Nursing Care of Patients With Lower Respiratory Tract Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A patient is admitted to a respiratory unit with a diagnosis of left lower lobe pneumonia. The nursing assessment reveals the patient to be febrile and experiencing a weak, congested-sounding cough. The patient has moist crackles throughout the lung fields. Based on the data provided, which nursing diagnosis is most appropriate?
a. Anxiety
b. Impaired Gas Exchange
c. Ineffective Breathing Pattern
d. Ineffective Airway Clearance
____ 2. The nurse is caring for a patient with pneumonia. Which laboratory test would best help the nurse to monitor the condition of this patient?
a. Electrolytes, serum creatinine
b. Complete blood count (CBC), urinalysis
c. Partial thromboplastin time (PTT), serum potassium
d. White blood cell (WBC) count, arterial blood gases (ABGs)
____ 3. A patient is unable to maintain a clear airway effectively with coughing and has a respiratory rate of 22/min with coarse crackles bilaterally. Which intervention should the nurse provide first?
a. Encourage fluids.
b. Encourage bedrest.
c. Perform tracheal suctioning.
d. Assess the patient’s coughing technique.
____ 4. The nurse is reviewing data collected on a patient with a respiratory disorder. Which factor should the nurse identify that places the patient at risk for lung cancer?
a. Smoking and exposure to radon gas
b. Living in a cold climate and having pets
c. Eating foods high in beta carotene and fiber
d. Living in crowded conditions and lack of sunlight
____ 5. A patient with lung cancer who is scheduled to begin a course of radiation therapy asks the nurse, “How will they know if I’m cured?” The nurse’s best response is based on which understanding of the disease process?
a. Lung cancer is never a curable disease; prolonged life is the goal.
b. Eighty percent of lung cancers are curable with radiation therapy.
c. Radiation in lung cancer is most often used to increase comfort, not cure disease.
d. Radiation therapy reduces inflammation; chemotherapy is used to shrink the tumor.
____ 6. A patient with lung cancer develops pleural effusion. Which explanation by the nurse would help the patient understand this problem?
a. “Pus has developed in your alveoli that must be removed to improve your breathing.”
b. “You have large amounts of fluid collecting in your airways because of the lung cancer.”
c. “Fluid has collected in the space between your lungs and the sac surrounding your lungs.”
d. “Fluid in your pericardial sac places pressure on your lungs, making it difficult to breathe.”
____ 7. A patient diagnosed with a pleural effusion is very dyspneic. With which procedure should the nurse anticipate assisting?
a. Tracheostomy
b. Thoracentesis
c. Bronchoscopy
d. Pericardiocentesis
____ 8. The nurse is providing discharge teaching for a patient with newly diagnosed asthma. What should be included in the discharge teaching?
a. “Fluid fills the tiny sacs in the lungs and makes breathing difficult.”
b. “Symptoms are caused by inflammation in the lining of your airways.”
c. “You may notice large amounts of pus-like sputum that has a foul odor.”
d. “The chest wall becomes stiff and air movement is restricted in individuals with asthma.”
____ 9. The nurse is providing routine follow-up care for a young adult with asthma who has been on a 3-month course of maintenance therapy. Which activity would best help the nurse to determine if the patient’s treatment plan was effective?
a. Obtain an ABG analysis.
b. Determine the patient’s pulse oximeter reading.
c. Evaluate the patient’s use of an incentive spirometer.
d. Examine daily tracking records of the peak expiratory flow rate.
____ 10. A summer camp worker reports to the camp nurse with complaints of shortness of breath and audible wheezing. Which inhaled medication should the nurse provide?
a. Albuterol (Proventil)
b. Cromolyn sodium (Intal)
c. Triamcinolone (Azmacort)
d. Nedocromil sodium (Tilade)
____ 11. While reinforcing discharge teaching for a patient with emphysema, which patient statement indicates that teaching was effective?
a. “There are bacteria in my lungs so my body is trying to wall off the infection.”
b. “My disease is caused by spasm of the smooth muscles in my breathing pipes.”
c. “Emphysema causes swelling in the airways and an increase in mucus production.”
d. “Air gets trapped when damage to the air sacs makes it hard for air to move in and out.”
____ 12. A patient with chronic obstructive pulmonary disease is prescribed methylprednisolone (Solu-Medrol). For what reason should the nurse realize that corticosteroids are used in the treatment of this health problem?
a. Dry secretions
b. Treat infection
c. Improve the oxygen-carrying capacity of hemoglobin
d. Reduce airway inflammation
