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rEspiratory disorder part 1
1. Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause:a. Nasal congestionb. Nervousnessc. Lethargyd. Hyperkalemia
2. 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 a acute rhinitis, nasal drainage normally is:a. Yellowb. Greenc. Cleard. Gray
3. A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?a. Nausea or vomitingb. Abdominal pain or diarrheac. Hallucinations or tinnitusd. Lightheadedness or paresthesia
4. 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 attackb. Patients with narcolepsyc. Patients under age 6d. Elderly patients
5. 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 tubingb. A disconnected ventilator tubec. An endotracheal cuff leakd. A change in the oxygen concentration without resetting the oxygen level alarm
6. A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?a. Leg movementb. Finger movement
c. Lip movementd. Fighting the ventilator
7. On auscultation, which finding suggests a right pneumothorax?a. Bilateral inspiratory and expiratory cracklesb. Absence of breaths sound in the right thoraxc. Inspiratory wheezes in the right thoraxd. Bilateral pleural friction rub.
8. 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 balanceb. Arterial Bloodc. Arterial oxygen saturationd. Alveoli
9. 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 fatigueb. Anxiety related to actual threat to health statusc. Risk for infection related to retained secretionsd. Impaired gas exchange related to airflow obstruction
10. Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:a. Contralateral side in a simple pneumothoraxb. Affected side in a hemothoraxc. Affected side in a tension pneumothoraxd. Contralateral side in hemothorax
11. 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 chamberb. Clamp the chest tube once every shiftc. Encourage coughing and deep breathingd. Milk the chest tube every 2 hours
12. 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 possibleb. Develop an alternative communication methodc. Keep the tracheostomy cuff fully inflatedd. Keep the patient flat in bed
13. 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 levelb. Applying a dressing over the wound and taping it on three sidesc. Preparing a chest tube insertion trayd. Preparing to start an I.V. line
14. 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 dailyb. Keeping the patient in semi-fowler’s positionc. Using a high-flow venture mask to deliver oxygen as prescribed. Administering a sedative, as prescribe
15. A male patient’s X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:a. Cardiogenic pulmonary edemab. Respiratory alkalosisc. Increased pulmonary capillary permeabilityd. Renal failure
16. 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 dayb. Enforcing absolute bed restc. Teaching the patient how to perform controlled coughingd. Administering prescribe sedatives regularly and in large amounts
17. 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 findingb. Immediately clamp the chest tube and notify the physicianc. Check for an air leak because the bubbling should be intermittentd. Increase the suction pressure so that the bubbling becomes vigorous
18. 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 physicianb. Continue to monitor the clientc. Reinforce the occlusive dressingd. Encourage the client to deep-breathe
19. Nurse Ryan 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
b. Place the tube in bottle of sterile waterc. Immediately replace the chest tube systemd. Place a sterile dressing over the disconnection site
20. A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:a. Exhale slowlyb. Stay very stillc. Inhale and exhale quicklyd. Perform the Valsalva maneuver
21. 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 tubeb. Grasp the retention sutures to spread the openingc. Call the respiratory therapy department to reinsert the tracheotomyd. Cover the tracheostomy site with a sterile dressing to prevent infection
22. 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?a. Stridorb. Occasional pink-tinged sputumc. A few basilar lung crackles on the rightd. Respiratory rate 24 breaths/min
23. 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 rateb. Diminished breath soundsc. The presence of a barrel chestd. A sucking sound at the site of injury
24. 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. Hypocapniab. A hyperinflated chest noted on the chest x-rayc. Increased oxygen saturation with exercised. A widened diaphragm noted on the chest x-ray
25. 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 tentb. Venturi mask
c. Aerosol maskd. Tracheostomy collar
26. Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:a. Dyspneab. Chest painc. A bloody, productive coughd. A cough with the expectoration of mucoid sputum
27. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?a. Bronchoscopyb. Sputum culturec. Chest x-rayd. Tuberculin skin test
28. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:a. 1 L/minb. 2 L/minc. 6 L/mind. 10 L/min
29. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:a. Promote oxygen intakeb. Strengthen the diaphragmc. Strengthen the intercostal musclesd. Promote carbon dioxide elimination
30. 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. Pallorb. Low arterial PaO2c. Elevated arterial PaO2d. Decreased respiratory rate
answers
Answer B. Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Otther adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps.
