Respiratory
Content
Respiratory Questions in section:
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To go to the related information as listed below, close or minimize this application and select the Content Menu button. Be sure to print or note the specific section(s) you wish to review. Question 1: A client is admitted and the physician suspects atelectasis. When assessing this individual, the nurse would expect: Selected Choice: Diminished breath sounds Your Selection: Correct Rationale: Since atelectasis involves collapsing of the alveoli distal to the bronchioles, breath sounds would be diminished in the lower lobes. Related information: Chapter 6, section 70 Question 2: The efficacy of the abdominal-thoracic thrust (Heimlich maneuver) to expel a foreign object in the larynx demonstrates the gas volume related to the individual's: Selected Choice: Tidal volume Your Selection: Incorrect Correct Choice: Residual volume Rationale: The residual volume is the amount of air remaining in the lungs after maximum exhalation. Related information: Chapter 6, section 57 Question 3: A client who undergoes a submucosal resection should be observed carefully for: Selected Choice: Spitting up or vomiting of blood Your Selection: Correct Rationale: After a submucosal resection (SMR), hemorrhage from the area is frequently detected by vomiting of blood that has been swallowed. Related information: Chapter 6, section 21 Question 4: The nurse understands that in the absence of pathology, a client's respiratory center is stimulated by: Selected Choice: Carbon dioxide Your Selection: Correct
Rationale: The respiratory center in the medulla responds primarily to increased carbon dioxide concentration in the blood. Related information: Chapter 6, section 57 Question 5: Oxygen dissociation from hemoglobin and therefore oxygen delivery to the tissues are accelerated by: Selected Choice: A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood Your Selection: Correct Rationale: The lower the PO2 and the higher the PCO2, the more rapidly oxygen dissociates from the oxyhemoglobin molecule. Related information: Chapter 6, section 57 Question 6: A client is admitted with carbon monoxide poisoning. The nurse understands that the poisonous nature of carbon monoxide results from: Selected Choice: The bubbles it tends to form in blood plasma Your Selection: Incorrect Correct Choice: Its preferential combination with hemoglobin Rationale: Carbon monoxide (CO) binds with hemoglobin more avidly than does oxygen. The progressive results are dyspnea, asphyxia, and death. Related information: Chapter 6, section 80 Question 7: With an oxygen debt, muscle shows: Selected Choice: Low levels of ATP Your Selection: Correct Rationale: With an oxygen debt, a muscle would show primarily low levels of oxygen and low levels of ATP caused by the low levels of aerobic respiration and high levels of lactic acid formation. Related information: Chapter 6, section 164 Question 8: Clients who are emotionally disturbed and upset may threaten to hold their breaths unless the staff meets their demands. The nurse understands that if the threats are carried out:
Selected Choice: Accumulated CO2 will force resumption of breathing Your Selection: Correct Rationale: Accumulated carbon dioxide (CO2) will powerfully stimulate the breathing center of the brainstem, forcing resumption of respiration even if the person has fainted first. Related information: Chapter 6, section 57 Question 9: A nurse initially will use an AmbuBag in the intensive care unit when: Selected Choice: A respiratory arrest occurs Your Selection: Correct Rationale: An Ambu Bag is a piece of equipment that can be compressed at regular intervals by hand for temporary ventilation of the client in respiratory arrest. Related information: Chapter 6, section 62 Question 10: Cutting the left phrenic nerve results in: Selected Choice: Paralysis of the left side of the diaphragm Your Selection: Correct Rationale: The phrenic nerves conduct motor impulses to the diaphragm; cutting one phrenic nerve will paralyze the portion of the diaphragm innervated by that nerve. Related information: Chapter 6, section 58 Question 11: The nurse obtains a laboratory report that shows acidfast rods in a client's sputum. These are presumed to be: Selected Choice: Mycobacterium tuberculosis Your Selection: Correct Rationale: This is the acid fast causative organism of tuberculosis. Related information: Chapter 6, section 72 Question 12: A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means. The nurse explains that tidal volume is the amount of air: Selected Choice: Exhaled normally after a normal inspiration
Your Selection: Correct Rationale: Tidal volume (TV) is defined as the amount of air exhaled normally after a normal inspiration. Related information: Chapter 6, section 62 Question 13: Air rushes into the alveoli as a result of the: Selected Choice: Lowered pressure in the chest cavity Your Selection: Correct Rationale: Thoracic pressure is reduced because thoracic volume is increased as the diaphragm descends. Related information: Chapter 6, section 57 Question 14: A client is scheduled for a pulmonary function test. The nurse explains that during the test the respiratory therapist will ask the client to breathe normally to measure the: Selected Choice: Expiratory reserve Your Selection: Incorrect Correct Choice: Tidal volume Rationale: The tidal volume is the amount of air inhaled and exhaled while breathing normally. Related information: Chapter 6, section 57 Question 15: To facilitate maximum air exchange, a client should be placed in the: Selected Choice: Orthopneic position Your Selection: Correct Rationale: The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange, since the abdominal organs do not provide pressure against the diaphragm and gravity facilitates the descent of the diaphragm. Related information: Chapter 6, section 57 Question 16: A client begins to expectorate blood. The nurse describes this episode as: Selected Choice: Hemoptysis Your Selection: Correct Rationale: Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea.