____ 13. A nurse is providing home care for a patient with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?
a. Low-sodium diet
b. Increase activity as tolerated
c. Oxygen 4 L/min per nasal cannula
d. Tiotropium (Spiriva) inhalation once daily
____ 14. A patient prescribed theophylline for asthma has a theophylline level of 3 mcg/dL. What should the nurse do?
a. Notify the physician.
b. Double the next dose of theophylline.
c. No action is necessary; this is a therapeutic level.
d. Hold the next dose of theophylline until further orders are given.
____ 15. The nurse enters the room of a patient who is acutely short of breath. Which action should the nurse take first?
a. Assist the patient into Sims’ position.
b. Encourage use of pursed-lip breathing.
c. Ask the patient what caused the dyspnea.
d. Teach the patient use of accessory muscles.
____ 16. The nurse is providing care for a patient prescribed tiotropium (Spiriva). Which statement should be included in the patient education?
a. “Do not swallow the capsules.”
b. “This medication can cause blurred vision and anorexia.”
c. “It is important to alert the doctor to any abdominal pain or bloating.”
d. “You may experience a headache and sensitivity to light while taking this medication.”
____ 17. The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease. Which medication can help reduce acute dyspnea associated with this disease?
a. PO cortisone
b. IV morphine
c. IV propranolol (Inderal)
d. IM meperidine (Demerol)
____ 18. A patient’s arterial blood gas analysis shows a PaCO2 of 62 mm Hg. What action should the nurse take?
a. Notify the RN; this is abnormally high.
b. Have the patient breathe into a paper bag.
c. Increase the flow rate of the patient’s nasal oxygen.
d. No action is necessary; this is a normal PaCO2 level.
____ 19. A patient with chronic obstructive pulmonary disease works with the nurse to set a goal of ambulating to the bathroom with oxygen. Which statement best documents progress toward this goal?
a. “Dyspnea is controlled with oxygen and rest.”
b. “Arterial blood gases are within normal limits.”
c. “Patient assisted to bathroom three times today.”
d. “Ambulated to bathroom with oxygen, dyspnea level 3 on a 0-to-10 scale.”
____ 20. A patient with cystic fibrosis has ineffective airway clearance. What intervention would worsen this problem?
a. Fluids
b. Bedrest
c. Mucolytics
d. Percussion and postural drainage
____ 21. The nurse is assisting in the preparation of content that focuses on respiratory health for a community health fair. What should the nurse include as a major risk factor for many respiratory problems?
a. Smoking
b. Eating spicy foods
c. Eating a high-fat diet
d. Excessive sun exposure
____ 22. A patient has difficulty raising pulmonary secretions, and the nurse writes a nursing diagnosis of “Ineffective Airway Clearance related to weak cough and fatigue.” What would best help the patient maintain a clear airway?
a. Teach relaxation exercises.
b. Allow rest periods between activities.
c. Encourage fluids; suction prn as ordered.
d. Instruct in abdominal and pursed-lip breathing.
____ 23. A patient with a lung infection has blood-tinged sputum. What term should the nurse use to document this finding?
a. Hypoxemia
b. Hemoptysis
c. Hypercarbia
d. Hematemesis
____ 24. A nurse performs purified protein derivative and Candida skin tests on a patient suspected of TB. After 48 hours, what finding at the injection sites should the nurse document as a positive result?
a. Warmth
b. Redness
c. Induration
d. Purulent discharge
____ 25. A patient with suspected TB is prescribed a Candida skin test. What should the nurse explain as the purpose of this test?
a. Provides a control test
b. Tests for skin superinfection
c. Potentiates the purified protein derivative (PPD) test
d. Determines if the patient has a Candida albicans infection
____ 26. The nurse is reviewing the health histories for an assigned group of patients. Which patient should the nurse identify as being the most at risk for TB?
a. The patient with lung cancer
b. The patient with a history of alcohol abuse
c. The patient with chronic airflow limitation
d. The patient with acquired immunodeficiency syndrome
____ 27. The nurse is reviewing medication orders for a patient with TB. Which drugs should the nurse expect to have prescribed for this patient?
a. Isoniazid and rifampin
b. Claforan and penicillin
c. Aspirin and guaifenesin
d. Alupent and theophylline
____ 28. A patient with TB who is in respiratory isolation must go to the x-ray department. Which action should the nurse take?
a. Place a gown and gloves on the patient.
b. Place a mask over the patient’s nose and mouth.
c. Notify the x-ray department that the test must be cancelled.
d. Call the x-ray department to make sure the waiting room is empty.
