
44. A male adolescent with cystic fibrosis whose parents are both carriers of the disease asks the nurse, "When I have children could they have cystic fibrosis like me?" The nurse should base a response on the knowledge that: A. Men with cystic fibrosis generally have a 50% chance of having children with the disease B. Only women pass this disease to their children because it is carried on the sex chromosome C. This client has a greater chance of passing the disease to his children because his parents were only carriers D. Men with cystic fibrosis are usually unable to father a baby, although their sexual functioning is not affected
44. ANSWER: D This is not true; most men with cystic fibrosis are sterile. A: Cystic fibrosis is inherited as an autosomal recessive trait; it is not sex-linked. B: This is not true; most men with cystic fibrosis are sterile. C: Because of a failure of normal development of the vas deferens, epididymis, and seminal vesicles and a blockage of the vas deferens with abnormal secretions, there is decreased or absent sperm production.
45. The nurse formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: A. drinking more than 1,500 ml of fluid daily. B. being overweight. C. eating a high-protein snack at bedtime. D. eating more than three large meals per day.
45. ANSWER: B Conditions that increase oxygen demands include being overweight, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals per day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six per day).
46. The nurse recognizes that a client with tuberculosis needs further teaching when the client states: A. "I'll have to take these medications for 9 to 12 months." B. "It won't be necessary for the people I work with to take medication." C. "I'll need to have scheduled lab tests while I'm on the medication." D. "The people I have contact with at work should be checked regularly."
46. ANSWER: D Casual contacts such as people at work need not be tested for tuberculosis. However, a person in close contact with a person who is infectious is at risk and should be checked. Taking the medication for 9 to 12 months, coworkers not needing medications, and having scheduled laboratory tests are all appropriate statements.
47. Following surgery, the physician orders an incentive spirometer for a client. The nurse would know that the client was using the spirometer correctly when observing that the client: A. Coughs twice before inhaling deeply through the mouthpiece B. Uses the incentive spirometer for 10 consecutive breaths per hour C. Inhales deeply, seals the lips around the mouthpiece, and exhales D. Inhales deeply through the mouthpiece, relaxes, and then exhales
47. ANSWER: D These are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. A: Coughing is done after deep breathing. B: The breaths should not be in succession; they should be spaced by several normal breaths to avoid fatigue. C: These are incorrect techniques; inhalation should be through the mouthpiece.
48. The nurse notes 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. The nurse should explain to the client that this: A. Test result is negative, and no follow-up is needed B. Test was used for screening and a tine test will now be given C. Skin test is inconclusive and will have to be repeated in 6 weeks D. Result indicates a need for further tests, including a chest x-ray film examination
48. ANSWER: D A: The test result was positive, not negative; further testing is necessary. B: The tine test is less accurate than the Mantoux and would not be used as a follow-up test. C: More than 10 mm induration is a positive test result, not a doubtful test result. D: The Mantoux is the most accurate skin test because of the testing material used and the intradermal method; no other skin test would be appropriate as a follow-up; further tests are now warranted, including a chest x-ray film.
49. The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. The reason for this change is that: A. the attack is over. B. the airways are so swollen that no air can get through. C. the swelling has decreased. D. crackles have replaced wheezes.
49. ANSWER: B During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack.
50. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking one pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications? A. Weight reduction B. Decreasing salt intake C. Smoking cessation D. Decreasing caffeine intake
50. ANSWER: C Smoking cessation should receive highest priority when trying to reduce risk factors for respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension.
52. When assessing the child with asthma for allergic rhinitis, which of the following would the nurse expect to find? A. Nasal crease. B. Abdominal pain. C. Fever. D. Mouth breathing.
52. ANSWER: A In the child with asthma and allergic rhinitis, the allergic reaction to inhaled particles generally causes frequent nose rubbing, subsequently leading to a nasal crease. The child also may exhibit allergic shiners, dark circles under the eyes caused by nasal congestion. B: Typically abdominal pain, although associated with numerous disorders, is not related to allergic rhinitis. C: Fever, although a common assessment finding with numerous disorders, is unrelated to allergic rhinitis. Fever would be present if the child developed a subsequent infection secondary to the allergic rhinitis. D: Mouth breathing usually occurs when the child has enlarged tonsils or adenoids.