Answer C. Normally, nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.
Answer D. 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.
Answer D. Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.
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 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 tigger the oxygen alarm.
Answer D. Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.
Answer B. 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.
Answer B. 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.
Answer D. 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.
Answer D. 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.
Answer C. 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.
Answer B. 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.
Answer B. 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.
Answer C. 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.
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 does not cause ARDS. Renal failure does not cause ARDS, either.
Answer C. 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.
Answer A. 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.
Answer B. 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.
Answer B. 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.
Answer D. 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.
Answer B. 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.
Answer A. 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.
Answer B. 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.
Answer B. 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.
Answer B. 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.
Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.
Answer B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.
Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
Answer B. 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.
Part 2
1. A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client’s baseline theophylline level was:a. 10 mcg/mLb. 12 mcg/mLc. 15 mcg/mLd. 18mcg/mL
2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous 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 bubbling becomes vigorous.
3. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult 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.
4. The nurse caring for a male 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.b. Place the tube in a bottle of sterile water.
c. Immediately replace the chest tube system.d. Place the sterile dressing over the disconnection site.
5. Nurse Paul 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.
6. While changing the tapes on a tracheostomy tube, the male client coughs and the 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.
7. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?a. Stridorb. Occasional pink-tinged sputumc. A few basilar lung crackles on the rightd. Respiratory rate of 24 breaths/min
8. An emergency room nurse is assessing a female 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 respiratoryb. Diminished breathe soundsc. The presence of a barrel chestd. A sucking sound at the site of injury
9. A nurse is caring for a male 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. Hypocapniab. A hyperinflated chest noted on the chest x-rayc. Increase oxygen saturation with exercised. A widened diaphragm noted on the chest x-ray
10. A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:a. Dyspneab. Chest pain
c. A bloody, productive coughd. A cough with the expectoration of mucoid sputum
11. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis?a. Bronchoscopyb. Sputum culturec. Chest x-rayd. Tuberculin skin test
12. The nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this information if the student states that the tuberculosis is transmitted by:a. Hand and mouthb. The airborne routec. The fecal-oral routed. Blood and body fluids
13. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:a. 1 L/minb. 2 L/minc. 6 L/mind. 10 L/min
14. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:a. Promote oxygen intake.b. Strengthen the diaphragm.c. Strengthen the intercostal muscles.d. Promote carbon dioxide elimination.
15. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?a. Limiting fluidsb. Having the clients take three deep breathsc. Asking the client to split into the collection containerd. Asking the client to obtain the specimen after eating
16. A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians?a. Dry coughb. Hematuria
c. Bronchospasmd. Blood-streaked sputum
17. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:a. 1 minuteb. 5 secondsc. 10 secondsd. 30 seconds
18. 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 of the following is the appropriate nursing intervention?a. Continue to suction.b. Notify the physician immediately.c. Stop the procedure and reoxygenate the client.d. Ensure that the suction is limited to 15 seconds.
19. An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of:a. Metabolic acidosisb. Respiratory acidosisc. Overcompensated respiratory acidosisd. Combined respiratory and metabolic acidosis
20. A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?a. Dyspneab. Bradypneac. Bradycardiad. Decreased respiratory
21. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching?a. Inhales the mist and quickly exhalesb. Removes the cap and shakes the inhaler well before usec. Presses the canister down with the finger as he breathes ind. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
22. A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?a. Administering atropine intravenouslyb. Administering small doses of midazolam (Versed)
c. Encouraging additional fluids for the next 24 hoursd. Ensuring the return of the gag reflex before offering food or fluids
23. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following?a. Slow deep respirationsb. Rapid deep respirationsc. Paradoxical respirationsd. Pain, especially with inspiration
24. A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest?a. Cyanosisb. Hypotensionc. Paradoxical chest movementd. Dyspnea, especially on exhalation
25. A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:a. Right pneumothoraxb. Pulmonary embolismc. Displaced endotracheal tubed. Acute respiratory distress syndrome
26. A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to:a. Inhale quicklyb. Inhale through the nosec. Hold the breath after inhalationd. Take two inhalations during one breath
27. A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?a. Bilateral wheezingb. Inspiratory cracklesc. Intercostal retractionsd. Increased respiratory rate
28. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is:a. High and expectedb. Low and unexpected
c. Normal and expectedd. Uncertain and unexpected
29. A nurse is assessing a male client with chronic airflow limitations and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitations?a. Emphysemab. Bronchial asthmac. Chronic obstructive bronchitisd. Bronchial asthma and bronchitis
30. A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem?a. Coughb. High-grade feverc. Chills and night sweatsd. Anorexia and weight loss
ANSWERS PART 2
1. Answer A. The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the disorder. Although all the options identify values within the therapeutic range, option A is the option that reflects a need for compliance with medication. 2. Answer A. 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. 3. Answer B. 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.