____ 29. The nurse teaches a patient with TB about drug therapy. Which patient statement indicates that teaching has been effective?
a. “I will have to take the antibiotics for 10 days.”
b. “I will get a prescription for 2 weeks of antibiotics.”
c. “I will have to take antibiotics for the rest of my life.”
d. “I will probably need to be on antibiotic therapy for 6 months to 2 years.”
____ 30. A patient with TB takes the prescribed drugs until the bottle runs out and then feels better and does not refill the prescription. The home health nurse explains that continuing the drugs is important for which reason?
a. “If taken consistently, your drugs will prevent hemoptysis.”
b. “If you don’t take all your drugs you can develop a superinfection.”
c. “The drugs will keep you pain free so you can cough more effectively.”
d. “You must take all the drugs to prevent development of resistant bacteria.”
____ 31. The nurse is beginning morning care after receiving report. Which patient should the nurse monitor most closely for symptoms of a pulmonary embolism (PE)?
a. A patient who smokes
b. A patient with a deep vein thrombosis in the leg
c. A patient with a history of radiation therapy for lung cancer
d. A patient with chronic obstructive pulmonary disease (COPD)
____ 32. The nurse answers a call light and finds the patient gasping for breath and looking very anxious. Based on the patient’s history, the nurse believes the patient may be experiencing a pulmonary embolism (PE). Which action should the nurse take first?
a. Contact the physician.
b. Call for help and start oxygen.
c. Check the patient’s vital signs.
d. Place the patient in a left lateral position.
____ 33. A patient is diagnosed with a pulmonary embolism. Which medication should the nurse anticipate administering to this patient?
a. Heparin
b. Expectorant
c. Theophylline
d. Corticosteroid
____ 34. A patient with a pneumothorax has a chest drainage system. The family asks when the chest tube will be removed. What should the nurse respond to the family?
a. “The tube is removed when serous drainage has stopped collecting in the system.”
b. “The tube is taken out when the patient is able to cough and deep breathe effectively.”
c. “When the adventitious lung sounds are resolved, it is usually safe to remove the tube.”
d. “When tidaling stops and lung sounds are equal on both sides, the tube can be removed.”
____ 35. The nurse auscultates the lung sounds of a patient with a pneumothorax every 4 hours. What is the nurse listening for during this auscultation?
a. Evidence of obstruction
b. Presence of crackles or wheezes
c. Evidence of bilateral lung sounds
d. Presence of secretions in the lungs
____ 36. A patient is diagnosed with respiratory failure. Which acid-base abnormality should the nurse expect the patient to demonstrate?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
____ 37. An LPN is collecting data on a patient recovering from thoracic surgery. Vital signs following surgery were: blood pressure 156/94 mm Hg, pulse 100 beats/min, respirations 14/min, and temperature 97.4°F (approximately 36.3°C). Which new finding should the nurse report immediately to the physician?
a. Pulse 88 beats/min
b. Respirations 18/min
c. Blood pressure 110/76 mm Hg
d. Temperature 98.4°F (approximately 36.9°C)
____ 38. The nurse develops a plan for impaired gas exchange for a patient with end-stage chronic obstructive pulmonary disease (COPD). Which finding best helps the nurse to know when the goal has been reached?
a. The patient is alert and oriented.
b. The patient’s oxygen saturation is 92%.
c. The patient is able to clear the airway with coughing.
d. The patient correctly demonstrates pursed lip breathing.
____ 39. A patient asks the nurse what can be done to prevent the development of lung cancer. What measure should the nurse explain as the most effective way to prevent this disease?
a. Avoid smoking.
b. Eat a balanced diet.
c. Avoid excessive sun exposure.
d. Avoid exposure to air pollution.
____ 40. The nurse is assisting in the preparation of an inservice on infections. What should the nurse include as being the most common cause of death from infection?
a. AIDS
b. Influenza
c. Pneumonia
d. TB
____ 41. A patient has a positive response to a Candida test, in addition to a positive purified protein derivative (PPD) skin test. Which interpretation of these results is correct?
a. The patient is anergic.
b. The patient’s PPD test is reliable.
c. The patient has a Candida infection.
d. The patient has active TB infection.
____ 42. The nurse is reviewing the health statuses for assigned patients to determine the risk for pneumonia. Which type of pneumonia occurs most often as a nosocomial infection in hospitalized patients, very young patients, and older patients?
a. Viral pneumonia
b. Lobar pneumonia
c. Fungal pneumonia
d. Bronchopneumonia
