Deck 30: Acute Respiratory Disorders

Question 1

The assessment that ensures the nurse that the chest tube in a water seal drainage device is working correctly is the:

A) Constant bubbling in the suction control chamber
B) Decrease of accumulation in the drainage chamber
C) Fluctuation of the column of water in the water seal
D) Constant bubbling in the water seal chamber

Answer 1

Fluctuation of the column of water in the water seal

Question 2

If the nurse can hear coarse crackles in the lower right lobe,then the nurse would assess that the bronchus is:

A) Partially filled with fluid
B) Narrowed by spasm
C) Partially filled with thick mucus
D) Completely obstructed

Answer 2

Partially filled with fluid

Question 3

A patient who is severely dyspneic and cyanotic enters the emergency department.The nurse gives the patient oxygen at:

A) 2 L to preserve the hypoxic drive
B) 6 L to relieve the dyspnea
C) 8 L, humidified, to liquefy secretions
D) 10 L, humidified aerosol, to dilate the bronchi

Answer 3

2 L to preserve the hypoxic drive

Question 4

A worried patient asks the nurse to explain the advantage of a fluoroscopy.The best response would be that a fluoroscopy:

A) Shows respiratory function in motion.
B) Helps the physician evaluate ventilation-perfusion ratio.
C) Allows the physician to take tissue samples.
D) Facilitates the removal of fluid from the bronchi.

Question 5

The nurse charts that the patient has had periods of tachypnea during the night.This means that the respiration rate was:

A) Below 12 breaths/min
B) Uneven, with periods of apnea
C) Gradually deepening, then shallow, and then periods of apnea
D) Above 20 breaths/min

Question 6

Before performing the arterial stick for an arterial blood gas,the nurse performs an Allen test.The purpose of this test is to assess the:

A) Respiratory function
B) Tidal volume
C) Concentration of oxygen
D) Perfusion of the hand

Question 7

A home health nurse who is caring for an 88-year-old patient with severe hypertension in addition to a respiratory problem notices several drugs on the bedside table.The medication that the nurse would suggest the patient should avoid is:

A) Aspirin
B) Antitussive
C) Expectorant
D) Decongestant

Question 8

The nurse would advise which one of the following groups to have a vaccination with conjugated pneumococcal?

A) Adults with diabetes
B) Persons 65 years and older
C) Children younger than 24 months
D) Persons with cardiovascular disorders

Question 9

A patient asks the nurse about how air goes from the nose to the lung.The nurse draws the route according to which sequence?

A) Trachea, larynx, bronchi
B) Pharynx, trachea, bronchi, alveoli
C) Bronchi, trachea, bronchioles
D) Larynx, trachea, alveoli, bronchi

Question 10

A patient with acute bronchitis is being discharged with a prescription for an antimicrobial medication to be taken for the next 14 days.In the discharge teaching,the nurse will stress:

A) Take the drug on an empty stomach before meals.
B) Complete the entire course as prescribed.
C) Maintain a thorough oral hygiene regimen.
D) Maintain a daily fluid intake of 500 ml.

Question 11

To enhance gas exchange,the nurse would position a patient who had a left pneumonectomy in the morning:

A) On the right side
B) On the left side
C) In a semi-Fowler position
D) In a flat position with a small pillow

Question 12

The assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage device would require intervention that would:

A) Ensure no dependent loops in the chest tube.
B) Place the patient in a semi-Fowler position.
C) Change the level of water in the water seal chamber.
D) Increase the level of drainage to 20 ml in 8 hours.

Question 13

To auscultate breath sounds in the right middle lobe from the anterior aspect,the nurse would place the diaphragm of the stethoscope at which intercostal space?

A) Second
B) Third
C) Fourth
D) Fifth

Question 14

A 90-year-old patient complains to the nurse of shortness of breath after walking up a flight of stairs.The nurse explains that this problem is a result of age-related changes,such as a(n):

A) Flexible rib cage
B) High-arched diaphragm
C) Increased chest movement
D) Enlarged bronchioles

Question 15

The nurse closely monitors bilateral breath sounds and chest movement after a thoracentesis because:

A) Fluid may quickly accumulate as a result of inflammation.
B) The lung may have been punctured during the procedure.
C) Severe bronchospasm may cause atelectasis.
D) Asthma may result after the procedure.

Question 16

When documenting the findings in the functional assessment portion of the nursing assessment for a patient with a respiratory disorder,the nurse would exclude:

A) Occupation
B) Usual diet
C) Smoking history
D) Previous respiratory disorders

Question 17

The discharge planning for a patient with sleep apnea includes a continuous positive airway pressure (CPAP)ventilation device that:

A) Delivers 100% oxygen during apneic periods.
B) Delivers oxygen per aerosol to dilate the alveoli.
C) Activates a burst of pressure if the patient's respiration drops below a preset rate.
D) Maintains a continuous pressure in the airway to avoid apnea.