53. Staff nurses learn that a patient they have been caring for during the last few weeks has just been diagnosed with tuberculosis. When the nurses express concern about contracting tuberculosis themselves, the charge nurse's response should be based on which of the following statements? A. Tuberculosis is easily treated with a short course of antibiotics. B. The Mantoux test is used to confirm diagnosis of tuberculosis. C. Tuberculosis is not highly infectious when standard precautions are followed. D. Vaccination with Bacille Calmette Guerin (BCG) will be used to immunize the nurses against infection.
53. S ANSWER: C The infectious stage of tuberculosis declines immediately after effective chemotherapy. The risk of infectious tuberculosis is much higher for persons who are immunosuppressed. Patients need to be taught to cover their mouth when coughing, because tuberculosis is spread by droplets. A: Antimycobacterial therapy is usually prescribed for six to nine months. Short-term use of antibiotics is not effective chemotherapy. The Centers for Disease Control (COG) recommends a minimum of six months of therapy. B: For a definite diagnosis of tuberculosis, a positive sputum culture is necessary. A Mantoux test identifies individuals exposed to mycobacterium tuberculosis. This test does not differentiate between active and dormant infection. D: BCG (Bacille Calmette-Guerin) strengthens the body's immune system.
54. The client with acute bronchitis requires careful monitoring when receiving: A. oxygen therapy. B. fluid resuscitation. C. humidified air. D. postural drainage.
54. ANSWER: A The client should be monitored closely and given low-flow oxygen to decrease chances of depressing the respiratory drive. Increasing fluids to liquefy secretions, humidifying the air, and performing postural drainage are also important for a client with acute bronchitis.
55. The nurse knows that when a client has a tracheostomy tube with a high-volume, low- pressure cuff, it is used primarily to prevent: A. Lung infection B. Leakage of air C. Mucosal necrosis D. Tracheal secretion
55. ANSWER: C These cuffs do not compress the capillary beds and thus do not cause tracheal damage. A: Surgical asepsis, not the use of these cuffs, prevents infection. B: A minimal air leak is desirable to ensure the lowest possible pressure in the cuff while still maintaining placement of the tube. D: Secretions will be increased because the cuff is a foreign body in the trachea.
63. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching? A. Make inhalation longer than exhalation. B. Exhale through an open mouth. C. Use diaphragmatic breathing. D. Use chest breathing.
63. ANSWER: C In chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.
56. Which of the following statements by the parents of a child with asthma being taught the reasons for using a peak expiratory flow meter indicates the need for additional teaching? A. "If there is no increase in flow after he gets his bronchodilator, we should give another treatment." B. "Finally, we have a way to monitor his condition and predict when he is getting worse." C. "This meter will help to monitor our child's condition, so changes can be made in therapy." D. "The meter readings will help us determine if he has other possible triggers besides dust and cold."
56. ANSWER: A Although the meter does assist in evaluating the effectiveness of a treatment, repeating the dose of bronchodilator therapy is not recommended unless prescribed by a physician. Bronchodilators have serious side effects, and the child would need to be monitored closely if several treatments were given in a row. B: The peak expiratory flow meter is used to follow trends for diurnal variations that predict instability of asthma and need for increased therapy. It also assists in early detection of exacerbation of the asthma because decreases in the peek expiratory flow rate may indicate a worsening condition. C: The peak expiratory flow meter is used to monitor the asthma and assist in making decisions about increasing or decreasing therapy. D: By monitoring trends in readings and the child's condition, a peak expiratory flow meter can also be used to identify triggers of asthma.
57. A client with pulmonary tuberculosis is being treated in the home. To help control the spread of the disease, the client should be instructed to: A. Have visitors sit at least 8 feet away B. Keep personal articles away from the rest of the family C. Open the windows slightly to allow a good airflow throughout the house D. Avoid putting used dishes in the dishwasher with the rest of the family's dishes
57. ANSWER: C Fresh airflow into the house changes the air and lowers the concentration of microorganisms. A: This is not necessary. B: This is not necessary; only articles contaminated with infected sputum, such as used tissues, should be contained. D: It is permissible to do this because the extreme heat used to process the dishes kills the mycobacteria.