____ 43. The nurse is caring for a patient with long-standing bronchiectasis. Which manifestation should the nurse report immediately?
a. Copious sputum
b. Periodic episodes of harsh coughing
c. Distended neck veins and dependent edema
d. Fever of 100.6°F (approximately 38°C) and dyspnea
____ 44. The nurse is assisting with the development of content on lung diseases to be provided during an upcoming health fair. What should the nurse include as being the disease that one-third of the world’s population is currently infected?
a. AIDS
b. Cancer
c. Pneumonia
d. TB
____ 45. An older adult patient who reports difficulty breathing and a productive cough and has a low-grade fever is admitted to the hospital for diagnosis and treatment. Which new-onset symptom should take priority?
a. Fatigue
b. Confusion
c. Blood-tinged sputum
d. Crackles on lung auscultation
____ 46. The nurse is concerned that a patient with a chronic low oxygen saturation level should be wearing home oxygen. Which oxygenation level should be used to make this decision?
a. 95%
b. 90%
c. 88%
d. 72%
____ 47. A patient is having a therapeutic thoracentesis to remove pleural fluid. What volume of pleural fluid should the nurse recognize as being abnormal?
a. 5 mL
b. 7 mL
c. 13 mL
d. 30 mL
____ 48. A patient is diagnosed with a pulmonary embolism. To be effective, how soon should thrombolytic agents be administered?
a. 4 to 6 hours
b. 7 to 9 hours
c. 10 to 12 hours
d. 14 to 24 hours
____ 49. The nurse observes a newly admitted patient in the hospital room and determines that data collection should be focused on chronic obstructive pulmonary disease. What did the nurse observe to make this decision?
a. The patient is coughing.
b. The patient is lying supine in bed.
c. The patient is walking around the room.
d. The patient is sitting in the tripod position.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 50. According to Centers for Disease Control and Prevention (CDC) guidelines, which individuals should the nurse consider as being positive for the TB skin test? (Select all that apply.)
a. A 5-mm induration in a foreign-born individual
b. A 5-mm induration in an HIV-infected individual
c. A 10-mm induration in a child younger than 4 years old
d. A 5-mm induration in an individual from a low-income group
e. A 10-mm induration in an individual with no risk factors for TB
f. A 10-mm induration in an HIV-negative individual who uses illicit injected drugs
____ 51. The nurse is caring for a patient with a suspected pulmonary embolism. Which diagnostic tests or procedures should the nurse expect to be prescribed for this patient? (Select all that apply.)
a. D-dimer
b. Spirometry
c. Angiogram
d. Bronchoscopy
e. Ventilation-perfusion lung scan
f. Spiral computed tomography (CT) scan
____ 52. A nurse is providing care for a patient with Ineffective Airway Clearance. Which are appropriate interventions to address this problem? (Select all that apply.)
a. Weigh patient every day.
b. Teach patient proper use of an incentive spirometer.
c. Place patient in supine position and turn every 2 hours.
d. Assess respiratory rate and pattern every 4 hours and prn.
e. Encourage patient to deep breathe and cough every 2 hours.
f. Administer guaifenesin (Mucinex) every 4 to 6 hours prn as ordered.
____ 53. The nurse needs to collect a sputum specimen for culture from a patient with a chronic cough. What actions should the nurse take when collecting this specimen? (Select all that apply.)
a. Obtain the specimen first thing in the morning
b. Obtain the specimen before the patient eats breakfast
c. Administer an antibiotic before collecting the specimen
d. Provide the patient with warm water to drink before obtaining the specimen
e. Have the patient rinse the mouth with warm water before collecting the specimen
____ 54. The nurse is assisting in the planning of care for a patient with chronic obstructive pulmonary disease. What should be the goals of care for this patient? (Select all that apply.)
a. Smoking cessation
b. Improve activity tolerance
c. Prevent disease progression
d. Complete an advance directive
e. Prevent and treat exacerbations
____ 55. A young adult is admitted with manifestations associated with cystic fibrosis. What should the nurse expect to find when collecting data from this patient? (Select all that apply.)
a. Extreme thirst
b. Finger clubbing
c. Body mass index 16
d. Thick sputum production
e. Complaints of frequent foul-smelling stool
____ 56. A patient is prescribed long-term anticoagulant therapy as treatment for pulmonary emboli. What should the nurse ensure the patient is instructed before being discharged home? (Select all that apply.)
a. Wear shoes at home.
b. Use an electric razor.
c. Use a soft toothbrush.
d. Expect bruising to occur.
e. Restrict the intake of citrus fruits.

Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: D
Data point to excessive secretions that the patient is not completely coughing up, so Ineffective Airway Clearance is the best choice. A. B. C. Although they may be concerns with pneumonia, there is no evidence of anxiety, impaired gas exchange, or ineffective breathing pattern.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

2. ANS: D
WBC is elevated in infection, and ABGs may be abnormal if gas exchange is impaired with pneumonia. CBC may be helpful, but WBC is more specific. A. B. Urinalysis, electrolytes, and creatinine are useful in kidney and bladder problems. C. PTT and potassium may be ordered for cardiovascular problems, among other disorders.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

3. ANS: D
Assessment is the first step before providing care, and effective coughing is important to clear the airway. A. Fluids may be helpful once assessment is complete. B. Bedrest will reduce mobilization of secretions. C. Suctioning is only necessary in patients who are unable to cough.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

4. ANS: A
Smoking is the biggest risk factor for lung cancer. Radon exposure is also a significant factor. B. C. D. Living in a cold climate, having pets, eating foods high in beta carotene and fiber, living in crowded conditions, and lack of sunlight are not identified risk factors for the development of lung cancer.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

5. ANS: C
Radiation may be used to shrink a tumor to reduce symptoms in patients who are unable to undergo surgery. D. It generally is not curative, and it will not reduce inflammation. A. B. Lung cancer is curable in some cases but not usually with radiation alone.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application

6. ANS: C
When excess fluid collects in the pleural space, it is called a pleural effusion. Fluid normally enters the pleural space from surrounding capillaries and is reabsorbed by the lymphatic system. When a pathological condition causes an increase in fluid production or inadequate reabsorption of fluid, excess fluid collects. A. B. D. The fluid is not in the airways or alveoli or around the heart.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

7. ANS: B
Thoracentesis can be done by the physician to remove some of the fluid that has collected and is compressing lung tissue. A. Tracheostomy creates a stoma for the placement of an artificial airway. C. Bronchoscopy visualizes the major airways with an endoscope. D. Pericardiocentesis removes fluid from around the heart.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

8. ANS: B
Asthma is characterized by inflammation of the mucosal lining of the bronchial tree and spasm of the bronchial smooth muscles (bronchospasm). A. Alveoli are not generally affected in asthma. C. Some sputum may be present, but purulent sputum suggests infection, not asthma. D. Noncompliance of the chest wall occurs in restrictive, not obstructive, disorders.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

9. ANS: D
Many patients with asthma monitor their peak expiratory flow rate at home. This is a measure of the amount of air the patient can blow into a peak flowmeter from fully inflated lungs and is measured in liters per minute. Daily tracking records will indicate respiratory status over time. C. An incentive spirometer encourages deep breathing; correct use will not help evaluate asthmatic control. B. Current pulse oximetry will only provide a measure of current oxygenation and will not indicate long-term efficacy of the treatment plan. A. ABGs may be helpful in severe cases but are invasive and not routine and will only give a current measurement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Evaluation