Related information: Chapter 6, section 72 Question 17: The position in which a client with dyspnea should be placed is: Selected Choice: Orthopneic Your Selection: Correct Rationale: Orthopneic position refers to sitting up and leaning slightly forward. This drops the diaphragm, allowing the lungs more room for expansion. Related information: Chapter 6, section 57 Question 18: The nurse must establish and maintain an airway in a client who has experienced a near drowning. The nurse should recognize that one danger of near drowning that must be assessed for is: Selected Choice: Pulmonary edema Your Selection: Correct Rationale: This may occur because of the high osmotic pressure of the aspirated ocean water. Related information: Chapter 6, section 65 Question 19: The common factor of puerperal sepsis, scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis is that all: Selected Choice: Result from streptococcal infections that enter via the upper respiratory tract Your Selection: Correct Rationale: Streptococcal organisms are present on the skin, mucous membranes, and in the environment at all times. The most frequent portals of entry are the respiratory tract and breaks in the skin. Related information: Chapter 6, section 60 Question 20: An example of a rapidly acting diuretic that can be administered intravenously to clients with acute pulmonary edema is: Selected Choice: Furosemide Your Selection: Correct Rationale: Furosemide (Lasix) acts on the loop of Henle by increasing the excretion of chloride and sodium.
Related information: Chapter 6, section 32 Question 21: The nurse is aware that when emphysema is present there is a decreased oxygen supply because of: Selected Choice: Loss of aerating surface Your Selection: Correct Rationale: Destruction of the alveolar walls leads to diminished surface area for gaseous exchange and an increased CO2 level in the blood. Related information: Chapter 6, section 73 Question 22: To assist a client in obtaining maximum benefits after postural drainage, the nurse should: Selected Choice: Encourage the client to cough deeply Your Selection: Correct Rationale: Coughing is needed to raise the secretions for expectoration. Related information: Chapter 6, section 58 Question 23: The nurse administers oxygen at 2 L/minute via nasal cannula to a client with emphysema. The nurse should observe the client closely for: Selected Choice: Drowsiness and decreased respirations Your Selection: Correct Rationale: Clients with COPD (chronic obstructive pulmonary disease) respond only to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will eliminate the stimulus to breathe, leading to decreased respirations and lethargy. Related information: Chapter 6, section 73 Question 24: When the alveoli lose their normal elasticity as a result of emphysema, the nurse teaches the client exercises that lead to effective use of the diaphragm because: Selected Choice: Inspiration has been markedly prolonged and difficult
Your Selection: Incorrect Correct Choice: The residual capacity of the lungs has been increased Rationale: Loss of elasticity causes difficult exhalation, with subsequent air trapping. Clients who have emphysema are taught to use accessory abdominal muscles and to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Related information: Chapter 6, section 73 Question 25: A client with a history of emphysema is now terminally ill with cancer of the esophagus. The client is weak, dyspneic, emaciated, and apathetic. The plan of care includes a soft diet, modified postural drainage, and nebulizer treatments. The nursing care plan for this client should give priority to: Selected Choice: Hygiene and comfort Your Selection: Correct Rationale: Since the client's condition is described as terminal, the nursing priority should be directed toward providing comfort. Related information: Chapter 2, section 24 Question 26: A terminally ill client is visited frequently by the spouse, a 16-year-old daughter, and a 20-year-old son. In view of the client's extreme weakness and dyspnea, nursing care plans should include: Selected Choice: Encouraging family members to feed and assist the client Your Selection: Correct Rationale: Since family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Related information: Chapter 4, section 15 Question 27: When determining the method of oxygen administration to be used for a specific client, the major concern is: Selected Choice: Pathologic condition
Your Selection: Correct Rationale: There are several modes for the administration of oxygen. Selection is based on the disease and the client's adaptation. Oxygeninduced hypoventilation is a particular concern for clients with COPD. Related information: Chapter 6, section 62 Question 28: As a result of fractured ribs, the client may develop: Selected Choice: Pneumothorax Your Selection: Correct Rationale: The ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung. Related information: Chapter 6, section 75 Question 29: A client with emphysema experiences a sudden episode of shortness of breath. The physician diagnoses a spontaneous pneumothorax. The nurse is aware that the probable cause of the spontaneous pneumothorax is a: Selected Choice: Rupture of a subpleural bleb Your Selection: Correct Rationale: The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters. Related information: Chapter 6, section 75 Question 30: When a spontaneous pneumothorax is suspected in a client with a history of emphysema, the nurse should call the physician and: Selected Choice: Give O2 2L per minute via nasal cannula Your Selection: Correct Rationale: Oxygen is supplied to prevent anoxia but cannot be given in higher concentrations because, in an individual with emphysema, a low PO2 (not high PCO2) is the only respiratory stimulus. Related information: Chapter 6, section 62