58. In addition to raising the head of the bed of an infant who has had a surgical repair of a diaphragmatic hernia, the nurse should place the infant in the: A. Contour position in an infant seat B. Supine position with the knees flexed C. Prone position with the head to the side D. Side-lying position on the operative side
58. ANSWER: D A: This would not maximally promote aeration of the unaffected lung. B: This would not maximally promote aeration of the unaffected lung. C: This would not maximally promote aeration of the unaffected lung; the prone position increases the effort of breathing because respiratory excursion is impeded by the weight of the body. D: Placing the infant on the operative side promotes gas exchange in the unimpaired lung.
59. The nurse is assessing the breath sounds of a client with emphysema. The nurse understands that the client's respiratory status is affected by what primary pathophysiologic changes? A. Constricted airspaces in the lungs. B. Destruction of alveolar walls. C. Elevation of the diaphragm. D. Increased airflow out of the lungs.
59. ANSWER: B Emphysema is characterized by destruction of the alveolar walls, hyperinflation of the alveoli, and loss of lung elasticity. A: Airspace is not constricted as air can flow easily into the lungs. C: The diaphragm becomes flattened due to the hyperinflated lungs. D: The air becomes trapped due to the loss of elasticity and airflow going out of the lungs is decreased.
6. A chronically ill, elderly female client tells the home care nurse that the daughter with whom she lives seems run-down and disinterested in her own health as well as the health of her children, ages 2, 5, 7, and 12. The client tells the nurse that her daughter coughs a good deal and does a lot of sleeping. In this situation the nurse should pursue the daughter's condition for potential case finding because: A. Children younger than 12 are very susceptible to tuberculosis B. Deaths from tuberculosis have been generally on the decrease C. Tuberculosis has been dramatically rising in the general population D. Aging clients with chronic illness are most adversely affected by tuberculosis
6. ANSWER: D The client's chronic illness and increased age increase vulnerability; the daughter's condition should be explored in more detail. A: Children before puberty and adolescence have the least incidence of tuberculosis. B: The morbidity and mortality resulting from tuberculosis are increasing, not decreasing. C: Although the incidence of tuberculosis has increased in the general population, it is increasing at an alarming rate in those who are HIV positive.
60. In teaching a client with tuberculosis about self-care at home, the nurse will include all of the following measures. Which of the measures would have the highest priority? A. Getting adequate rest. B. Eating a nourishing diet. C. Taking medications as prescribed. D. Quitting smoking.
60. ANSWER: C It is essential that a client with tuberculosis take medications exactly as prescribed. A: Sufficient rest is important for the healing process but not as important as taking medications as prescribed. B: Eating a nourishing diet is important for the healing process but not as important as taking medications as prescribed. D: Smoking cessation is a priority for all clients, especially those with respiratory problems. However, taking antitubercular medication as prescribed has the highest priority.
61. Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia? A. Change current diet habits. B. Seek prompt antibiotic therapy for viral infections. C. Receive prophylactic antibiotic therapy. D. Obtain annual influenza and pneumococcal vaccines.
61. ANSWER: D Annual influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia. A: Dietary changes are not indicated in the prevention of pneumonia. B: Antibiotics are ineffective against viral infections. C: Prophylactic antibiotic therapy is not typically prescribed because of the increasing prevalence of resistant bacterial strains.
62. During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect: A. the client's pupils to become dilated. B. the client to experience bronchodilation. C. a decrease in the client's gastric secretions. D. a drop in the client's heart rate.
62. ANSWER: D During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.
64. A client is on a ventilator. One of the nurses asks what should be done when condensation resulting from humidity collects in the ventilator tubing. The best response to this question would be to: A. "Notify the respiratory therapist." B. "Empty the fluid from the tubing." C. "Decrease the amount of humidity." D. "Measure the fluid and record it on the I&O."
64. ANSWER: B This is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid and others have to be temporarily disconnected while emptying the fluid. A: This circumstance does not require assistance from a respiratory therapist. C: This is unsafe; humidity is necessary to preserve moistness of the respiratory tract and liquefy secretions. D: The amount of condensation is irrelevant in terms of recording the intake and output.