10. ANS: A
Albuterol is an adrenergic bronchodilator and would be used to help immediately relieve acute bronchospasm. B. D. Cromolyn and nedocromil are mast cell inhibitors. C. Triamcinolone is a corticosteroid.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

11. ANS: D
Emphysema affects the alveolar membranes, causing destruction of the alveolar walls, loss of elastic recoil, and air trapping. B. Smooth muscle spasm is associated with asthma. C. Inflammation and mucus production are associated with chronic bronchitis. A. Walled-off bacteria are characteristic of tuberculosis (TB).

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

12. ANS: C
Corticosteroids are potent anti-inflammatory agents. A. B. They do not dry secretions, and they may cause infection to worsen. C. They do not directly affect oxygenation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

13. ANS: C
Oxygen is generally ordered at a flow rate of 1 to 2 L/min for patients with chronic lung disease. Higher flow rates may suppress the hypoxic drive in patients who are chronic CO2 retainers. B. D. Tiotropium and increasing activity as tolerated are common orders in COPD. A. A low-sodium diet is not contraindicated.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

14. ANS: A
A therapeutic theophylline level is 10 to 20 mcg/mL. The physician should be notified. D. Holding the next dose will further lower the level. B. Doubling the dose is inappropriate without a physician’s order.
C. This is not a therapeutic level and action is necessary.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

15. ANS: B
Pursed-lip breathing can help open alveoli and promote excretion of carbon dioxide. A. Fowler’s, not Sims’, position will help lung expansion. C. Asking the patient the cause is appropriate after the dyspnea is resolved. D. Accessory muscle use is a sign of respiratory distress, not a therapeutic measure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

16. ANS: A
Tiotropium (Spiriva) is a capsule that is placed in a device and activated before inhalation. The patient should be instructed to not swallow the capsules. B. This medication does not cause blurred vision and anorexia. C. Abdominal pain and bloating is not associated with this medication. D. A headache and sensitivity to light are not adverse effects of this medication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

17. ANS: B
IV morphine helps acute dyspnea and anxiety in patients with end-stage disease. A. Cortisone may reduce inflammation, but the oral route is too slow for acute dyspnea. D. Meperidine has not been shown to reduce dyspnea. C. Propranolol is a beta blocker and may aggravate bronchoconstriction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

18. ANS: A
Normal PaCO2 is 35 to 45 mm Hg. 62 mm Hg is evidence of hypoventilation and the inability to excrete carbon dioxide. The RN or physician should be notified. C. Increasing nasal oxygen will not help CO2 excretion. B. Breathing into a paper bag will increase the CO2 level. D. This is not a normal level and action must be taken immediately.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

19. ANS: D
“Ambulated to bathroom with oxygen, dyspnea level 3 on a 0-to-10 scale” directly addresses the goal. A. B. C. Normal arterial blood gases (ABGs), controlled dyspnea, and being assisted to the bathroom are all good outcomes, but they do not directly address the goal.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Evaluation

20. ANS: B
Movement helps mobilize secretions, so bedrest is not helpful. A. C. D. Percussion, postural drainage, fluids, and mucolytics will all help clear the airway.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

21. ANS: A
Smoking is the most important risk factor for chronic obstructive pulmonary disease (COPD) and most other respiratory disorders. B. C. D. Spicy foods, sun, and diet are not risk factors.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

22. ANS: D
Fluids help reduce viscosity of secretions, and suction can remove secretions in patients who are unable to cough effectively. A. B. Rest and relaxation can help with activity intolerance and anxiety. D. Breathing exercises help correct impaired gas exchange.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

23. ANS: B
Hemoptysis is blood-tinged sputum. D. Hematemesis is bloody emesis. A. Hypoxemia is low blood oxygen. C. Hypercarbia is high blood carbon dioxide.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

24. ANS: C
Induration is a raised area at the injection site and is considered positive. A. B. D. Redness, discharge, and warmth are not positive results.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

25. ANS: A
Candida is used to test a patient for anergy, or the inability of the immune system to react to an antigen. If the Candida or mumps test produce positive results, the TB results are considered to be reliable. B. D. It is not done to identify Candida infection or superinfection, as most patients are positive. C. It does not affect the PPD test.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