4. Answer B. 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. 5. Answer D. 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.
6. Answer B. 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 1 and 3 will delay treatment in this emergency situation. 7. Answer A. 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. 8. Answer B. 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. 9. Answer B. 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. 10. Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement. 11. Answer B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy. 12. Answer B. Tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis and is spread primarily by the airborne route. Options A, C, and D are incorrect. 13. Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. 14. Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing. 15. Answer B. 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. 16. Answer C. 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. 17. Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
18. Answer C. 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. 19. Answer A. In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect. 20. Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. 21. Answer A. The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options B, C, and D are accurate instructions regarding the use of the inhaler. 22. Answer D. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after. 23. Answer D. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. 24. Answer C. Flail chest results from fracture of two or more ribs in at least two places each. This results in a “floating” section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a telltale sign of flail chest. 25. Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. 26. Answer C. Instructions for using a metered-dose inhaler include shaking the canister, holding it right side up, inhaling slowly and evenly through the mouth, delivering one spray per breath, and holding the breath after inhalation. 27. Answer D. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. 28. Answer C. The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because
the edema is in the interstitium of the lung and is noncardiac. 29. Answer A. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as “barrel chest.” The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. 30. Answer B. The client with tuberculosis usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.
NCLEX Review Respiratory Questions
46. Which of the following assessment findings in a client with a closed chest tube drainage should concern the nurse most?
a) continuous, vigorous bubbling in the suction control chamberb) continuous, gentle bubbling in the suction control chamberc) continuous fluctuations of fluid along the tube in the water-seal chamberd) absence of bubbling in the water-seal chamber
47. A 4-year old female client is brought to the emergency room after waking up with bark-like cough and stridor. On arrival to the ER, she has respiratory distress and is afebrile. The diagnosis is croup. What instruction should you give the parents?
a) perform percussion and postural drainage before putting the child to bed and before mealsb) run a cool mist vaporizer in patient's room during the dayc) encourage the child to do coughing and deep breathing exercisesd) bring the child to the bathroom and have the tap run with warm water during acute episodes of cough
48. Which of the following teachings should be given to the mother when her child is in a mist tent for liquefication of secretions?
a) give the child a stuff toy inside the mist tentb) avoid nylon blanket inside the mist tentc) advise mother to let the child stay in the mist tentd) give the child coloring book inside the mist tent
49. A nurse assesses a client with a chest tube who is restless and diaphoretic, and has a temperature of 101.2 F. The client reports pain at the chest tube site. Which action should the nurse take first?
a) administer pain medication
b)auscultate the client's lungsc) check the client's blood pressure and pulsed) check the chest tube dressing and tubing
50. A nurse 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 physicianb) continue to monitor the clientc) reinforce the occlusive dressingd) encourage the client to deep-breathe
NCLEX Review Respiratory Questions:ANSWERS AND RATIONALE
46) A- vigorous bubbling in the suction control chamber indicates that the pressure of suction is very high. This may cause trauma to the pleura, and should concern the nurse. Options B, C, and D are normal findings.
47) B- cool mist vaporizer will relieve spasm of airways. This will promote easy breathing of the child with croup.
48) C- a child should stay inside the mist tent to liquefy mucous secretions and facilitate breathing. Toys that absorb moisture like stuff toys and coloring book should be avoided. Dampness lowers resistance to infection.
49) B- assessment of the respiratory status is a priority among clients with chest tube.