Question 31: When teaching a client about a spontaneous pneumothorax, the nurse bases the explanation on the understanding that: Selected Choice: Inspired air will move from the lung into the pleural space Your Selection: Correct Rationale: As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space. This creates a positive pressure and causes partial or complete collapse of the lung. Related information: Chapter 6, section 75 Question 32: Following a spontaneous pneumothorax, the client becomes extremely drowsy and the pulse and respirations increase. The nurse should suspect: Selected Choice: Hypercapnia Your Selection: Correct Rationale: A pneumothorax results in decreased surface area for gaseous exchange. If the unaffected pleural regions cannot compensate, carbon dioxide builds up in the blood (hypercapnia). The client becomes drowsy and may lose consciousness. The body attempts to compensate by increasing the respiratory and pulse rates and by the renal retention of bicarbonate. Related information: Chapter 6, section 75 Question 33: When assessing an individual with a spontaneous pneumothorax, the nurse should expect dyspnea and: Selected Choice: Unilateral chest pain Your Selection: Correct Rationale: Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder. Related information: Chapter 6, section 75 Question 34: When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, it may lead to: Selected Choice: Rupture of the pericardium or aorta Your Selection: Incorrect Correct Choice: Decreased filling of the right heart
Rationale: Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output. Related information: Chapter 6, section 75 Question 35: The physician inserts a chest tube in a client who has been stabbed in the chest and attaches it to a closed-drainage system. When caring for the client, the nurse should: Selected Choice: Observe for fluid fluctuations in the waterseal chamber Your Selection: Correct Rationale: Fluctuations occur with normal inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged. Related information: Chapter 6, section 62 Question 36: Complete lung expansion before the removal of chest tubes is evaluated by: Selected Choice: Comparison of chest radiographs Your Selection: Correct Rationale: Chest x-ray films or radiographs reveal the degree to which the lung fills the pleural cavity and also the presence of any mediastinal shift. Related information: Chapter 6, section 62 Question 37: While receiving metaproterenol sulfate (Alupent) for asthma the client complains of palpitation, chest pain, and a throbbing headache. In view of these symptoms, the most appropriate nursing action would be to: Selected Choice: Withhold the drug until additional orders are obtained from the physician Your Selection: Correct Rationale: Alupent is a selective beta-2 adrenergic antagonist that causes increased heart contraction (positive inotropic effect) and
increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur and the drug should be withheld until the physician is notified. Related information: Chapter 6, section 61 Question 38: An asthmatic client's pulmonary function studies are abnormal. The nurse should realize that one of the most common complications of chronic asthma is: Selected Choice: Emphysema Your Selection: Correct Rationale: As a result of the narrowed airways, exhalation is difficult, leaving air trapped in the lung. Distention of alveolar walls to accommodate this volume leads to emphysema. Related information: Chapter 6, section 73 Question 39: A client with a long history of asthma is scheduled for surgery. Preoperative teaching should include the fact that the client: Selected Choice: Should try to limit coughing, because this causes distention of the chest Your Selection: Incorrect Correct Choice: Will be quite prone to respiratory tract infections Rationale: Hypersecretion of the mucous glands provides an excellent, warm, moist medium for microorganisms. Related information: Chapter 6, section 73 Question 40: The nurse should position a client recovering from general anesthesia in a: Selected Choice: Side-lying position Your Selection: Correct Rationale: Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway in the relaxed state. Related information: Chapter 6, section 21
Question 41: During the immediate postoperative period the nurse should give the highest priority to: Selected Choice: Checking the vital signs every 15 minutes Your Selection: Incorrect Correct Choice: Maintaining a patent airway Rationale: Maintenance of a patent airway is always the priority, since airway obstruction impedes breathing and may result in death. Related information: Chapter 6, section 21 Question 42: A client has seeds containing radium implanted in the pharyngeal area. When caring for this client, the nurse should: Selected Choice: Use rubber gloves when giving the client a bath Your Selection: Incorrect Correct Choice: Maintain the client in isolation Rationale: During radiation therapy with radium implants the client is placed in isolation so exposure to radiation by family and staff will be decreased. Related information: Chapter 6, section 173 Question 43: The nurse can expect a client who has had a splenectomy to complain of: Selected Choice: Pain on expiration Your Selection: Incorrect Correct Choice: Pain on inspiration Rationale: Because of the location of the spleen, expansion of the thoracic cavity during inspiration causes pain at the operative site. Related information: Chapter 6, section 21 Question 44: A client has a bronchoscopy in ambulatory surgery. To prevent laryngeal edema, the nurse should: Selected Choice: Keep the client in the semi-Fowler's position Your Selection: Correct Rationale: With the head elevated, rather than horizontal or dependent, fluid will not collect in the interstitial spaces around the trachea. Related information: Chapter 6, section 62