26. ANS: D
Patients with immune dysfunction are most at risk for becoming ill with TB. A. B. C. Patients with cancer, airflow limitation, or alcohol abuse are only at risk if their immune function is compromised.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

27. ANS: A
Isoniazid and rifampin are antibiotics effective against TB. B. C. D. These medications may be used for respiratory disorders, but they are not specific to TB.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

28. ANS: B
The patient should be in respiratory isolation, so a mask over the nose and mouth is essential. A. Gown and gloves are not necessary. C. D. Ideally, traveling outside the room should be kept to a minimum, but not all x-rays can be done at the bedside.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

29. ANS: D
Drugs for TB must be taken for 6 months, or up to 2 years for multidrug-resistant TB (MDR-TB). A. B. C. The medications must be taken longer than 10 days to 2 weeks however do not need to be taken for the rest of the patient’s life.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Evaluation

30. ANS: D
Unfinished antibiotic prescriptions allow stronger bacteria to survive and become resistant. A. C. Antibiotics do not directly prevent hemoptysis or pain. B. Superinfection can occur even if all the drugs are taken as prescribed.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

31. ANS: B
Clots in the legs can mobilize and move to the lungs. D. COPD is not associated with blood clots. A. Smoking causes many lung disorders but does not directly cause PE. C. History of radiation therapy is not a risk factor for PE.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

32. ANS: B
Be alert to the presence of risk factors, and obtain immediate assistance if the cause of dyspnea might be PE. Death can occur if treatment is not quick and effective. D. Left lateral position will not help. A. Leaving the patient to call the physician is not appropriate—someone else can contact the physician. C. Checking vital signs is important but is not more important than oxygen.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

33. ANS: A
If a thrombolytic agent is not used, treatment is aimed at preventing extension of the clot and the formation of additional clots. Heparin will prevent clot extension. C. Theophylline is a bronchodilator. D. Corticosteroids are anti-inflammatory. B. An expectorant will help raise secretions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

34. ANS: D
Absence of tidaling and bilateral breath sounds are signs that the lung is reinflated and the chest tube can be safely removed. A. Drainage will generally have stopped at this time also, but it is not the primary determinant for removal. B. C. Coughing and deep breathing and clear lung sounds are not signs that the lung is reinflated.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

35. ANS: C
Lung sounds are absent over a pneumothorax. Return of bilateral sounds signifies that the lung is reinflated. A. B. D. Crackles, wheezes, secretions, or obstruction are concerning but do not provide direct information about pneumothorax.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

36. ANS: C
Arterial blood gases in respiratory failure show decreasing PaO2 and pH and increasing PaCO2, which lead to respiratory acidosis. D. Respiratory alkalosis is associated with hyperventilation. A. B. Metabolic imbalances are not caused by respiratory dysfunction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

37. ANS: C
Although the blood pressure is still normal, it has dropped significantly and could signify bleeding or impending shock. A. B. D. The other vital signs are not as remarkable.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

38. ANS: B
Oxygen saturation of 92% is desirable in a patient with COPD. It reflects adequate oxygenation. A, C, and D are all important but are not as objective as oxygen saturation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Evaluation

39. ANS: A
Smoking causes lung cancer. B, C, and D can help prevent a variety of cancers.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

40. ANS: C
Pneumonia is the cause of more than 10% of hospital admissions each year and is the most common cause of death from infection. A. B. D. AIDS, TB, and influenza are also deadly diseases, but they are not the most common cause of death from an infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

41. ANS: B
The positive Candida reaction means the patient’s immune system is intact and that the PPD test is reliable. A. Two negative results would indicate anergy. C. All patients react to Candida. D. Active infection is possible but must be confirmed with a culture.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

42. ANS: D
Generalized pneumonia is very serious and is called bronchopneumonia. Bronchopneumonia occurs more often as a nosocomial (hospital-acquired) infection in hospitalized patients, the very young, and the very old. B. Lobar pneumonia is localized. A. C. Fungal and viral pneumonias refer to specific causes but are not necessarily more frequent in the populations listed.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Analysis