65. With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in: A. Modified Trendelenburg's position with the lower extremities elevated. B. Reverse Trendelenburg's position with the head down. C. Left side-lying position with the head elevated 15 to 30 degrees. D. Semi- to high-Fowler's position, tilted toward the right side.
65. ANSWER: D Pneumothorax will cause a client to feel extremely short of breath. Semi- or high- Fowler's position will facilitate ventilation by the unaffected lung. A: A flat Trendelenburg's position places additional pressure on the chest and inhibits ventilation. B: Reverse Trendelenburg places additional pressure on the chest and inhibits ventilation. C: Likewise, positioning the client on the unaffected side compromises the remaining functional lung.
66. A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-headed and of having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to: A. Eupnea B. Hyperventilation C. Kussmaul's respirations D. Carbon dioxide intoxication
66. ANSWER: B The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis. A: Eupnea is normal, quiet breathing; the client has shallow, rapid breathing. C: Kussmaul's respirations are deep, gasping respirations associated with diabetic acidosis and coma, not hyperventilation associated with anxiety. D: These symptoms are related to a decreased carbon dioxide level in the body.
67. The physician orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to use which oxygen delivery device? A. Nasal cannula B. Venturi mask C. Partial rebreathing mask D. Nonrebreathing mask
67. ANSWER: D A nonrebreathing mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A partial rebreathing mask delivers oxygen concentrations up to 90%.
68. A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instructions? A. "Weigh yourself daily and report a loss of 1 lb in 1 day." B. "Eat a high-sodium diet." C. "Weigh yourself daily and report a gain of 2 lb in 1 day." D. "Maintain bedrest."
68. ANSWER: C COPD causes pulmonary hypertension, leading to right ventricular failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy.
69. A hospitalized client develops a nosocomial upper respiratory infection. After being informed of this fact the client asks the nurse what this means. The nurse should reply: A. "The infection you had prior to hospitalization has flared up." B. "You acquired the infection after being admitted to the hospital." C. "This is a highly contagious infection requiring complete isolation." D. "As a result of medical treatment, you have developed a secondary infection."
69. ANSWER: B A nosocomial infection, by definition, is acquired during hospitalization. A: This is unrelated to a nosocomial infection. C: The need for precautions relates to the type of infection, not to the situation in which it was acquired. D: The infection may or may not be associated with medical treatment.
7. When turning a client following a right pneumonectomy, the nurse should plan to place the client in either the: A. Right or left side-lying position B. High-Fowler's or supine position C. Supine or right side-lying position D. Left side-lying or low-Fowler's position
7. ANSWER: C These positions permit ventilation of the remaining lung and prevent fluid from draining into the sutured bronchial stump. A: Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. B: Although the high-Fowler's position promotes ventilation, it is extremely tiring. D: Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump.
70. A client with oat cell lung cancer is scheduled for a mediastinoscopy with biopsy. The nurse should: A. Tell the client that chest tubes will be present after the procedure B. Explain that the procedure will visualize the lungs and the chest cavity C. Advise the client of the NPO status after midnight the night before the test D. Inform the client that some pleural fluid will be removed during the procedure
70. ANSWER: C To prevent aspiration during the procedure, clients are required to be NPO for at least 8 to 12 hours prior to the procedure. A: Chest tubes are not required unless the lungs are accidentally punctured; the client will have a small incision near the clavicle. B: A mediastinoscopy permits visualization of the anterior mediastinum or hilum extrapleurally; a bronchoscopy permits visualization of the main stem bronchus. D: Fluid is removed from the pleural space during a thoracentesis.
71. In the evaluation of the condition of a client with burns of the upper body, an assessment that would indicate potential respiratory obstruction is: A. Deep breathing B. Pink-tinged, frothy sputum C. Hoarse quality to the voice D. Rapid abdominal breathing
71. ANSWER: C Hoarseness is a sign of potential respiratory insufficiency as a result of inhalation burns, which cause edema in the surrounding tissues, including the vocal cords. A: This would indicate metabolic acidosis, not respiratory insufficiency. B: Sputum would be sooty, not frothy; pink-tinged, frothy sputum is associated with pulmonary edema. D: This would indicate metabolic acidosis, not respiratory insufficiency.
72. The breathing exercises that the nurse teaches to a client with emphysema (COPD) should include: A. An inhalation that is longer than an exhalation B. Abdominal exercises to limit the use of accessory muscles C. Sit-ups to strengthen the abdominal and intercostal muscles D. Diaphragmatic exercises to improve contraction of the diaphragm
72. ANSWER: D With COPD the diaphragm is flattened and weakened; strengthening the diaphragm is desirable. A: The opposite is more desirable; clients with COPD retain too much carbon dioxide, which eventually causes a barrel chest. B: The abdominal muscles are accessory muscles of respiration, and their contraction and relaxation are involved in diaphragmatic breathing. C: Sit-ups are too strenuous for clients with emphysema.
73. During a routine physical examination, a client's chest x-ray film reveals a lesion in the right upper lobe. When the nurse obtains a history from the client, the information that supports the physician's tentative diagnosis of pulmonary tuberculosis is: A. Frothy sputum and fever B. Dry cough and pulmonary congestion C. Night sweats and blood-tinged sputum D. Productive cough and engorged neck veins
73. ANSWER: C Blood-tinged sputum in the absence of pronounced coughing may be the presenting symptom; diaphoresis at night is a later symptom. A: Recurrent fever is present; however, frothy sputum is present with pulmonary edema, not tuberculosis. B: The cough would be productive, not dry. D: A productive cough may occur, but engorged neck veins are symptomatic of congestive heart failure.
74. A client is admitted to the intensive care unit with a diagnosis of adult respiratory distress syndrome. When assessing this client the nurse should expect to find: A. Hypertension B. Tenacious sputum C. An altered mental status D. A slowed rate of breathing
74. ANSWER: C This is secondary to cerebral hypoxia, which accompanies ARDS; cognition and level of consciousness are reduced. A: Hypotension occurs because of the hypoxia of the heart. B: The sputum is not tenacious, but it may be frothy if pulmonary edema is present. D: Breathing will be fast and shallow.
75. A male client with cystic fibrosis (CF) becomes romantically involved with a female with the same disease. He asks the nurse about the chances of having an affected child like himself. The most appropriate response by the nurse would be: A. "Use condoms for protection from pregnancy." B. "Young women with cystic fibrosis are not fertile." C. "All of your children would be carriers of cystic fibrosis." D. "You are probably not able to father children because of your cystic fibrosis."
75. ANSWER: D With few exceptions males are sterile; failure of normal development of the wolffian duct structures (vas deferens, epididymis, and seminal vesicles) and blockage of the vas deferens by abnormal secretions result in decreased or absent sperm production. A: This does not answer the client's question. B: Females with CF generally have normal ovaries and fallopian tubes and are fertile; however, fertility can be inhibited by highly viscous cervical secretions. C: Theoretically, all offspring of couples who are homozygous for a recessive gene will have the disease; however with cystic fibrosis, affected men are usually sterile.
76. Which of the following assessments would be the priority for a 2-year-old after a bronchoscopy? A. Cardiac rate. B. Respiratory quality. C. Sputum color. D. Pulse pressure changes.
76. ANSWER: B After bronchoscopy, airway obstruction secondary to laryngeal edema may occur. Therefore, assessment of the child's respiratory quality is the priority. The child should be observed for signs and symptoms of respiratory distress including tachypnea, increased stridor and retractions, and tachycardia. A: Assessing cardiac rate and rhythm is important and would be done once the client's respiratory status is assessed. C: Although observing the color of the sputum is an important assessment, it is not the priority. The sputum may be bloody after bronchoscopy. D: A change in pulse pressure is not associated with bronchoscopy but rather with intracranial pressure and shock. A pulse deficit is associated with some dysrhythmias.
77. For the child diagnosed with an asthmatic attack, which of the following manifestations would best correlate with the child's arterial blood gas results, which include pH of 7.46, bicarbonate of 21, and a PCO2 of 33 mm Hg? A. Greatly diminished breath sounds. B. A tingling sensation in the fingertips. C. Heart rate of 68 beats/minute. D. Absence of urination for several hours.