Question 45: After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. This is most likely the result of: Selected Choice: Extension of cancerous lesions Your Selection: Correct Rationale: Cancerous lesions in the pleural space increase the osmotic pressure causing a shift in fluid to that space. Related information: Chapter 6, section 66 Question 46: A client has a right pneumonectomy. During surgery the phrenic nerve is accidently severed: Selected Choice: Permitting greater excursion of the thoracic cavity Your Selection: Incorrect Correct Choice: Producing a partially atonic diaphragm Rationale: The phrenic nerve stimulates the diaphragm; accidental severance of one phrenic nerve would result in partial paralysis of the diaphragm. Related information: Chapter 6, section 58 Question 47: The factor that would have little influence in predisposing an individual to cancer of the larynx would be: Selected Choice: Poor dental hygiene Your Selection: Correct Rationale: Inadequate dental hygiene may predispose a person to oral infections but would be only remotely involved in laryngeal neoplasms because of the anatomical relationship of the oral cavity and the larynx. Related information: Chapter 6, section 78 Question 48: When cleaning a tracheostomy tube that has an inner cannula, the nurse should plan to remove the inner cannula: Selected Choice: In order to cleanse it with hydrogen peroxide Your Selection: Correct Rationale: The inner cannula, if nondisposable, must be removed, cleaned with peroxide, and rinsed
with saline to prevent mucus accumulation and occlusion of the tube. Related information: Chapter 6, section 62 Question 49: When suctioning a client with a tracheostomy the nurse must remember to: Selected Choice: Initiate suction as the catheter is being withdrawn Your Selection: Correct Rationale: During suctioning of a client, negative pressure (suction) should not be applied until the catheter is ready to be drawn out because, in addition to the removal of secretions, oxygen is being depleted. Related information: Chapter 6, section 62 Question 50: A client complains of severe pain 2 days following surgery. The nurse's initial action should be to: Selected Choice: Take the client's vital signs Your Selection: Correct Rationale: Immediately prior to administration, an assessment of vital signs is necessary to determine whether any contraindications to analgesia exist (e.g., hypotension, a respiratory rate of 12 or less). Related information: Chapter 6, section 18 Question 51: The nurse expects that the initial treatment for a client who has a leak of the thoracic duct following radical neck surgery would include inserting a: Selected Choice: Rectal tube to prevent distention, a low-fat diet, and increased activity Your Selection: Incorrect Correct Choice: Chest tube to drain the fluid, total parenteral nutrition, and bed rest Rationale: A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow; bed rest is recommended because lymphatic flow increases with activity. Related information: Chapter 6, section 78
Question 52: As a result of pulmonary tuberculosis, a client has a decreased surface area for gaseous exchange in the lungs. Oxygen and carbon dioxide are exchanged in the lungs by: Selected Choice: Diffusion Your Selection: Incorrect Correct Choice: Osmosis Rationale: The respiratory membrane, consisting of the alveolar and capillary walls, is extremely thin. This thinness facilitates exchange of respiratory gases without the need for additional energy. Related information: Chapter 6, section 57 Question 53: Before discontinuing airborne precautions (respiratory isolation) for a client with pulmonary tuberculosis, the nurse must determine that: Selected Choice: No acid-fast bacteria are in the sputum Your Selection: Correct Rationale: The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Related information: Chapter 6, section 72 Question 54: A thoracentesis is performed. Following the procedure it is most important for the nurse to observe the client for: Selected Choice: Expectoration of blood Your Selection: Correct Rationale: Expectoration of blood is an indication that the lung itself was damaged during the procedure; a pneumothorax may occur. Related information: Chapter 6, section 62 Question 55: A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should: Selected Choice: Suction two to three times in quick succession to remove all secretions Your Selection: Incorrect
Correct Choice: Hyperoxygenate with 100% oxygen before and after suctioning Rationale: Suctioning also removes oxygen which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning. Related information: Chapter 6, section 62 Question total: 55 Questions correct: 42 Score: 76%