43. ANS: C
Distended neck veins and dependent edema are signs of cor pulmonale and should be reported immediately. A. B. D. Fever, sputum, and cough are expected in patients with bronchiectasis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

44. ANS: D
One-third of the world’s population is currently infected with TB. A. B. C. One third of the world’s population is not currently infected with AIDS or pneumonia or has cancer.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

45. ANS: B
New onset confusion in a patient with respiratory symptoms is a sign of impaired gas exchange. It must be corrected immediately. A. C. D. Crackles, blood-tinged sputum, and fatigue are all important but are not the first priority.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

46. ANS: C
Patients with chronic oxygen saturation levels of less than or equal to 88% should be placed on home oxygen. A. B. Oxygenation levels greater than 88% do not need to be prescribed home oxygen. D. The patient may need additional intervention if the oxygen level is 72%

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

47. ANS: D
More than 25 mL of fluid is considered abnormal. A. B. C. A normal amount of pleural fluid around each lung is 1 to 15 mL.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

48. ANS: A
Thrombolytic agents such as alteplase (Activase) or reteplase (Retavase) may be used in life-threatening emergencies to dissolve the clot Thrombolytics must be administered within 4 to 6 hours of the clot’s occurrence. B. C. D. Administering the medication after 6 hours would be ineffective to dissolve the clot.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

49. ANS: D
In chronic obstructive pulmonary disease patients use accessory muscles to breathe and tend to assume the classic tripod position to aid breathing. A. B. C. Coughing, lying supine in bed and walking around the room do not necessarily indication that the patient has chronic obstructive pulmonary disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

MULTIPLE RESPONSE

50. ANS: B, C, F
5 mm or more is positive in patients with HIV, close contacts with TB, a history of TB, or IV drug abuse and unknown HIV status. A. D. 10 mm or more is positive in persons who are foreign-born, are IV drug abusers and HIV-negative, are low income, reside in residential facilities, or are children younger than age 4. E. A 15-mm result is positive in a person with no TB risk factors.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

51. ANS: A, C, E, F
A spiral CT scan is a new and fast type of CT scan that is noninvasive and can diagnose PE quickly. If this is not available, a lung scan (ventilation-perfusion scan) is done to assess the extent of ventilation of lung tissue and the areas of blood perfusion. A pulmonary angiogram can outline the pulmonary vessels with a radiopaque dye injected via a cardiac catheter. D-dimer is a fibrin fragment that is found in the blood after any thrombus formation. It can be present in a number of disorders, but if it is negative, PE can be eliminated as a possible cause of the patient’s symptoms. D. Bronchoscopy is not used to determine PE. B. Spirometry is not a diagnostic test.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

52. ANS: A, B, C, D, E, F
Interventions to help with ineffective airway clearance include teaching the use of incentive spirometry, assessing respiratory rate and pattern every 4 hours and as needed, encouraging the patient to deep breathe and cough every 2 hours, and administering medication to thin secretions as prescribed. A. Daily weights may be done for other reasons but are not directly related to the problem of ineffective airway clearance.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

53. ANS: A, B
A specimen for culture should be obtained first thing in the morning before the patient eats breakfast. C. The culture specimen should be obtained before antibiotics are started to avoid altering culture results. D. The patient does not need to drink warm water before obtaining the specimen. E. If the patient has eaten, the mouth should be rinsed with water to keep food particles out of the specimen.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

54. ANS: A, B, C, E
The goals of COPD treatment include cessation of cigarette smoking, improve activity tolerance, prevent disease progression, and prevent and treat exacerbations. D. Completing an advance directive is not a goal for treatment.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

55. ANS: B, C, D, E
Symptoms of cystic fibrosis usually first appear in infancy or childhood, although a few individuals are not diagnosed until adulthood. Manifestations include finger clubbing, malnutrition, thick sputum production, and frequent foul-smelling stools. A. Extreme thirst is not a manifestation of cystic fibrosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

56. ANS: A, B, C
The patient on long-term anticoagulant therapy needs to be instructed to avoid accidental injury and bleeding. The patient should be instructed to wear shoes at home, use an electric razor, and use a soft toothbrush. D. Bruising is not expected and should be reported to the health care provider. E. There is no reason to restrict the intake of citrus fruits.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential