Nursing Care of Patients With Upper Respiratory Tract Disorders

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

____ 1. The nurse is reviewing the arterial blood gas results for a patient with a respiratory disorder. What should the nurse recognize as being the most important chemical regulator of respiration?
a. The blood level of oxygen
b. The blood level of nitrogen
c. The blood level of carbon dioxide
d. The amount of hemoglobin in red blood cells
____ 2. The nurse is reviewing the results of a patient’s pulmonary function tests. Which result describes the air remaining in lungs after normal expiration?
a. Tidal volume
b. Expiratory reserve
c. Forced vital capacity
d. Functional residual capacity
____ 3. The nurse is reviewing the exchange of gases in the blood stream with a patient prescribed oxygen therapy. How should the nurse explain the transport of carbon dioxide in the blood?
a. As CO2 in plasma
b. As bicarbonate ions in plasma
c. As hydrogen ions in red blood cells
d. As part of hemoglobin in red blood cells
____ 4. A patient is having problems with oxygenation of body tissues. What is important for the nurse to consider about the transport of oxygen in the blood?
a. It is in blood plasma as free oxygen.
b. It travels on red blood cell membranes.
c. It is bonded to hemoglobin in blood plasma.
d. It is bonded to hemoglobin in red blood cells.
____ 5. The nurse is reviewing the physiology of the respiratory system with a patient being treated for pneumonia. What structure should the nurse identify as sweeping mucus and pathogens from the nasal cavities and trachea to the pharynx?
a. Ciliated epithelium
b. Alveolar macrophages
c. Elastic connective tissue
d. Simple squamous epithelium
____ 6. The nurse is coaching a patient to empty the lungs of all air before using a metered-dose inhaler. What air that is expired beyond tidal volume in a forceful exhalation is the nurse coaching the patient to remove from the lungs?
a. Tidal volume
b. Expiratory reserve
c. Forced vital capacity
d. Peak expiratory flow rate
____ 7. A patient has a low oxygen level. Which body structure should the nurse consider as being responsible for this low level?
a. Larynx
b. Alveoli
c. Bronchi
d. Nasal passages
____ 8. The nurse is providing care to a patient who experienced an ischemic stroke and now requires respiratory support with mechanical ventilation. The nurse realizes that the stroke most likely occurred in which part of the brain?
a. Medulla
b. Cerebrum
c. Cerebellum
d. Hypothalamus
____ 9. A nurse is providing care for a patient who complains of difficulty breathing. Which assessment will best help the nurse determine the severity of the patient’s dyspnea?
a. Count the patient’s respiratory rate.
b. Ask the patient to describe the dyspnea.
c. Have the patient rate the dyspnea on a 0-to-10 scale.
d. Observe the patient throughout two to three respirations.
____ 10. While providing care for a patient with asthma, the nurse notes the patient’s shoulders are rising with each breath. What should the nurse realize this action represents?
a. Hyperinflation of the chest
b. The use of accessory muscles to aid breathing
c. Shoulder muscle fatigue related to difficulty breathing
d. Effective use of a breathing exercise to increase ventilation
____ 11. During the admission assessment of an individual admitted to the medical respiratory unit, the nurse notes the patient has a barrel-shaped chest. Which assessment should the nurse perform next?
a. Assess the patient’s rate and character of respirations.
b. Ask the patient about presence of a productive cough.
c. Palpate the patient’s thorax to determine presence of tenderness.
d. Obtain a blood sample for arterial blood gas (ABG) to detect respiratory acidosis.
____ 12. The nurse is auscultating a patient’s chest and hears an adventitious sound in the left lower lobe. What is the first step in determining whether this is an abnormality?
a. Call another nurse to listen to the patient’s lungs.
b. Ask the patient if this has ever occurred in the past.
c. Have the physician listen and verify what the nurse is hearing.
d. Listen to the corresponding area in the patient’s right lower lobe.
____ 13. The nurse is auscultating a patient’s lungs but is unable to hear much air movement. What should the nurse do to most effectively hear the lung sounds?
a. Try another stethoscope.
b. Have the patient rest between breaths.
c. Have the patient assume a side-lying position.
d. Ask the patient to breathe deeply through the mouth.
____ 14. The nurse observes a patient who has periods of fast, deep respirations alternating with periods of apnea. What term should the nurse use to describe this pattern?
a. Tachypnea
b. Kussmaul’s
c. Cheyne-Stokes
d. Hyperventilation
____ 15. An adult patient has a respiratory rate of 36 breaths per minute. Which term should the nurse use to document this finding?
a. Apnea
b. Bradypnea
c. Tachypnea
d. Within normal limits
____ 16. A patient with pulmonary edema has moist, bubbling lung sounds. How should the nurse describe this finding?
a. Wheezing
b. Fine crackles
c. Coarse crackles
d. Pleural friction rub