77. ANSWER: B The arterial blood gas results indicate respiratory alkalosis. As the alkalinity of body fluids increases, ionization of calcium decreases. A low level of circulating ionized calcium increases the excitability of nerve and muscle tissue, manifested by paresthesia (numbness and tingling) of the digits, upper lip, and earlobes. A: In mild asthma with respiratory alkalosis, breath sounds are typically loud with expiratory wheezing. C: In mild asthma with respiratory alkalosis, the heart rate is usually elevated because of hyperventilation. D: In mild asthma with respiratory alkalosis, urine production is increased because of the increased renal circulation. As a result, bicarbonate, sodium, and potassium excretion increases in an attempt to conserve hydrogen to correct the alkalosis.
78. When assessing a client with pleural effusion, the nurse should expect to find: A. Moist crackles at the posterior of the lungs B. Deviation of the trachea toward the involved side C. Reduced or absent breath sounds at the base of the lung D. Increased resonance with percussion of the involved area
78. ANSWER: C Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange. A: There is no fluid in the alveoli, so no crackles are produced. B: If there is tracheal deviation, it is away from the involved side. D: Dullness is produced on percussion of the involved area.
79. During the weaning of the postoperative client from mechanical ventilation, the nurse organizes activities to: A. Remain with the client to assess responses B. Allow family members to participate in the process C. Permit the client more extended times alone for independence D. Observe monitoring devices at the control panel of the ventilator
79. ANSWER: A This is a critical time; the client's response to reduction of ventilator support must be closely observed and evaluated for signs of respiratory distress such as shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, tachypnea, etc. B: This delegates the professional responsibility inappropriately. C: This does not ensure client's safety. D: This does not provide client with support and professional assistance.
8. What should the nurse do first for a client with a sucking stab wound to the chest? A. Draw blood for hematocrit and hemoglobin values. B. Apply a dressing and tape it on three sides. C. Prepare a chest-tube insertion tray. D. Prepare to start an I.V. line.
8. ANSWER: B The nurse should immediately apply a dressing over the stab wound. Then the nurse should tape this dressing on three sides to allow air to escape and to prevent tension pneumothorax, which is more life-threatening than an open chest wound. Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist the physician in inserting a chest tube, and start an I.V. line.
80. The nurse is caring for four clients on a step-down intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who: A. has a respiratory infection. B. is intubated and on a ventilator. C. has pleural chest tubes. D. is receiving feedings through a jejunostomy tube.
80. ANSWER: B When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artifical airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. With standard procedures the other choices wouldn't be at high risk.
81. Theophylline ethylenediamide is administered to a client with COPD to: A. Reduce bronchial secretions. B. Relax bronchial smooth muscle. C. Strengthen myocardial contractions. D. Decrease alveolar elasticity.
81. ANSWER: B Theophylline ethylenediamide is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Strengthen myocardial contractions. Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used. 1 A: Theophylline ethylenediamide does not reduce bronchial secretions. C: Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used. D: Theophylline ethylenediamide does not decrease alveolar elasticity.
82. A patient who has acquired immune deficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia (PCP). The patient asks the nurse, "How did I get this pneumonia?" The nurse's response should be based on which of these statements about PCP? A. It occurs in immunosuppressed persons from proliferation of organisms that are normally present in the body. B. It is transmitted from close contact with an infected individual who has a suppressed immune system. C. It results from exposure to a carrier of the organism who has not taken appropriate precautions. D. It is most often acquired from unprotected sex with an infected individual.
82. ANSWER: A Pneumocystis carinii pneumonia (PCP) is an opportunistic infection that develops in patients with AIDS because the regulators of the immune system are destroyed by the HIV virus. The pathogens responsible for opportunistic infection are ubiquitous. Pneumocystis carinii pneumonia is in the air we breathe. People with intact immune systems do not become sick from this organism. Morbidity and mortality from this complication has been reduced by prophylactic drug treatment. B: Most opportunistic infections result from secondary reactivation of previously acquired pathogens rather than from a new or primary infection. Most people become infected with Pneumocystis carinii pneumonia in the pre-school years and the child's intact immune system brings it under control. The organism remains dormant in the person's body and can be reactivated when immunodeficiency occurs. C: The pathogen responsible for PCP is airborne and can be found in the lungs of humans and animals. Lifetime suppressive therapy with antibiotics is given to people with PCP to keep the infection under control. Helping patients comply with the antibiotic regimen is an essential part of the nursing care plan. D: PCP is an airborne organism. It is not acquired from unprotected sex with an infected individual
83. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has: A. poor peripheral perfusion. B. a possible hematologic problem. C. a psychosomatic disorder. D. left-sided heart failure.