50) B- 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 re-expanded. Option A, C, and D are incorrect.
NCLEX Review Respiratory Questions
51. A nurse 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?
a) stridorb) occasional pink-tinged sputumc) a few basilar lung crackles on the rightd) respiratory rate of 24 bpm
52. A nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Select all expected assessment findings
a) excessive bubbling in the water seal chamberb) vigorous bubbling in the suction control chamberc) 50 ml of drainage in the drainage collection chamberd) drainage system maintained below the client's cheste) occlusive dressing in place over the chest tube insertion sitef) fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
53. A clinic nurse reads the results of a Mantoux test on a 3-year old child. The results indicate an area of induration measuring 10 mm. The nurse interpret this results as:
a) positiveb) negativec) inconclusived) definitive and requiring a repeat test
54. A nurse provides home care instructions to the parents of a child hospitalized with pertussis. The child is in convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instructions?
a) we need to encourage our child to drink fluidsb) coughing spells may be triggered by dust or smokec) vomiting may occur when our child has coughing episodesd) we need to maintain droplet precautions and a quiet environment for at least 2 weeks
55. A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?
a) do nothing, because this is an expected findingb) immediately clamp the chest tube and notify the physicianc) check for an air leak because the bubbling should be intermittent
d) increase the suction pressure so that the bubbling becomes vigorous
NCLEX Review Respiratory Questions:ANSWERS AND RATIONALE
51) A- 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. Option B, C, and D are not signs that require immediate notification of the physician.
52) C, D, E- the bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 ml drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 100 ml/hr is considered excessive and requires physician notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.
53) A- Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as the child with an immunosuppressive condition or the child with human immunodeficiency virus infection. A reaction of 15 mm or more is positive in children 4 years of age or older without any risk factors.
54) D- Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options A, B, and C are components of home care instructions.
55) A- 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.
Situation: A 20 year old client is being treated for pneumonia. he has persistent cough and complained severe pain on coughing.
1. Which of the following organisms most commonly causes community acquired pneumonia in adults?
a) haemophilus influenzaeb) klebsiella pnemoniaec) streptococcus pneumoniaed) staphylococcus aureus
2. What type of instruction could be given to help the client reduce the discomfort he is ahving?
a) hold in your cough as much as possibleb) place the head of your bed flat to help with coughingc) restrict fluids to help decrease the amount of sputumd) splint your chest wall with pillow for comfort
3. A diagnosis of pneumonia is typically achieved by which of the following diagnostic test?
a) ABG analysisb) chest x-rayc) blood culturesd) nutritional intake
4. The client has been treated with antibiotic therapy for left lower lobe pneumonia for 10 days. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge the client?
a) continued dyspneab) temperature of 102 Fc) respiratory rate of 32 bpmd) vesicular breath sounds in left base
5. A nurse is caring for a client with chest-tube drainage system. The nurse notes constant bubbling in the suction control chamber. Which of the following nursing actions is most appropriate?
a) reposition the clientb) notify the physicianc) this is normal, expected finding and no action is necessaryd) turn off suction machine
6. The nurse determines that influenza vaccine must be given regularly to clients with
a) hypertensionb) diabetes mellitusc) urinary calculid) chronic illness
Try to read the latest type of cancer, it might be included in the exam --> Mesothelioma CancerANSWERS AND RATIONALE
1) C- pneumonia is inflammation of the bronchioles and alveoli that is usually accompanied by increased interstitial or alveolar fluid. Infectious pneumonia is caused by the following microorganisms:Microorganisms that causes Pneumonia
Streptococcus pneumoniae - most common cause of community acquied pneumonia Mycoplasma pneumoniae and hemophillus influenza - are other causes of community
acquired pneumonia Pneumocystiis carinii - affects immunocompromised individuals such as those with AIDS Staphylococcus aureus, kleibsiella pneumoniae, P. aeruginosa and E. coli are common
caused of nosochomial pneumonia.
Non-infectious pneumonia is caused by aspiration of gastric contents (aspiration pneumonia) and inhalation of toxic gases, dusts, smoke or chemicals.