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To go to the related information as listed below, close or minimize this application and select the Content Menu button. Be sure to print or note the specific section(s) you wish to review. Question 1: A client is admitted and the physician suspects atelectasis. When assessing this individual, the nurse would expect: Selected Choice: Diminished breath sounds Your Selection: Correct Rationale: Since atelectasis involves collapsing of the alveoli distal to the bronchioles, breath sounds would be diminished in the lower lobes. Related information: Chapter 6, section 70 Question 2: The efficacy of the abdominal-thoracic thrust (Heimlich maneuver) to expel a foreign object in the larynx demonstrates the gas volume related to the individual's: Selected Choice: Tidal volume Your Selection: Incorrect Correct Choice: Residual volume Rationale: The residual volume is the amount of air remaining in the lungs after maximum exhalation. Related information: Chapter 6, section 57 Question 3: A client who undergoes a submucosal resection should be observed carefully for: Selected Choice: Spitting up or vomiting of blood Your Selection: Correct Rationale: After a submucosal resection (SMR), hemorrhage from the area is frequently detected by vomiting of blood that has been swallowed. Related information: Chapter 6, section 21 Question 4: The nurse understands that in the absence of pathology, a client's respiratory center is stimulated by: Selected Choice: Carbon dioxide Your Selection: Correct
Rationale: The respiratory center in the medulla responds primarily to increased carbon dioxide concentration in the blood. Related information: Chapter 6, section 57 Question 5: Oxygen dissociation from hemoglobin and therefore oxygen delivery to the tissues are accelerated by: Selected Choice: A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood Your Selection: Correct Rationale: The lower the PO2 and the higher the PCO2, the more rapidly oxygen dissociates from the oxyhemoglobin molecule. Related information: Chapter 6, section 57 Question 6: A client is admitted with carbon monoxide poisoning. The nurse understands that the poisonous nature of carbon monoxide results from: Selected Choice: The bubbles it tends to form in blood plasma Your Selection: Incorrect Correct Choice: Its preferential combination with hemoglobin Rationale: Carbon monoxide (CO) binds with hemoglobin more avidly than does oxygen. The progressive results are dyspnea, asphyxia, and death. Related information: Chapter 6, section 80 Question 7: With an oxygen debt, muscle shows: Selected Choice: Low levels of ATP Your Selection: Correct Rationale: With an oxygen debt, a muscle would show primarily low levels of oxygen and low levels of ATP caused by the low levels of aerobic respiration and high levels of lactic acid formation. Related information: Chapter 6, section 164 Question 8: Clients who are emotionally disturbed and upset may threaten to hold their breaths unless the staff meets their demands. The nurse understands that if the threats are carried out:
Selected Choice: Accumulated CO2 will force resumption of breathing Your Selection: Correct Rationale: Accumulated carbon dioxide (CO2) will powerfully stimulate the breathing center of the brainstem, forcing resumption of respiration even if the person has fainted first. Related information: Chapter 6, section 57 Question 9: A nurse initially will use an AmbuBag in the intensive care unit when: Selected Choice: A respiratory arrest occurs Your Selection: Correct Rationale: An Ambu Bag is a piece of equipment that can be compressed at regular intervals by hand for temporary ventilation of the client in respiratory arrest. Related information: Chapter 6, section 62 Question 10: Cutting the left phrenic nerve results in: Selected Choice: Paralysis of the left side of the diaphragm Your Selection: Correct Rationale: The phrenic nerves conduct motor impulses to the diaphragm; cutting one phrenic nerve will paralyze the portion of the diaphragm innervated by that nerve. Related information: Chapter 6, section 58 Question 11: The nurse obtains a laboratory report that shows acidfast rods in a client's sputum. These are presumed to be: Selected Choice: Mycobacterium tuberculosis Your Selection: Correct Rationale: This is the acid fast causative organism of tuberculosis. Related information: Chapter 6, section 72 Question 12: A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means. The nurse explains that tidal volume is the amount of air: Selected Choice: Exhaled normally after a normal inspiration
Your Selection: Correct Rationale: Tidal volume (TV) is defined as the amount of air exhaled normally after a normal inspiration. Related information: Chapter 6, section 62 Question 13: Air rushes into the alveoli as a result of the: Selected Choice: Lowered pressure in the chest cavity Your Selection: Correct Rationale: Thoracic pressure is reduced because thoracic volume is increased as the diaphragm descends. Related information: Chapter 6, section 57 Question 14: A client is scheduled for a pulmonary function test. The nurse explains that during the test the respiratory therapist will ask the client to breathe normally to measure the: Selected Choice: Expiratory reserve Your Selection: Incorrect Correct Choice: Tidal volume Rationale: The tidal volume is the amount of air inhaled and exhaled while breathing normally. Related information: Chapter 6, section 57 Question 15: To facilitate maximum air exchange, a client should be placed in the: Selected Choice: Orthopneic position Your Selection: Correct Rationale: The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange, since the abdominal organs do not provide pressure against the diaphragm and gravity facilitates the descent of the diaphragm. Related information: Chapter 6, section 57 Question 16: A client begins to expectorate blood. The nurse describes this episode as: Selected Choice: Hemoptysis Your Selection: Correct Rationale: Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea.