____ 17. A patient is making a loud crowing sound caused by an obstruction of the airways by a foreign body. How should the nurse document this patient’s lung sound?
a. Stridor
b. Wheeze
c. Crackles
d. Pleural friction rub
____ 18. The nurse is providing care for a patient diagnosed with asthma. Which adventitious sound should the nurse expect when auscultating this patient’s lung sounds?
a. Crackles
b. Wheezes
c. Pleural friction rub
d. Diminished breath sounds
____ 19. A patient with pneumonia is having difficulty raising secretions for a sputum culture. Which action should the nurse take first?
a. Administer a bronchodilator.
b. Suction the patient to obtain a specimen.
c. Encourage the patient to take deep breaths.
d. Obtain the specimen with a cotton-tipped swab.
____ 20. A laboratory technician has just completed drawing arterial blood gases from a patient. What action should the nurse take first?
a. Increase the patient’s oxygen to 4 L/min.
b. Hold pressure on the puncture site for 5 minutes.
c. Have the patient hold his or her hand in a fist for 2 to 3 minutes.
d. Notify the physician that the blood is in the laboratory for analysis.
____ 21. A patient’s arterial blood gas analysis shows a PaCO2 of 68 mm Hg. What action should the nurse take first?
a. Notify the physician.
b. Remove the patient’s oxygen mask.
c. Have the patient breathe into a paper bag.
d. Place the patient in a left side-lying position.
____ 22. A patient’s arterial blood gas analysis shows a pH of 7.28. The PaCO2 is high. Which acid–base imbalances is the patient experiencing?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
____ 23. A patient’s oxygen saturation value is 92% on room air. What does this value mean to the nurse?
a. The percentage of oxygen in the lungs
b. The partial pressure of the oxygen in the blood
c. The amount of oxygen saturating the lymphocytes
d. The percentage of hemoglobin that is saturated with oxygen
____ 24. A patient’s oxygen saturation is 89%. Which actions should the nurse take first?
a. Raise the head of the patient’s bed.
b. Call the respiratory therapist STAT.
c. Place the patient in a supine position.
d. No action; this is a normal oxygen saturation.
____ 25. A patient returns to the medical unit after a pulmonary angiogram. Which instructions by the nurse would help prevent complications from the test?
a. “Lie flat for 8 hours so the injection site does not bleed.”
b. “Stay in Fowler’s position to help excrete the radioactive gas.”
c. “Try not to cough for 6 hours because this could cause irritation and bleeding.”
d. “Don’t eat or drink anything for 6 hours after the test, because your gag reflex may not be intact.”
____ 26. After a bronchoscopic examination, the patient must remain NPO (nothing by mouth) until the return of the gag reflex. How can the nurse determine when the gag reflex has returned?
a. Ask the patient to swallow.
b. Give the patient a sip of water.
c. Touch the back of the throat with a cotton swab.
d. Touch the roof of the mouth with a gloved finger.
____ 27. The nurse is caring for a patient experiencing dyspnea. What should the nurse instruction the patient to breathe more effectively?
a. “Use deep breathing, and exhale as forcefully as you are able.”
b. “Take four quick, panting breaths, and then blow out for 6 seconds.”
c. “Hold your breath for 3 seconds after each exhalation to empty all the alveoli.”
d. “Breathe using your abdominal muscles, and blow out slowly through pursed lips.”
____ 28. The nurse places a patient who is experiencing dyspnea in the Fowler’s position. What is the rationale for the nurse to use this position?
a. Fowler’s position helps dilate diseased bronchioles.
b. Fowler’s position allows maximum lung expansion.
c. Fowler’s position increases use of accessory muscles.
d. Fowler’s position relieves stress on the back and chest.
____ 29. A patient with cancer in the left lung is acutely short of breath. Which position should the nurse suggest the patient assume?
a. Prone
b. Supine
c. Left side-lying
d. Right side-lying
____ 30. The LPN is assigned to monitor a patient with chronic lung disease who is receiving oxygen via a non-rebreathing mask. Which observation indicates to the nurse that the system is functioning as expected?
a. Both side vents open, reservoir bag inflated
b. Both side vents open, reservoir bag deflated
c. Both side vents closed, reservoir bag inflated
d. Both side vents closed, reservoir bag deflated
____ 31. A patient is being taught to administer nebulized mist treatments (NMTs) at home. Which outcome indicates that the patient is able to administer the treatments?
a. The patient verbalizes all the steps in the NMT procedure correctly.
b. The patient demonstrates the correct procedure for administering the NMT.
c. The patient lists the side effects of the medications that are administered via the NMT.
d. The patient states understanding of the importance of administering the NMTs during periods of shortness of breath.
____ 32. A nurse is providing discharge instructions for a patient who is to use an adrenergic bronchodilator metered dose inhaler (MDI). What should be included in the teaching?
a. “Avoid using the MDI at night.”
b. “Take one puff every 5 minutes until your symptoms are relieved.”
c. “Using the MDI more often than prescribed can result in worsening symptoms.”
d. “Take two puffs whenever you feel wheezy but no more than six puffs per day.”
____ 33. A postoperative patient is taking shallow breaths because of fear of incisional pain. Which action should the nurse take first?
a. Instruct the patient on the use of an incentive spirometer.
b. Measure peak expiratory flow rate with a peak flow meter.
c. Call respiratory therapy to provide a metered-dose inhaler (MDI).
d. Contact the physician to request nebulized mist treatments (NMTs).
____ 34. After providing chest physiotherapy, the nurse notes the patient has loose secretions and a slight rattle with expiration. Which action should the nurse take first?
a. Administer an expectorant.
b. Suction the patient’s airway.
c. Keep the patient on bedrest for 4 hours.
d. Encourage the patient to cough and deep breathe.
____ 35. A patient has a thoracentesis for dyspnea caused by a pleural effusion. The physician obtains 1000 mL of fluid. Which outcome indicates that the thoracentesis has been effective?
a. No bleeding at the site is noted.
b. No cancer cells are found in the fluid.
c. The patient states that the dyspnea has lessened.
d. The fluid is sent to the laboratory in a timely manner.
____ 36. A patient enters the emergency department with a stab wound to the chest. The physician places chest tubes to drain air and blood from the patient’s thoracic cavity. The nurse sets up the chest tube drainage system. Where should the nurse place the system?
a. Below the patient’s chest
b. At the level of the patient’s heart
c. 1 inch higher than the head of the bed
d. At the level of the patient’s diaphragm
____ 37. A patient with a chest drainage system is admitted to the respiratory unit. The nurse notes vigorous bubbling in the water seal chamber of the system. What should the nurse do?
a. Lower the level of suction.
b. Ask the patient to cough forcefully.
c. No action is necessary; this is an expected finding.
d. Examine the entire system and tubing for air leaks.
____ 38. The nurse is examining a chest drainage system on a patient with a pneumothorax and notes the water level in the water seal chamber fluctuating with each of the patient’s respirations. What should the nurse do?
a. Clamp the tubing and call for help.
b. Have the patient take a deep breath.
c. Examine the entire system and tubing for leaks.
d. No action is necessary; this is an expected finding.
____ 39. A patient with a tracheostomy is dyspneic and has coarse crackles anteriorly on auscultation. What should the nurse do first?
a. Suction the tracheostomy.
b. Perform routine tracheostomy care.
c. Administer a prn nebulized mist treatment.
d. Ask the patient to take a deep breath and cough.
____ 40. A patient with a tracheostomy requires suctioning. How many seconds can the nurse suction safely with each pass of the catheter?
a. 3 seconds
b. 15 seconds
c. 30 seconds
d. 60 seconds
____ 41. The nurse is asked to assist with the intubation of a confused patient with respiratory failure. What should the nurse do first?
a. Ask the patient to sign a consent form.
b. Check the patient’s advance directives.
c. Place the patient in a supine position with neck extended.
d. Obtain necessary equipment according to institution policy.
____ 42. The nurse is caring for a patient with myasthenia gravis who is on a ventilator. The high-pressure alarm sounds. What should the nurse consider as the cause for this alarm?
a. The patient is fatigued.
b. The tubing is disconnected.
c. The electricity is interrupted.
d. The patient needs to be suctioned.
____ 43. A patient being mechanically ventilated is prescribed peak end-expiratory pressure (PEEP). How does this setting assist the ventilated patient?
a. It delivers a breath only if the patient does not breathe spontaneously.
b. It provides positive pressure on expiration to keep small airways open.
c. It delivers a breath in a set pattern regardless of the patient’s respiratory pattern.
d. It provides positive pressure on inspiration and expiration to increase oxygenation.
____ 44. The nurse hears a ventilator alarm from the hallway. Which action should the nurse take first?
a. Call for help.
b. Check the patient.
c. Turn off the alarm.
d. Check the ventilator.
____ 45. A patient is prescribed noninvasive positive-pressure ventilation (NIPPV). How can the nurse increase the patient’s comfort when using this ventilation system?
a. Administer opioid analgesics.
b. Remove the unit while the patient is sleeping.
c. Re-tape the tube to the opposite side of the mouth every 24 hours.
d. Use a skin barrier on the area where the mask comes in contact with the skin.
____ 46. A patient’s chest x-ray shows a suspicious area, and the physician plans a bronchoscopy. How should the nurse describe this procedure to the patient?
a. “You will be asked to use a mouthpiece to blow into a machine.”
b. “You will need to drink a thick white liquid that will be opaque on the x-rays.”
c. “A dye will be injected to help visualize the structures of the bronchioles. Do you have any allergies?”
d. “The physician will place a small tube through your nose or mouth and into the bronchi to look at your airways.”
____ 47. A patient is recovering after a bronchoscopy. Which action is a priority for this patient?
a. Encourage oral fluids.
b. Check for swallow and gag reflexes.
c. Monitor the patient for return to consciousness.
d. Order a meal because the patient has been NPO for 8 hours.
____ 48. A patient with ineffective airway clearance is being discharged home. Which home therapy will help the patient loosen and expectorate secretions?
a. Capnography
b. Water-seal chest drainage
c. Transtracheal oxygenation
d. Vibratory positive expiratory pressure device
____ 49. The nurse is reviewing the results of a patient’s pulmonary function studies. Which result indicates the patient’s tidal volume is within normal limits?
a. 100 to 200 mL
b. 400 to 600 mL
c. 800 to 1100 mL
d. 1500 to 2000 mL
____ 50. The nurse documents that a patient’s chest is within normal limits. What does this statement mean?
a. The chest is deeper than it is wide.
b. The chest is equally wide and deep.
c. The chest is twice as wide as it is deep.
d. The chest is greater than 30 inches in diameter.
____ 51. The nurse coaches a patient with chronic obstructive pulmonary disease to make one long “huff” when performing huff coughing. What should the nurse explain as the purpose of the long huff when using this approach to clear the airway?
a. Increases oxygenation
b. Removes excess carbon dioxide
c. Ensures thorough lung expansion
d. Helps to open and clear smaller airways
____ 52. The nurse observes a patient place one hand on the abdomen and the other on the chest as the abdomen is pushed out with each breath. Which breathing technique did the nurse observe the client perform?
a. Huff coughing
b. Pursed-lip breathing
c. Controlled breathing
d. Diaphragmatic breathing
____ 53. The nurse is caring for a patient who has just had a chest tube inserted. What should the nurse ensure is available at the bedside while this chest tube is in place?
a. 2 padded clamps
b. Suture removal set
c. 1 L sterile normal saline
d. Suction catheter and equipment
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 54. The nurse is caring for an individual whose respiratory rate of 14 is even and easy; breath sounds are normal. Which terms should the nurse use in this patient’s narrative note? (Select all that apply.)
a. Apnea
b. Eupnea
c. Rhonchi
d. Bradypnea
e. Clear to auscultation
f. Inspiratory crackles
____ 55. A licensed practical nurse (LPN) is helping prepare a patient for a thoracentesis. What should the nurse include in the teaching? (Select all that apply.)
a. “You will need to be NPO for 6 hours.”
b. “You will need to sign a consent form for the procedure.”
c. “You will assume a sitting position at the side of the bed.”
d. “This is a sterile procedure, so the site will be covered in a drape.”
e. “You will need to take frequent deep breaths during the procedure.”
f. “The doctor will collect fluid from the space between your lung and your chest wall.”
____ 56. The LPN is providing care for an 88-year-old patient. Which age-related assessment findings should the nurse expect? (Select all that apply.)
a. Peripheral cyanosis due to reduced gas exchange
b. Weakened cough due to atrophied respiratory muscles
c. Increased nasal discharge due to increased number of cilia
d. Decreased gas exchange due to decreased number of alveoli
e. Large peak expiratory flow rate due to increased lung elasticity
f. Increased risk of respiratory infection due to decreased ciliary activity
____ 57. The nurse observes a patient us accessory muscles while walking for the first time after hip surgery. Which muscles are commonly used in respiration during exercise or strenuous activity? (Select all that apply.)
a. Scalene
b. Diaphragm
c. Abdominal
d. Vastus lateralis
e. Intercostal muscles
f. Sternocleidomastoid
____ 58. A patient is diagnosed with respiratory acidosis. Which health problems should the nurse consider as causing this patient’s diagnosis? (Select all that apply.)
a. Anxiety
b. Kidney failure
c. Hyperventilation
d. Shallow respirations
e. Chronic lung disease
f. Uncontrolled diabetes
____ 59. The nurse is participating in the planning of care for a patient with a newly placed tracheostomy. Which interventions should the nurse identify as a priority for this patient? (Select all that apply.)
a. Restrict fluids.
b. Turn and reposition every shift.
c. Assess lung sounds every 4 hours.
d. Suction using sterile technique as needed.
e. Perform tracheostomy care according to policy.
____ 60. A client who is being mechanically ventilated is admitted to the care area. What should the nurse do to prevent this patient from developing ventilator-assisted complications? (Select all that apply.)
a. Suction the airway when needed.
b. Ensure adequate nutritional intake.
c. Adjust ventilator alarms to promote rest.
d. Keep the head of the bed at a 45 degree angle.
e. Provide oral care with 0.12% chlorhexidine solution.
Other