2) D- Nursing care for patients with Pneumonia includes:
pleuritic chest pain may prevent the patient from coughing and performing deep breathing exercises effectively. To minimize the patient's discomfort the nurse can teach the patient to splint the chest wall with pillow during coughing. Pleuritic chest pain is sharp localized chest pain that occurs with breathing and coughing.
place patient in fowler's or high fowler's position to promote lung expansion and facilitate breathing.
change position every 2 hours in patient's who have altered level of consciousness to mobilize secretions, preferably placed in side lying to prevent aspiration with the head of the bed raised to 45 degrees.
activity intolerance may result due to impaired oxygen and carbon dioxide exchange. Schedule patient's activity after treatment and medication. Activity of the patient should be according to tolerance
chest physiotherapy including percussion, vibration and postural drainage is performed to reduce lung consolidation and prevent atelectasis. These activities help to mobilize secretions.
suctioning, coughing and deep breathing to clear airways provide liberal fluid intake of 2,500 to 3,000 ml a day to help liquefy secretions.
Diagnostic Test used to determine Pneumonia
Chest x-ray - is ordered to determine the extent and pattern of lung tissue involvement. On chest x-ray, areas of pneumonia appear as consolidation. On auscultation, bronchial breath sounds will be heard over consolidated areas. Presence of fluids, atelectasis and infiltrates will also be seen with x-ray.
Sputum culture and sensitivity - not blood culture, is ordered for pneumonia to identify the infecting microorganism and determine which antibiotic would be most effective in destroying the pathogenic agent.
ABG analysis - is ordered to assess the patient's gas exchange as areas of consolidated tissue will not be able to exchange carbon dioxide and oxygen properly with blood which could result in impaired gas exchange. The ABG is abnormal is arterial oxygen tension (PO2) is less than 80mmHg. This indicates the need to place patient under oxygen therapy.
3) B- the major diagnostic tests used to identify the extent of the lung tissue affected by pneumonia is chest x-ray and to identify the causitive agent is sputum culture and microscopy.
4) D- Common Manifestation of pneumonia includes fever, headache, chills, sweating, pleuritic chest pain, cough, sputum production, dyspnea, muscle pain and fatigue. On auscultation limited breath sounds crackles or rales maybe heard over the affected part of the lungs. Pleural friction rub may also be heard.
Type of Pneumonia and its Manifestations:
1. Pneumococcal pneumonia
sudden onset of chills fever stabbing pleuritic chest pain dyspnea tachypnea high WBC consolidation on chest x-ray productive cough - rusty brown or blood streaked purulent sputum turns yellow
and mucoid
2. Bronchopneumonia
gradual onset with cough scattered crackles
minimal dyspnea low grade fever patchy areas of consolidation on chest x-ray
3. Legionaires's disease
gradual onset with chills fever body malaise headache confusion lack of appetite diarrhea muscle and joint pain dyspnea elevated WBC dry cough -scant mucoid or blood tinged sputum
4. Staphylococcal pneumonia
sudden onset with fever multiple chills pleuritic pain dyspnea rales decreased breath sounds chest x-ray may show patcht infiltrates empyema abscesses and pneumothorax elevated WBC productive cough - purulent golden yellow or blood streaked sputum
5. Viral pneumonia
sudden or gradual onset with flulike symptoms fever muscle aches normal to slightly elevated WBC dyspnea breath sounds maybe normal or with occasional wheezing and crackles dry cough - with scant mucoid that turns to purulent sputum
6. Pneumocystis carinii pneumonia
abrupt onset with tachypnea shortness of breath
fever respiratory distress dry cough
5) C- Rationale: constant bubbling in the suction control bottle is normal. It indicates proper functioning of the apparatus
6) D - Rationale: clients with chronic illness have low resistance to infection. Therefore, they should receive influenza vaccine yearly
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14. A 14-year old male is to be admitted to the unit due to high fever related to influenza. With whom among the following clients should he be placed together in the room?
a) the 12-year old male client who had undergone appendectomyb) the 12-year old female client with fluc) the 12-year old boy with flud) the 12-year old boy with leukemia
15. Why is influenza vaccine given to adults annually?
a) immunity last only for a yearb) some organisms are resistant to the vaccinec) this is the routine procedured) adults have low resistance to flu virus
16. Which of the following nursing interventions should be implemented for a client with influenza?
a) instructing family members not to visit the client until the fever declinesb) instructing family members or visitors to wear surgical mask before entering the client's roomc) instructing family members that there are no special precautions needed when caring for
the clientd) instructing family members to wear gown and gloves before entering the client's room
17. Which of the following should concern the nurse most, when caring for a client who will undergo bronchoscopy?
a) the client had a glass of orange juice an hour agob) the client has yellowish sputumc) the client complains of thirst and dryness of mouthd) the client says, he had removed his dentures
18. The client had undergone decortication of the right lung. The nurse needs to intervene when the unlicensed nursing assistant does which of the following?
a) instructs the client to lie on the operated sideb) instructs the client to lie on the unoperated sidec) keeps the client on supine with head of the bed elevatedd) ensures that chest tube with water-seal drainage functions properly
19. Which of the following findings should concern the nurse that the oxygen saturation monitor is not working?
a) there is no sensor light on the probeb) oxygen saturation (Sa O2) is 92%c) pulse rate= 58/min; Sa is 97%d) mucous membrane in the mouth appears pinkish
20. The client had left chest injury. The nurse can feel air going in and out of injured site during breathing. Which of the following should the nurse do initially?
a) apply petrolatum jelly dressing at the siteb) turn the client to right sidec) give oxygen therapy at 2 L/mind) transport the client to the nearest medical facility
ANSWERS AND RATIONALE
14) Ccohorts (client with the same diagnosis) can be roomed-in as long as one does not have infection which is different from the other. Age group is another consideration as well as gender of clients.
15) A- annual influenza vaccine is required to maintain adequate protection.
16) B- influenza requires droplet precaution. Healthcare workers and family members should wear surgical mask when entering client's room to ensure prevention of contamination.
17) A- the client should be on NPO 6-8 hours before bronchoscopy if the client had taken anything by mouth, aspiration and airway obstruction may occur.
18) A- the nurse should intervene when the nursing assistant instructs the client to lie on the operated side. This may inhibit expansion of the affected lung. Options B, C, and D are correct nursing interventions.
19) A- if the O2 saturation monitor is not working, there will be no sensor light on the probe.
20) A- cover the injured site of the chest with occlusive dressing like petrolatum jelly dressing to prevent pneumothorax and atelectasis.
Situation: Mr. Tan, a 40 year old with asthmatic attack is admitted in the medical ward.
21. Mr. Tan admits to the nurse that he takes the following medications. Which medication may cause asthma attack?
a) milk of magnesiab) pepcid ( famotidine)c) acetylsalicylic ( aspirin)d) benadryl ( diphenhydramine)
22. Your finding in your assessment would include the following except:
a) ability to speak words without taking deep breathb) tachycardia, cool and moist skinc) air hunger and presence of wheezing soundd) tachycardia, warm and moist skin
23. With your assessment which of these symptoms would you expect to develop late?
a) nasal flaringb) lips pursed in an effort exhalec) cyanosisd) use of accessory muscles for breathing
24. Which has the least tendency to precipitate or trigger asthmatic attack?
a) air pollutionb) cold climatec) sudden changes in climated) molds, house dust
25. The most comfortable position for him to assume during asthmatic attack is:
a) sittingb) orthopneicc) fowlersd) supine
26. Which of the following breathing patterns shows that the patient with chronic asthma has improved respiratory status?
a) a rate of exhalation twice that of inhalationb) a rate of inhalation twice that of exhalationc) slow, shallow inhalationd) slow, deep exhalation
27. Which finding below would indicate the most effective response to asthma medications?
a) the ability to participate in active sports for longer periodsb) cyanosis subsidesc) peak expiratory flow rate (PEFR) within normal limitsd) patient can breathe on his own without oxygen
28. The child with asthma, has elevated WBC and eosinophils. Which of the following should be included in the nursing care plan of the client?
a) provide a private roomb) room-in the child with another child with asthma
c) room-in the child with another child with chicken poxd) room-in the child with another child with glomerulonephritis
ANSWERS AND RATIONALE
21) C- Common Factors Triggering an Asthmatic Attack1. Medications:
Aspirin and NSAID - can trigger allergic reaction, its anti-inflammatory effect decreases histamine secretion and mucus secretion causing pooling of thick mucus that obstructs the airway and triggers an asthmatic attack
beta blockers cholinergic drugs - eye drops used in glaucoma (pilocarpine) and bladder contraction chemicals - paint, solvents, rubber, plastic - avoid engaging in tasks that involves the use
of these chemicals, avoid powder detergents
2. Air pollutants - instruct to close car window and use airconditioner
3. Sudden changes in temperature
4. Cold air - exercising in cold air
5. Allergens - feather, pollen, dust, molds, animal dander - keep away from pets, remove carpets and curtains, damp dusting, stay indoor when grass cutting and when pollen count is high, close window at night, avoid garage and basements, avoid feather pillow
6. Exercise - irregular exercise schedules and excessive physical exertion
7. stress
8. Strong odors
22) A- common assessment findings in asthma include: wheezing, chest tightness, breathlessness, coughing, anxiety, apprehension, tachypnea and tachycardia.Patients experiencing asthmatic attack can usually speak only one or two words between breaths because of severe dyspnea, anxiety, fatigue and apprehension.
23) C- Signs and Symptoms of Asthma
Asthma is caused by inflammatory response in the lungs triggered by any of the above
mentioned allergens. When a patient comes in contact with allergens. IgE is produced which stimulate the mast cells in the lungs to release inflammatory mediators in the lungs such as histamine, prostaglandins and leokotrienes. These substances cause the following pathologic changes in the lungs that cause the signs and symptoms of asthma:
bronchospasms which narrows airways causing wheezing, shortness of breath increased mucus production which blocks airways and causes nonproductive cough increased capillary permeability which causes edema of the airways decreasing area for
gas exchange.
All these contribute to airway obstruction. In an effort to overcome the airway obstruction, the patient must exert much respiratory effort when breathing such as nasal flaring, pursed lip breathing and use of accessory muscles. Cyanosis is a late sign in asthma. It indicates impaired gas exchange and that the tissues are no longer receiving adequate oxygen supply. Auscultation reveals wheezing especially on expiration. The absence of wheezing is a dangerous sign that indicates that the small airways are too constricted to allow air to pass through.
24) B- cold climate does not trigger asthmatic attack but it is the sudden changes in environmental temperature or sudden weather changes that does. However, exercising in cold weather usually trigger asthma.
25) B- the ideal position for a patient with asthma is the orthopneic position in which the patient is in high fowler's position with the head and arms resting on the over bed table. This position promotes lung expansion and facilitates breathing
26) A
27) C- PERF and Drugs used in Asthma
PERF refers to amount of air inspired. If the PERF is below the amount of air inspired, it means that air is trapped in the alveoli and bronchioles because of bronchial spasms and blockage by accumulated secretions, this prevents proper exchange of oxygen and carbon dioxide and leads to hypoxia and acidosis. Peak flow meters measures PERF. If medication used to relax and dilate bronchioles is effective, effective gas exchange will be manifested by an improved PERF because air will be able to freely enter and leave the lungs and normal gas exchange will be able to take place.
Drugs used in asthma include:
1. Bronchodilators - relieve bronchospasms
epinephrine/ephedrine/terbutaline theophylline
albuterol (ventalin and proventil) isoproterenol (isuprel)/metaproterenol (metaprel and alupent) give the inhaled bronchodilator before the ant-inflammatory steroids
2. Anti-inflammatory - prevent histamine and decrease mucus
hydrocortisone/dexamethasone/beclomethasone
3. Prophylactic therapy to prevent future attacks
cromolyn sodium (intal)
28) A- elevated WBC indicates that the child is experiencing infection. Therefore, the child should not be roomed-in with another child. Provide a private room for this child.
29. The client had undergone thoracentesis. Which of the following is a correct action by the LVN (Licensed Vocational Nurse) immediately after the procedure?
a) she turns the client towards the affected sideb) she turns the client towards the unaffected sidec) she places the client in a supine positiond) she places the client in semi-fowler's position
30. The client is diagnosed to have advanced chronic obstructive pulmonary disease (COPD). Which of the following nursing action would best promote adequate gas exchange?
a) administering sedative as prescribedb) placing the client in upright positionc) using high-flow venturi mask to deliver oxygend) encourage client to drink 6 glasses of fluid daily
31. A 48-year old man with tuberculosis is taking INH with pyridoxine (Vit. B6). The client asks why it is necessary for him to take pyridoxine. Which of the following is the most appropriate response by the nurse?
a) it increases INH absorptionb) it prevents INH-associated neuritisc) it decreases toxicity of INHd) it increases the effectiveness of INH
32. The child with croup is in a mist tent. Which of the following toys will be appropriate for the child?
a) stuffed toysb) drawing bookc) plastic balld) coloring book
33. The client had been subjected to thoracentesis without written consent. What offense are the health care providers liable for?
a) assaultb) batteryc) manslaughterd) invasion of privacy
34. The client with acute asthmatic attack is receiving Theophylline (Aminophylline) drip. Which of the following nursing actions should be included in the nursing care plan of the client?
a) note for decreased urine outputb) observe for elevated temperaturec) be alert for decreased BPd) monitor for decreased pulse rate
35. Which of the following is the best position for a client who had undergone lobectomy?
a) side-lying positionb) supine positionc) sitting upright, leaning forward positiond) semi-fowler's position
ANSWERS AND RATIONALE
29) B- after thoracentesis, turn the client towards unaffected side to prevent leakage of fluid into the thoracic cavity.
30) B- upright position enhances adequate ventilation. The client with COPD is best placed in upright, leaning forward position.
31) B- the common side effect of INH is peripheral neuritis. Vitamin B6 prevents this side effect.
32) C- plastic ball does not absorb moisture within the mist tent. Therefore, it is the most appropriate toy for the child. Toys that may absorb moisture should be avoided because dampness may lower the child's resistance to infection.
33) B- battery is intentional touching a person's body part without his consent.
34) C- aminophylline causes diuresis, and therefore hypotension may occur.
35) D- semi-fowler's position will promote maximum lung expansion. Therefore, this is the best position after a lung surgery like lobectomy.
36. Which of the following findings should be reported to the physician?
a) vesicular breath sounds at the peripheral areas of the lungsb) bronchovesicular breath sounds heard over the mainstem bronchic) bronchial breath sounds heard over the trachead) adventitious breath sounds heard all over the lungs
37. The client with chronic obstructive pulmonary disease (COPD) is receiving Aminophylline. Which of the following manifestations indicate that the client is experiencing an adverse effect of the drug?
a) elevated temperatureb) bradycardiac) restlessnessd) tachycardia
38. The client has closed chest drainage. Which of the following observations need prompt reporting to the physician?
a) the water in the water-seal drainage is constantly bubblingb) there is continuous bubbling in the suction control chamberc) fluctuation of fluids is noted in the water seal chamber if suction is not appliedd) the suction control chamber is filled with 20 cm of sterile NSS
39. The client is diagnosed to have COPD (Chronic Obstructive Pulmonary Disease). Which of the following signs and symptoms needs priority intervention by the nurse?
a) temperature of 37.5 Cb) tachycardiac) coughd) 91% oxygen saturation
40. A client who had vehicular accident was admitted to the emergency department. His trachea is deviated to the left. What does the nurse anticipate to be done to the client?
a) the client will have endotracheal intubationb) the client will have emergency tracheotomyc) the client will have oxygen by maskd) the client will have thoracentesis
ANSWERS AND RATIONALE
36) D- adventitious breath sounds are abnormal breath sounds and should be reported to the physician. Vesicular, bronchovesicular, and bronchial breath sounds are normal breath sounds.
37) D- aminophylline causes tachycardia, restlessness, insomnia, diuresis, hypotension, and diarrhea. Tachycardia is the most common adverse effect of bronchodilators.
38) Aconstant bubbling in the water-seal drainage indicates air leak. This should be reported to the physician. All the other findings are normal.
39) C- cough in COPD is caused by copious, tenacious mucous secretions. Problems with airway should be given highest priority. In COPD, 91% oxygen saturation is considered normal, because the client is breathing due to low oxygen levels in the blood.
40) D- this situation indicates pneumothorax. Therefore, there is a need to aspirate the air from he pleural space to prevent lung collapse.