Related information: Chapter 6, section 72 Question 17: The position in which a client with dyspnea should be placed is: Selected Choice: Orthopneic Your Selection: Correct Rationale: Orthopneic position refers to sitting up and leaning slightly forward. This drops the diaphragm, allowing the lungs more room for expansion. Related information: Chapter 6, section 57 Question 18: The nurse must establish and maintain an airway in a client who has experienced a near drowning. The nurse should recognize that one danger of near drowning that must be assessed for is: Selected Choice: Pulmonary edema Your Selection: Correct Rationale: This may occur because of the high osmotic pressure of the aspirated ocean water. Related information: Chapter 6, section 65 Question 19: The common factor of puerperal sepsis, scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis is that all: Selected Choice: Result from streptococcal infections that enter via the upper respiratory tract Your Selection: Correct Rationale: Streptococcal organisms are present on the skin, mucous membranes, and in the environment at all times. The most frequent portals of entry are the respiratory tract and breaks in the skin. Related information: Chapter 6, section 60 Question 20: An example of a rapidly acting diuretic that can be administered intravenously to clients with acute pulmonary edema is: Selected Choice: Furosemide Your Selection: Correct Rationale: Furosemide (Lasix) acts on the loop of Henle by increasing the excretion of chloride and sodium.
Related information: Chapter 6, section 32 Question 21: The nurse is aware that when emphysema is present there is a decreased oxygen supply because of: Selected Choice: Loss of aerating surface Your Selection: Correct Rationale: Destruction of the alveolar walls leads to diminished surface area for gaseous exchange and an increased CO2 level in the blood. Related information: Chapter 6, section 73 Question 22: To assist a client in obtaining maximum benefits after postural drainage, the nurse should: Selected Choice: Encourage the client to cough deeply Your Selection: Correct Rationale: Coughing is needed to raise the secretions for expectoration. Related information: Chapter 6, section 58 Question 23: The nurse administers oxygen at 2 L/minute via nasal cannula to a client with emphysema. The nurse should observe the client closely for: Selected Choice: Drowsiness and decreased respirations Your Selection: Correct Rationale: Clients with COPD (chronic obstructive pulmonary disease) respond only to the chemical stimulus of low oxygen levels. Administration of high concentrations of oxygen will eliminate the stimulus to breathe, leading to decreased respirations and lethargy. Related information: Chapter 6, section 73 Question 24: When the alveoli lose their normal elasticity as a result of emphysema, the nurse teaches the client exercises that lead to effective use of the diaphragm because: Selected Choice: Inspiration has been markedly prolonged and difficult
Your Selection: Incorrect Correct Choice: The residual capacity of the lungs has been increased Rationale: Loss of elasticity causes difficult exhalation, with subsequent air trapping. Clients who have emphysema are taught to use accessory abdominal muscles and to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Related information: Chapter 6, section 73 Question 25: A client with a history of emphysema is now terminally ill with cancer of the esophagus. The client is weak, dyspneic, emaciated, and apathetic. The plan of care includes a soft diet, modified postural drainage, and nebulizer treatments. The nursing care plan for this client should give priority to: Selected Choice: Hygiene and comfort Your Selection: Correct Rationale: Since the client's condition is described as terminal, the nursing priority should be directed toward providing comfort. Related information: Chapter 2, section 24 Question 26: A terminally ill client is visited frequently by the spouse, a 16-year-old daughter, and a 20-year-old son. In view of the client's extreme weakness and dyspnea, nursing care plans should include: Selected Choice: Encouraging family members to feed and assist the client Your Selection: Correct Rationale: Since family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Related information: Chapter 4, section 15 Question 27: When determining the method of oxygen administration to be used for a specific client, the major concern is: Selected Choice: Pathologic condition
Your Selection: Correct Rationale: There are several modes for the administration of oxygen. Selection is based on the disease and the client's adaptation. Oxygeninduced hypoventilation is a particular concern for clients with COPD. Related information: Chapter 6, section 62 Question 28: As a result of fractured ribs, the client may develop: Selected Choice: Pneumothorax Your Selection: Correct Rationale: The ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung. Related information: Chapter 6, section 75 Question 29: A client with emphysema experiences a sudden episode of shortness of breath. The physician diagnoses a spontaneous pneumothorax. The nurse is aware that the probable cause of the spontaneous pneumothorax is a: Selected Choice: Rupture of a subpleural bleb Your Selection: Correct Rationale: The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters. Related information: Chapter 6, section 75 Question 30: When a spontaneous pneumothorax is suspected in a client with a history of emphysema, the nurse should call the physician and: Selected Choice: Give O2 2L per minute via nasal cannula Your Selection: Correct Rationale: Oxygen is supplied to prevent anoxia but cannot be given in higher concentrations because, in an individual with emphysema, a low PO2 (not high PCO2) is the only respiratory stimulus. Related information: Chapter 6, section 62
