Respiratory Questions Nursing
For a female patient 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 patient how to perform controlled coughing D Administering prescribe sedatives regularly and in large amounts
ALWAYS DEEP COUGH Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.
On auscultation, which finding suggests a right pneumothorax? A Bilateral inspiratory and expiratory crackles B Absence of breaths sound in the right thorax C Inspiratory wheezes in the right thorax D Bilateral pleural friction rub
Absence of breath sounds in the right side. Remember that a pneumothorax is a collapsed lung, there aint nothing happening. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: A Monitor fluctuations in the water-seal chamber B Clamp the chest tube once every shift C Encourage coughing and deep breathing D Milk the chest tube every 2 hours
Always cough, it just makes sense...Never milk/clamp When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase "a" in ABG value present? A Acid-base balance B Arterial Blood C Arterial oxygen saturation D Alveoli
Arterial Blood This is a knowledge based question and kind of stupid tbh A lowercase "a" in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid-base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase "A" represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli.
For a male client with an endotracheal (ET) tube, which nursing action is most essential? Auscultating the lungs for bilateral breath sounds B Turning the client from side to side every 2 hours C Monitoring serial blood gas values every 4 hours D Providing frequent oral hygiene
Auscultating the lungs For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? A Activity intolerance related to fatigue B Anxiety related to actual threat to health status C Risk for infection related to retained secretions D Impaired gas exchange related to airflow obstruction
Ayyy This is easy, impaired gas exchange, remember kids, Always be clearing. You need a clear airway A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.
Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician? A Dry cough Hermaturia Bronchospasm D Blood-streaked sputum
Bronchospasm is really bad If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis, nasal drainage normally is: A Yellow B Green C Clear D Gray
Clear Think of the clear rhino, Idk what else to say... Green and Yellow is always an indicator of a spread of infection.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A Inform the physician B Continue to monitor the client C Reinforce the occlusive dressing D Encourage the client to deep-breathe
Continue to monitor fluid is meant to collect in the chamber, that's what it's there for The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen? A Limiting fluid Having the client take deep breaths C Asking the client to spit into the collection container D Asking the client to obtain the specimen after eating
Deep breathing is usually the answer To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A A low respiratory rate B Diminished breath sounds C The presence of a barrel chest D A sucking sound at the site of injury
Diminished breath sounds or lack off This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous
Do nothing.... Only clamp if leak Bubbles should not be intermittent you can't time intermittent, it's like saying you can predict the stock market Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for: A Patients with an acute asthma attack B Patients with narcolepsy C Patients under age 6 D Elderly patients
Elderly patients because they are more susceptible to confusion. Remember the EXTREMES OF AGE. Pt's under 6 is not an extreme age, <2yr, now that's an extreme
Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? A Hypocapnia A hyperinflated chest noted on the chest x-ray C Increased oxygen saturation with exercise D A widened diaphragm noted on the chest x-ray
Hyper inflated chest is a barrel chest Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
A male 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 Non-rebreather mask C Face tent D Nasal cannula
I always use a non-rebreather as my choice A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A Call the physician Place the tube in bottle of sterile water C Immediately replace the chest tube system Place a sterile dressing over the disconnection site
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm 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
Kinking a tube causes high pressure Think of this logically, if you KINK a tube, HIGH PRESSURE BACKS UP Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus (a block), mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's 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.
A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A Nausea or vomiting B Abdominal pain or diarrhea C Hallucinations or tinnitus D Lightheadedness or paresthesia
Light Headedness from all that fast breathing The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance (Think tripping on acid for resp acidosis).
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A Pallor Low arterial PaO2 C Elevated arterial PaO2 D Decreased respiratory rate
Low PaO2, you're gonna have lower O2 sat The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: A Lips Mucous membranes Nail beds D Earlobes
Mucous Membranes Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause: A Nasal congestion B Nervousness C Lethargy D Hyperkalemia
Nervousness, I'd be nervous too if I had to take an inhaler all my life. It can cause irritation of the throat, but NOT nasal congestion. You're puffed on meds, you're more likely to stay awake than be tired, and you're gonna be HYPO-kalemic. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps.
assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A Contralateral side in a simple pneumothorax Affected side in a hemothorax C Affected side in a tension pneumothorax Contralateral side in hemothorax
Remember that a thorax pushes away to the other side The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? A Continue to suction B Notify the physician immediately Stop the procedure and reoxygenate the client D Ensure that the suction is limited to 15 seconds
Should stop because in practice we reoxygenate During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? Stridor B Occasional pink-tinged sputum C A few basilar lung crackles on the right Respiratory rate 24 breaths/min
Stridor The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician.
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally B The client has a pneumothorax The system has an air leak D The chest tube is obstructed
System has an air leak Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? A Encouraging the patient to drink three glasses of fluid daily B Keeping the patient in semi-fowler's position C Using a high-flow venturi mask to deliver oxygen as prescribe D Administering a sedative, as prescribe
The answer should be to give them air, so use a high flow venturi mask The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to: A Encourage oral feeding as soon as possible B Develop an alternative communication method C Keep the tracheostomy cuff fully inflated D Keep the patient flat in bed
They will never speak again, develop an alt communication method A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the patient in semi-Fowler's position.
While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to: A Call the physician to reinsert the tube B Grasp the retention sutures to spread the opening C Call the respiratory therapy department to reinsert the tracheotomy D Cover the tracheostomy site with a sterile dressing to prevent infection
This is trach care, keep that hole open, grasp the retention sutures to spread the opening If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation.
The nurse is teaching a male 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 Use diaphragmatic breathing D Use chest breathing
Use the diaphram never chest breathe 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.
The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? A Diaphragmatic breathing Use of accessory muscles C Pursed-lip breathing D Controlled breathing
Using other muscles The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A Exhale slowly B Stay very still C Inhale and exhale quickly D Perform the Valsalva maneuver
Valsalva means to take a deep breath and bear down (prepare for bm) When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.
An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A Face tent B Venturi mask C Aerosol mask D Tracheostomy collar
Venturi is the way to go, sounds designer The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first? A Drawing blood for a hematocrit and hemoglobin level B Applying a dressing over the wound and taping it on three sides C Preparing a chest tube insertion tray D Preparing to start an I.V. line
When there's a hole, you still need a hole. So apply a dressing with three pieces of tape The nurse immediately should apply a dressing over the stab wound and tape it 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 with chest tube insertion, and start an I.V. line.