83. ANSWER: B SaO2 is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.
84. A 10-year-old with history of bronchial asthma triggered by exposure to cold, smoke, and nuts is brought to the hospital's emergency room by his mother. Appearing restless and anxious, the child has a respiratory rate of 36 breaths/minute and pulse rate of 160 bpm. Which of the following findings would be of greatest concern to the nurse? A. Increased respiratory effort. B. Moist, loose cough. C. Absence of wheezing. D. Prolonged expiratory phase.
84. ANSWER: C Knowing that this child is most likely experiencing an asthmatic attack, the nurse would expect to hear wheezing and note some shortness of breath with a prolonged expiratory phase. However, of greatest concern would be the absence of wheezing indicating that the child is not moving air well through the lungs and is at risk for hypoxia and possible respiratory failure. A: Increased respiratory effort would be suspected secondary to bronchospasm associated with asthma. B: During an asthma attack, the cough usually is dry and sounds tight due to mucus accumulation and bronchoconstriction. D: Typically during an asthmatic attack, the client would demonstrate a prolonged expiratory phase because of air trapping and the increased effort to move air through constricted bronchioles.
85. The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: A. helping him communicate. B. keeping his airway patent. C. encouraging him to perform activities of daily living. D. preventing him from developing an infection.
85. ANSWER: B Maintaining a patent airway is the most basic and most critical human need. All other interventions are important to the client's well-being, but they aren't as important as having sufficient oxygen to breathe.
86. For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A. Restricting fluid intake to 1,000 ml per day B. Enforcing absolute bed rest C. Teaching the client how to perform controlled coughing D. Administering prescribed sedatives regularly and in large amounts
86. ANSWER: C Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 qt [2 L] or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.
87. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include: A. diminished or absent breath sounds on the affected side. B. paradoxical chest wall movement with respirations. C. tracheal deviation to the unaffected side. D. muffled or distant heart sounds.
87. ANSWER: A In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade.
88. A positive Mantoux test indicates that the client: A. is actively immune to tuberculosis. B. has produced an immune response. C. will develop full-blown tuberculosis. D. has an active case of tuberculosis.
88. ANSWER: B Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual is exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has or will develop tuberculosis.
89. A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should: A. Apply suction while inserting the catheter B. Hyperoxygenate with 100% oxygen before and after suctioning C. Use short, jabbing movements of the catheter to loosen secretions D. Suction two to three times in quick succession to remove all secretions
89. ANSWER: B Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning. A: To prevent trauma to the trachea, suction should only be applied while removing the catheter. C: This kind of movement could cause tracheal damage. D: Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production.
9. A female client develops increased respiratory secretions because of radiation therapy to the lung. When teaching postural drainage, the nurse should explain that the client will know that it is effective when she: A. Is free of crackles B. Can breathe deeply C. Has a productive cough D. Is able to expectorate saliva
9. ANSWER: C A productive cough indicates mucus is being raised from the lungs. A: Crackles (rales) are unaffected by postural drainage or coughing. B: The depth of respirations may not be altered by postural drainage. D: Saliva comes from the mouth and does not indicate clearance of lungs.
90. While inspecting the client's chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. From this assessment, she suspects: A. hemothorax. B. flail chest. C. pneumothorax. D. tension pneumothorax.
90. ANSWER: B Flail chest occurs when two or more adjacent ribs are fractured at two or more sites, resulting in a free-floating segment. This loss of chest wall stability causes respiratory impairment and notable paradoxical chest wall movement. Hemothorax or pneumothorax both decrease chest wall excursion on the affected side. A tension pneumothorax causes a mediastinal shift and tracheal deviation toward the unaffected side.
91. The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that he'll require: A. monitoring of arterial oxygen saturation (SaO2). B. arterial blood gas (ABG) studies. C. chest auscultation. D. a chest X-ray.
91. ANSWER: D Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax, but they typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently.