Question 31: When teaching a client about a spontaneous pneumothorax, the nurse bases the explanation on the understanding that: Selected Choice: Inspired air will move from the lung into the pleural space Your Selection: Correct Rationale: As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space. This creates a positive pressure and causes partial or complete collapse of the lung. Related information: Chapter 6, section 75 Question 32: Following a spontaneous pneumothorax, the client becomes extremely drowsy and the pulse and respirations increase. The nurse should suspect: Selected Choice: Hypercapnia Your Selection: Correct Rationale: A pneumothorax results in decreased surface area for gaseous exchange. If the unaffected pleural regions cannot compensate, carbon dioxide builds up in the blood (hypercapnia). The client becomes drowsy and may lose consciousness. The body attempts to compensate by increasing the respiratory and pulse rates and by the renal retention of bicarbonate. Related information: Chapter 6, section 75 Question 33: When assessing an individual with a spontaneous pneumothorax, the nurse should expect dyspnea and: Selected Choice: Unilateral chest pain Your Selection: Correct Rationale: Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder. Related information: Chapter 6, section 75 Question 34: When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, it may lead to: Selected Choice: Rupture of the pericardium or aorta Your Selection: Incorrect Correct Choice: Decreased filling of the right heart
Rationale: Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output. Related information: Chapter 6, section 75 Question 35: The physician inserts a chest tube in a client who has been stabbed in the chest and attaches it to a closed-drainage system. When caring for the client, the nurse should: Selected Choice: Observe for fluid fluctuations in the waterseal chamber Your Selection: Correct Rationale: Fluctuations occur with normal inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged. Related information: Chapter 6, section 62 Question 36: Complete lung expansion before the removal of chest tubes is evaluated by: Selected Choice: Comparison of chest radiographs Your Selection: Correct Rationale: Chest x-ray films or radiographs reveal the degree to which the lung fills the pleural cavity and also the presence of any mediastinal shift. Related information: Chapter 6, section 62 Question 37: While receiving metaproterenol sulfate (Alupent) for asthma the client complains of palpitation, chest pain, and a throbbing headache. In view of these symptoms, the most appropriate nursing action would be to: Selected Choice: Withhold the drug until additional orders are obtained from the physician Your Selection: Correct Rationale: Alupent is a selective beta-2 adrenergic antagonist that causes increased heart contraction (positive inotropic effect) and
increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur and the drug should be withheld until the physician is notified. Related information: Chapter 6, section 61 Question 38: An asthmatic client's pulmonary function studies are abnormal. The nurse should realize that one of the most common complications of chronic asthma is: Selected Choice: Emphysema Your Selection: Correct Rationale: As a result of the narrowed airways, exhalation is difficult, leaving air trapped in the lung. Distention of alveolar walls to accommodate this volume leads to emphysema. Related information: Chapter 6, section 73 Question 39: A client with a long history of asthma is scheduled for surgery. Preoperative teaching should include the fact that the client: Selected Choice: Should try to limit coughing, because this causes distention of the chest Your Selection: Incorrect Correct Choice: Will be quite prone to respiratory tract infections Rationale: Hypersecretion of the mucous glands provides an excellent, warm, moist medium for microorganisms. Related information: Chapter 6, section 73 Question 40: The nurse should position a client recovering from general anesthesia in a: Selected Choice: Side-lying position Your Selection: Correct Rationale: Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway in the relaxed state. Related information: Chapter 6, section 21
Question 41: During the immediate postoperative period the nurse should give the highest priority to: Selected Choice: Checking the vital signs every 15 minutes Your Selection: Incorrect Correct Choice: Maintaining a patent airway Rationale: Maintenance of a patent airway is always the priority, since airway obstruction impedes breathing and may result in death. Related information: Chapter 6, section 21 Question 42: A client has seeds containing radium implanted in the pharyngeal area. When caring for this client, the nurse should: Selected Choice: Use rubber gloves when giving the client a bath Your Selection: Incorrect Correct Choice: Maintain the client in isolation Rationale: During radiation therapy with radium implants the client is placed in isolation so exposure to radiation by family and staff will be decreased. Related information: Chapter 6, section 173 Question 43: The nurse can expect a client who has had a splenectomy to complain of: Selected Choice: Pain on expiration Your Selection: Incorrect Correct Choice: Pain on inspiration Rationale: Because of the location of the spleen, expansion of the thoracic cavity during inspiration causes pain at the operative site. Related information: Chapter 6, section 21 Question 44: A client has a bronchoscopy in ambulatory surgery. To prevent laryngeal edema, the nurse should: Selected Choice: Keep the client in the semi-Fowler's position Your Selection: Correct Rationale: With the head elevated, rather than horizontal or dependent, fluid will not collect in the interstitial spaces around the trachea. Related information: Chapter 6, section 62
Question 45: After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. This is most likely the result of: Selected Choice: Extension of cancerous lesions Your Selection: Correct Rationale: Cancerous lesions in the pleural space increase the osmotic pressure causing a shift in fluid to that space. Related information: Chapter 6, section 66 Question 46: A client has a right pneumonectomy. During surgery the phrenic nerve is accidently severed: Selected Choice: Permitting greater excursion of the thoracic cavity Your Selection: Incorrect Correct Choice: Producing a partially atonic diaphragm Rationale: The phrenic nerve stimulates the diaphragm; accidental severance of one phrenic nerve would result in partial paralysis of the diaphragm. Related information: Chapter 6, section 58 Question 47: The factor that would have little influence in predisposing an individual to cancer of the larynx would be: Selected Choice: Poor dental hygiene Your Selection: Correct Rationale: Inadequate dental hygiene may predispose a person to oral infections but would be only remotely involved in laryngeal neoplasms because of the anatomical relationship of the oral cavity and the larynx. Related information: Chapter 6, section 78 Question 48: When cleaning a tracheostomy tube that has an inner cannula, the nurse should plan to remove the inner cannula: Selected Choice: In order to cleanse it with hydrogen peroxide Your Selection: Correct Rationale: The inner cannula, if nondisposable, must be removed, cleaned with peroxide, and rinsed
with saline to prevent mucus accumulation and occlusion of the tube. Related information: Chapter 6, section 62 Question 49: When suctioning a client with a tracheostomy the nurse must remember to: Selected Choice: Initiate suction as the catheter is being withdrawn Your Selection: Correct Rationale: During suctioning of a client, negative pressure (suction) should not be applied until the catheter is ready to be drawn out because, in addition to the removal of secretions, oxygen is being depleted. Related information: Chapter 6, section 62 Question 50: A client complains of severe pain 2 days following surgery. The nurse's initial action should be to: Selected Choice: Take the client's vital signs Your Selection: Correct Rationale: Immediately prior to administration, an assessment of vital signs is necessary to determine whether any contraindications to analgesia exist (e.g., hypotension, a respiratory rate of 12 or less). Related information: Chapter 6, section 18 Question 51: The nurse expects that the initial treatment for a client who has a leak of the thoracic duct following radical neck surgery would include inserting a: Selected Choice: Rectal tube to prevent distention, a low-fat diet, and increased activity Your Selection: Incorrect Correct Choice: Chest tube to drain the fluid, total parenteral nutrition, and bed rest Rationale: A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow; bed rest is recommended because lymphatic flow increases with activity. Related information: Chapter 6, section 78
Question 52: As a result of pulmonary tuberculosis, a client has a decreased surface area for gaseous exchange in the lungs. Oxygen and carbon dioxide are exchanged in the lungs by: Selected Choice: Diffusion Your Selection: Incorrect Correct Choice: Osmosis Rationale: The respiratory membrane, consisting of the alveolar and capillary walls, is extremely thin. This thinness facilitates exchange of respiratory gases without the need for additional energy. Related information: Chapter 6, section 57 Question 53: Before discontinuing airborne precautions (respiratory isolation) for a client with pulmonary tuberculosis, the nurse must determine that: Selected Choice: No acid-fast bacteria are in the sputum Your Selection: Correct Rationale: The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Related information: Chapter 6, section 72 Question 54: A thoracentesis is performed. Following the procedure it is most important for the nurse to observe the client for: Selected Choice: Expectoration of blood Your Selection: Correct Rationale: Expectoration of blood is an indication that the lung itself was damaged during the procedure; a pneumothorax may occur. Related information: Chapter 6, section 62 Question 55: A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should: Selected Choice: Suction two to three times in quick succession to remove all secretions Your Selection: Incorrect
Correct Choice: Hyperoxygenate with 100% oxygen before and after suctioning Rationale: Suctioning also removes oxygen which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning. Related information: Chapter 6, section 62 Question total: 55 Questions correct: 42 Score: 76%