61. The nurse is preparing to suction a patient’s tracheostomy Place in order the steps the nurse should take to complete this procedure. All options must be used.
A. ____ Connect oxygen source to manual resuscitation bag.
B. ____ Connect catheter to suction tubing, and turn on suction to level specified by institution policy.
C. ____ Pour saline into sterile container.
D. ____ Suction small amount of saline into catheter.
E. ____ Use thumb to stop suction, and insert catheter through tracheostomy tube until patient coughs or resistance is met.
F. ____ Oxygenate patient with three ventilations using a manual resuscitation bag connected to an oxygen source.
G. ____ Slowly withdraw catheter, suctioning intermittently while rotating it.

Chapter 30. Nursing Care of Patients With Upper Respiratory Tract Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: C
Carbon dioxide is usually the major regulator of respiration because even small changes in its blood level change the pH. A. Fluctuations in oxygen level have no effect on pH, and an adequate oxygen level in the blood can be maintained even if breathing ceases for a few minutes. B. Nitrogen does not control respirations. D. Hemoglobin level affects tissue oxygenation but is not the most important regulator of respiration.

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

2. ANS: D
Functional residual capacity is the air remaining in lungs after normal expiration. C. Forced vital capacity is the maximum amount of air expired forcefully after maximum inspiration. B. Expiratory reserve is the amount of air beyond tidal volume in the most forceful exhalation. A. Tidal volume is the air inspired and expired in one breath.

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

3. ANS: B
Most carbon dioxide is carried in the blood in the form of bicarbonate ions in the plasma. A. C. Hydrogen ions do not transport CO2, and it is not carried in plasma as CO2. D. Hemoglobin carries oxygen.

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

4. ANS: D
Hemoglobin carries oxygen in the blood. B. C. Hemoglobin is in red blood cells, not on cell membranes or in plasma. A. Oxygen is not transported free in plasma.

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

5. ANS: A
The mucosa in the nose and trachea is ciliated epithelium; mucus with trapped dust and microorganisms is swept upward toward the pharynx and is usually swallowed. D. Simple squamous epithelium does not have cilia. B. Alveolar macrophages destroy foreign particles in the alveoli, not the trachea. C. Connective tissue does not fight pathogens.

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

6. ANS: B
Expiratory reserve is the amount of air beyond tidal volume in the most forceful exhalation. C. Forced vital capacity is the maximum amount of air expired forcefully after maximum inspiration. D. Peak expiratory flow rate is the maximum flow rate of air expired during forced vital capacity. A. Tidal volume is the air inspired and expired in one breath.

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

7. ANS: B
Gas exchange occurs in the alveoli. A. C. D. The nasal passages, larynx, and bronchi transport air.

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

8. ANS: A
The respiratory centers are located in the medulla oblongata and pons. B. The cerebrum controls some motor functions, sensation, vision, and conscious thought, among other functions. C. The cerebellum controls movement. D. The hypothalamus controls a variety of functions.

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

9. ANS: C
Dyspnea or shortness of breath is subjective and can best be described using a 0-to-10 scale. A. B. D. Describing it, observing the patient, and respiratory rate all provide good information but do not quantify severity like a rating scale does.

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

10. ANS: B
Use of the sternocleidomastoid (accessory) muscles causes the shoulders to rise during labored inspiration. C. Fatigued muscles would contract less, not more, making the shoulders rise. A. Hyperinflation can occur with respiratory disease but does not cause shoulders to rise. D. Breathing exercises include diaphragmatic and pursed-lip breathing, not raising the shoulders.

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

11. ANS: A
A barrel-shaped chest is associated with air trapping that would be further assessed by the rate and character of the respirations. C. Chest tenderness is not associated with respiratory disease. B. D. Respiratory acidosis and cough are associated with pulmonary disease but do not cause a barreled chest and are not the priority at this time.

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

12. ANS: D
Comparing sounds on each side can help identify normal versus abnormal sounds. A. B. C. Having another nurse or physician listen or questioning the patient are good strategies, but the first step is to listen on both sides to verify differences.

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

13. ANS: D
Asking the patient to breathe deeply through the mouth can help enhance the sounds. Allow the patient to rest at intervals to prevent hyperventilation. A. If this does not work, then trying another stethoscope may be helpful. C. Sitting, not side-lying, best helps the patient to take deep breaths. B. Having the patient rest is helpful if he or she is fatigued or dyspneic but will not make breath sounds easier to hear.

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

14. ANS: C
Fast deep respirations alternated with periods of apnea are Cheyne-Stokes respirations. D. Hyperventilation is deep breathing. B. A. Kussmaul’s are slow and deep, and tachypnea is a rate that is too fast.

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

15. ANS: C
Thirty-six breaths per minute is too fast (normal 12 to 20), which describes tachypnea. B. Bradypnea is slow respirations. A. Apnea is no respirations. D. A normal adult respiratory rate is 12 to 20 breaths per minute.

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

16. ANS: C
Moist bubbling sound heard on inspiration or expiration is described as coarse crackles. B. Fine crackles occur with heart failure or atelectasis and are finer and less bubbly. A. D. Wheezing sounds like violins, and a friction rub sounds like leather rubbing together.

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

17. ANS: A
A loud crowing noise from airway obstruction is called stridor. B. Wheezes are from narrowed airways and are not as loud as stridor. C. Crackles are bubbling noises. D. A friction rub sounds like leather rubbing together.

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

18. ANS: B
Patients with asthma have narrowed airways that cause wheezing. A. D. Diminished breath sounds and crackles are less common with asthma. C. Friction rub is associated with pleurisy.

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

19. ANS: C
Deep breathing can trigger a cough and help raise sputum. A. B. Suctioning and bronchodilators may help but are more invasive and would not be tried first. D. A cotton-tipped swab can obtain a throat culture, not a sputum specimen.

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

20. ANS: B
Pressure must be held for 5 minutes as the pressure in an artery can cause bleeding. A. D. There is no reason to call the physician or increase oxygen. C. Holding a fist may increase bleeding.

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

21. ANS: A
A normal PaCO2 is 35 to 45 mm Hg, so 68 is abnormally high. The physician should be notified. B. C. Removing oxygen or breathing into a paper bag will worsen the PaCO2. D. Fowler’s position, not side-lying, will help ventilation.

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

22. ANS: C
A low pH with a high PaCO2 indicates respiratory acidosis. B. D. Alkalosis is associated with a high pH. A. Metabolic acidosis is associated with a low pH and HCO3.

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

23. ANS: D
Oxygen saturation measures the percentage of hemoglobin that is saturated with oxygen. A. Oxygen saturation does not reflect the percent of oxygen in the lungs. B. The partial pressure of oxygen describes a blood gas, not saturation. C. Oxygen does not saturate lymphocytes.

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

24. ANS: A
89% is low, and the first action is to raise the patient’s head to increase ventilation. This may be enough to raise the saturation. B. The respiratory therapist may be needed, but 89% is usually not an emergency. C. A supine position will worsen breathing. D. This is not a normal oxygen saturation level.

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

25. ANS: A
After angiography, place the patient flat in bed for 3 to 8 hours as ordered by the physician. Monitor vital signs, and observe the injection site for bleeding. A sandbag may be used to place pressure on the site. Encourage fluid intake to promote excretion of the dye. C. D. The gag reflex and gastrointestinal (GI) system are not affected by angiography. B. Fowler’s position may increase risk of bleeding.

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

26. ANS: C
The patient is NPO following bronchoscopy until the gag reflex returns. Check for the gag reflex by touching the pharynx with a cotton swab. A. B. After the gag reflex returns, ask the patient to swallow a sip of water before offering foods or fluids. D. Touching the roof of the mouth with a gloved finger does not assess for the gag reflex.

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

27. ANS: D
Using abdominal and pursed-lip breathing will help the patient calm down and increase carbon dioxide excretion. A, B, and C have not been shown to improve gas exchange.

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

28. ANS: B
Fowler’s or semi-Fowler’s position helps keep abdominal contents from crowding the lungs, allowing maximum lung expansion. C. Accessory muscle use is a sign of respiratory distress. D. Relieving stress on the back and chest does not necessarily improve breathing. A. Fowler’s is not a bronchodilator.

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

29. ANS: D
Patients with unilateral (one-sided) lung disease can benefit from the “good lung down” lateral position. This is a side-lying position with the good lung in the dependent position. Gravity causes greater blood flow to the dependent “good” lung, thereby increasing oxygen saturation. A, B, and C will not increase blood flow to the good lung.

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

30. ANS: C
A nonrebreather mask has one or both side vents closed to limit the mixing of room air with oxygen. The vents open to allow expiration but remain closed on inspiration. The reservoir bag has a valve to store oxygen for inspiration but does not allow entry of exhaled air. It is used to deliver oxygen concentrations of 70% to 100%. A. B. D. When a patient is using a partial rebreather or nonrebreather mask, ensure that the reservoir is never allowed to collapse to less than half full.

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

31. ANS: B
Demonstration is the best way for the nurse to know that the patient can administer the treatment. A/ C/ D. Verbalizing or stating the information is not strong evidence that the patient can do it correctly.

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

32. ANS: C
Adrenergic bronchodilators, when used too often, can cause severe rebound bronchoconstriction and even death. B. D. Using as needed may be too frequent, and every 5 minutes is not appropriate. A. MDIs are used at night to prevent nighttime symptoms.

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

33. ANS: A
Incentive spirometers are devices used to encourage deep breathing in patients at risk for collapse of lung tissue, a condition called atelectasis. These devices are commonly ordered for postoperative patients. Pain control is also essential for this patient. C. D. NMTs and MDIs are usually used for bronchodilator therapy, not to encourage deep breathing. B. A peak flow meter measures peak expiratory flow rate in asthmatic patients.

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

34. ANS: D
Chest physiotherapy loosens secretions. Having the patient cough and deep breathe can bring them up and out. A. An expectorant might be helpful but would not be the first action. B. Suction is only done if coughing is ineffective. C. It is not necessary to keep the patient on bedrest.

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

35. ANS: C
Pleural fluid can crowd the lungs and make breathing difficult. Removal of the fluid often results in relief of dyspnea. A. B. D. Timely delivery of the specimen, bleeding at the site, and laboratory results are all important but do not measure the effectiveness of the procedure.

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

36. ANS: A
The drainage system must always be kept upright and below the level of the chest to prevent drainage from returning to the chest. B. C. D. These are incorrect locations to place the chest drainage system.

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

37. ANS: D
Vigorous bubbling in the water seal chamber indicates an air leak. A. Lowering the suction level will help if vigorous bubbling is seen in the suction control chamber. B. Coughing forcefully can help mobilize clots. C. Doing nothing is inappropriate.

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

38. ANS: D
Tidaling is an expected finding. A. C. Tubing is sometimes clamped to find an air leak—vigorous bubbling, not tidaling, would signify an air leak. B. Having the patient take a deep breath can worsen the pneumothorax if a leak is present.

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

39. ANS: D
Often, coughing will help clear the airway and relieve dyspnea quickly, and it is noninvasive. A, B, C, can be attempted if coughing does not eliminate the course crackles.

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

40. ANS: B
The nurse can safely suction the patient for 15 seconds. C. D. More than 15 seconds can irritate mucosa and suction out too much oxygen. A. 3 seconds may not provide enough suction to remove secretions.

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

41. ANS: B
Many patients do not wish to be intubated, so checking advance directives is essential. C. D. Once it is confirmed that the patient will accept intubation, the nurse can assist with the procedure. A. Having a confused patient sign a consent form is not appropriate—the patient’s next-of-kin or power of attorney would have to sign.

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

42. ANS: D
High-pressure alarms sound for higher-than-normal resistance to air flow. This might occur if the patient needs to be suctioned; if the patient is biting on the tube, coughing, or trying to talk; if tubing is kinked or otherwise obstructed; or if worsening respiratory disease causes decreased lung compliance. B. Disconnected tubing causes a low-pressure alarm. C. Loss of power causes its own alarm. A. Fatigue should not cause an alarm.

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

43. ANS: B
PEEP provides positive pressure on expiration to help keep small airways open. D. It does not provide pressure on inspiration. A and C refer to respiratory patterns, not pressure.

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

44. ANS: B
Always check the patient first—in case the patient needs support while the ventilator is being checked. C. D. Once it is assured that the patient is safe, the machine can be checked. A. The nurse would need to check the patient and ventilator before calling for help.

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

45. ANS: D
Skin irritation can occur from the NIPPV mask; an adhesive skin barrier to the areas that come in contact with the mask can help prevent irritation. C. An endotracheal (ET) tube is in the mouth, not NIPPV. B. The unit should not be removed during sleeping—the patient may hypoventilate. A. Opioids can depress respirations and are used for severe pain, not skin irritation.

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

46. ANS: D
A bronchoscopy involves an endoscope through the nose or mouth to view the airways. A. Blowing into a machine occurs with pulmonary function studies. B. C. Thick, white liquids may be involved in gastrointestinal x-rays, and dyes may be used in some x-rays.

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

47. ANS: B
The throat is anesthetized during a bronchoscopy, so it is essential to check for swallow and gag reflexes before offering fluids or a meal. C. The patient may be given some sedation but is not usually put to sleep for the procedure. A. D. Fluids and food can be provided once the gag reflex returns.

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

48. ANS: D
An alternative to chest physiotherapy for promoting airway clearance is a small hand-held device called a vibratory positive expiratory pressure (PEP) device. It has a heavy steel ball that bounces and causes vibrations in the chest when the patient blows into it. A. Capnography measures exhaled carbon dioxide and is not therapeutic. B. C. Water-seal chest drainage is used for pneumothorax, and transtracheal oxygen is an oxygen delivery system.

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

49. ANS: B
A normal tidal volume is 400 to 600 mL at rest. A. This is an extremely low tidal volume which might not be compatible with life. C. D. These values are extremely high and should be questioned for potential errors.

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

50. ANS: C
Normally the chest is about twice as wide (side to side) as it is deep (front to back). A. The chest is not normally deeper than it is wide. B. The chest that is equally wide and deep is in the shape of a barrel. D. A chest that is greater than 30 inches in diameter does not provide enough information about the overall shape of the chest.

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

51. ANS: D
A short “huff” helps clear larger airways, while a longer “huff” held out for several seconds helps open and clear smaller airways. A. B. C. A shorter “huff” is not used to increase oxygenation, remove excess carbon dioxide, or ensure thorough lung expansion.

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

52. ANS: D
Diaphragmatic breathing is performed by placing one hand on the abdomen and the other on the chest. The abdomen is pushed during inspiration and relaxed on expiration. A. Huff coughing is a technique used to raise secretions from the respiratory passageways. B. Pursed-lip breathing is performed by inhaling slowly through the nose and exhaling through pursed lips. C. All breathing techniques might be referred to as being “controlled” however this is not a specific controlled breathing technique.

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

53. ANS: A
Two padded clamps are to be kept at the bedside. These are used for clamping the chest tube if the chest drainage system becomes accidentally disconnected from the tubing, for changing the drainage system, or for a trial period before chest tube removal. B. C. D. A suture removal set, normal saline, and suction equipment do not need to be kept at the bedside of a patient with a chest tube.

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

MULTIPLE RESPONSE

54. ANS: B, E
Normal breathing is eupnea. Normal breath sounds are clear to auscultation. A. Apnea is no breathing. F. Inspiratory crackles indicate fluid in the airways. D. Bradypnea is slow breathing. C. Rhonchi are heard with bronchoconstriction.

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

55. ANS: B, C, D, F
Thoracentesis is a sterile procedure done at the bedside, in which the physician uses a needle to withdraw and collect fluid from the potential space between the lung and the chest wall. The procedure is usually done with the patient in a sitting position. Consent is required because it is invasive. A. NPO status is not necessary for thoracentesis as patients only receive a local anesthetic. E. The patient will be asked to take a deep breath and hold it while the needle is being inserted—frequent deep breaths are not used.

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

56. ANS: B, D, F
Normal aging processes include weakened and atrophied respiratory muscles leading to a decreased cough reflex, reduced elasticity of the lung tissue, deteriorating cilia that increase risk of respiratory infection, decreased cough reflex, reduced efficacy of alveolar macrophages, which all lead to increased risk of respiratory infection, and reduced number of alveoli which decreased gas exchange. A. Cyanosis is not an expected finding. C. The number of cilia do not affect a nasal discharge. E. Peak expiratory flow rate will be decreased.

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

57. ANS: A, B, C, E, F
Accessory muscles of respiration are used during exercise and times of respiratory distress; these include the sternocleidomastoid and scalene muscles and abdominal musculature. The diaphragm and intercostal muscles are used in normal respiration and during activity. D. The vastus lateralis is in the leg.

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

58. ANS: D, E
Chronic lung disease and shallow respirations both are associated with hypoventilation, which causes respiratory acidosis. A. C. Anxiety and hyperventilation are associated with respiratory alkalosis. F. Diabetes is associated with metabolic acidosis. B. Kidney failure is associated with metabolic acidosis.

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

59. ANS: C, D, E
When caring for a patient with a tracheostomy, lung sounds should be assessed every 4 hours, suctioning should be performed as needed using sterile technique, and tracheostomy care should be performed according to agency policy. A. Fluids should be encouraged to thin secretions. B. The patient should be turned and repositioned every 2 hours to prevent pooling of respiratory secretions.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

60. ANS: A, B, D, E
Good nursing care is essential for preventing ventilator-associated complications and is accomplished by suctioning the airway when needed, ensuring adequate nutritional intake, keeping the head of the bed at a 45-degree angle to reduce the risk of aspiration, and providing oral care with 0.12% chlorhexidine solution. C. Ventilator alarms should be set to the appropriate level to alert the nurse of any potential respiratory problems.

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

OTHER

61. ANS:
B, A, C, D, F, E, G
B. Connect catheter to suction tubing, keeping catheter inside sterile sleeve. Turn on suction to level specified by institution policy (usually 80 to 120 mm Hg for wall suction). A. Connect oxygen source to manual resuscitation bag. C. Pour saline into sterile container. D. Suction small amount of saline into catheter. F. Oxygenate patient with three ventilations using a manual resuscitation bag connected to an oxygen source, using the nonsterile hand. If the patient is mechanically ventilated, use manual sigh. E. With thumb control uncovered to stop suction, insert suction catheter through tracheostomy tube until patient coughs or resistance is met. G. Slowly withdraw catheter, suctioning intermittently while rotating it. The entire procedure should take no more than 15 seconds. Allow patient to rest.

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