92. A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcome indicates that he has adequate respiratory function? A. The client exhibits orthopneic breathing. B. The client breathes at a rate of 16 to 20 breaths/minute C. The client uses accessory muscles to breathe. D. The client exhibits bilateral rales on auscultation.
92. ANSWER: B A respiratory rate of 16 to 20 breaths/minute is a normal finding, indicating adequate respiratory function. Orthopneic breathing, accessory muscle use, and bilateral rales indicate an interference with respiratory function.
93. A 3-year-old child with cystic fibrosis is admitted to the hospital with bronchopneumonia. Which of the following signs and symptoms would be most helpful in providing supportive diagnostic data for this child's condition? A. Weight loss and stringy stools. B. Cough and fever. C. Constipation and vomiting. D. Dysuria and rash.
93. ANSWER: B As a result of the infectious process and mucus accumulation, classic signs of pneumonia include fever and cough. A: Weight loss may occur in a child with cystic fibrosis because of the energy expenditure needed to fight the infection. Typically stools are large, bulky, and greasy. C: Constipation is not a common manifestation of pneumonia. However, vomiting may occur, especially if the child is coughing frequently and has a lot of mucus. D: Dysuria and rash are not associated with pneumonia.
94. A client has been diagnosed with bacterial pneumonia. After 1 day of antibiotic therapy, the client's white blood cell count is still 14,000/mm³. In response to this report, the nurse should: A. Notify the physician. B. Increase the next dose of the antibiotic. C. Initiate reverse isolation precautions. D. Administer the next scheduled antibiotic dose early.
94. ANSWER: A If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The physician should be notified as he or she may want to consider changing antibiotics. B: Altering prescribed medication doses is not a nursing responsibility. C: Reverse isolation is used for clients with a very low white blood cell count. D: The antibiotic dosing schedule should be strictly maintained.
95. A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? A. Partial pressure of arterial oxygen (PaO2) B. Partial pressure of arterial carbon dioxide (PaCO2) C. pH D. Bicarbonate (HCO3-)
95. ANSWER: A In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaO2 is elevated and the pH and HCO3- are depressed.
96. A young adult was told that he had a significant reaction to the Mantoux test. The nurse explains that this means he: A. has active tuberculosis. B. had active tuberculosis. C. has been exposed to tuberculosis. D. is immunocompromised.
96. ANSWER: C A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
97. The nurse knows that a closed chest drainage system connected to a client's pleural chest tube is functioning properly when the fluid in the water-seal chamber of the drainage system: A. Contains many small air bubbles B. Bubbles vigorously on inspiration C. Rises with inspiration and falls with expiration D. Remains at a consistent level during the respiratory cycle
97. ANSWER: C During inspiration negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration negative pressure in the pleural space decreases, causing fluid to drop in the chamber. A: If the system is closed to the atmosphere, as it should be, no bubbles will be present. B: If the system is closed to the atmosphere, as it should be, no bubbling will occur. D: Changes in intrapleural pressure cause fluid to rise on inspiration and fall on expiration (tidaling).
98. Medical therapy for a client with a newly positive Mantoux skin test who does not have active tuberculosis would involve which of the following? A. Reevaluating the client's condition every 6 months. B. Performing a repeat skin test every 6 months. C. Administering isoniazid for about 9 months. D. Administering isoniazid until the skin test reverts to negative.
98. ANSWER: C Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months. A: The client needs with a newly positive Mantoux test requires prophylactic drug treatment. B: Repeat skin testing should not be performed as it will always be positive. D: Skin tests do not convert to negative once a positive response has been obtained.
99. A young baby has an open repair of a fractured sternum and has a chest tube. The nurse explains to the baby's mother that the chest tube: A. Will be removed once the baby is feeding well and is afebrile B. Does not cause discomfort and is put in place for emergency use C. Is left in to drain the air from the chest cavity that entered during surgery D. Drains the extra air in the baby's chest that accumulated following the punctured lung
99. ANSWER: C The chest was opened during surgery for the sternal repair, and air was allowed into the thorax; the air must be removed for the lungs to expand properly. A: The chest tube is unrelated to the baby's ability to retain feedings. B: Chest tubes are uncomfortable; also, this response discounts the importance of the chest tube to the baby's respiratory status. D: The baby did not have a punctured lung.