Question 18

The nursing intervention that would be inappropriate in the immediate postprocedure care of a patient who has had a fiber-optic bronchoscopy would be to:

A) Place the patient in a semi-Fowler position.
B) Offer fluids to assess swallowing ability.
C) Assess for diminished breath sounds.
D) Assess for stridor.

Question 19

Which one of these interventions would be inappropriate in performing a tracheal suction?

A) Administer oxygen before the procedure.
B) Leave the thumb off the suction control on insertion.
C) Maintain suction pressure between 80 and 100 mm Hg.
D) Limit suction pass to 15 seconds.

Question 20

The nurse will record a positive reading of a tuberculin (TB)skin test when it is assessed:

A) 1 day after injection with a 10-mm area of redness and swelling
B) 2 days after injection with a 5-mm area of redness and swelling
C) 4 days after injection with a 3-mm area of redness and swelling
D) 5 days after injection with a 2-mm area of redness and swelling

Question 21

During the physical examination of a patient with respiratory difficulty,the nurse notices other clues to respiratory dysfunction that are: (Select all that apply.)

A) Flushed facial skin
B) Cyanotic nail beds
C) Abdomen distention
D) Curved spine
E) Clubbed fingers

Question 22

When the nurse observes the paradoxical movement in a patient with a flail chest who has significant dyspnea,the nurse should prepare for a(n):

A) Thoracotomy
B) Intubation
C) Thoracentesis
D) Body cast

Question 23

A patient comes to the emergency department with a sucking chest wound.Which one of the following types of dressing should the nurse apply to begin the process of lung reinflation?

A) Petroleum dressing covered with an airtight bandage
B) No dressing at all
C) Pillow weighted down with a sandbag
D) Air-occlusive dressing taped on three sides (vented dressing)

Question 24

The intervention that would be inappropriate for decreasing the risk of further emboli in a patient with a pulmonary embolism is:

A) Carefully applying compression stockings.
B) Performing passive range-of-motion exercises, especially the lower limbs.
C) Placing pillows under the knees to elevate the legs.
D) Ambulating frequently.

Question 25

When a patient complains of tachypnea,the nurse explains that the breathing pattern has altered because the: (Select all that apply.)

A) Increased pH levels stimulate chemoreceptors in the aorta and carotid arteries, which stimulates the phrenic nerve.
B) Decreased oxygen level signals the phrenic nerve to alter the respiration rate.
C) Muscles of respiration respond to the stimulus.
D) Brain has become hypoxic and causes an alteration in the respiration rate.
E) Deflated lung tissue results in an altered respiration rate.

Question 26

The nurse computes the number of "pack years" of a 24-year-old man who has smoked packs of cigarettes every day since he was 15 years old.This patient has ______ pack years.

Question 27

To reduce the risk of aspiration in a patient who is receiving continuous enteral feedings running at 70 ml/hr,the nurse should:

A) Check the position of the tube during every shift.
B) Notify the charge nurse or physician about a residual volume of 20 ml.
C) Elevate the patient's head during and for 10 minutes after feeding.
D) Position the patient on the left side after the feeding.

Question 28

After a thoracentesis has been performed,the nurse will position the patient:

A) On the unaffected side to help drain the affected side
B) In high Fowler position to help with dyspnea
C) Supine to decrease fluid accumulation
D) On the affected side to compress the puncture site

Question 29

Assessment of 24-year-old driver after an automobile accident,who is complaining of right-sided chest pain and is dyspneic,reveals the following:
Respirations: 26 breaths/min
Significant pain on inspiration
Hand is pressed to the rib area; large bruise is forming on the right chest
Blood pressure: 182/98 mm Hg
Based on these assessments,the nurse suspects ____________________.

Question 30

The nurse explains that the ventilator function of positive end-expiratory pressure assists the patient by:

A) Keeping pressure in the lungs after expiration.
B) Delivering 100 % oxygen on inspiration.
C) Allowing the patient to control expiratory pressure.
D) Delivering an inhalant medication under positive pressure.

Question 31

The nurse who is instructing a patient in deep breathing and coughing techniques directs the patient to: (Place the options in the appropriate sequence.)

A) Place the hand on the abdomen to check the rise and fall.
B) Inhale through the nose, pause 1 to 3 seconds, and then exhale.
C) Assume a high Fowler position.
D) Take 4 to 6 deep breaths.
E) Cough deeply.

Question 32

Just before the scheduled spirometry test,the nurse instructs a patient to: (Select all that apply.)

A) Avoid smoking.
B) Use the bronchodilator inhaler.
C) Exercise for a few minutes.
D) Drink two glasses of fluid.
E) Avoid eating.

Question 33

The symptoms of hypoxemia for which the nurse should be alert are:

A) Restlessness, tachycardia, and tachypnea
B) Bradycardia, cyanosis, and restlessness
C) Dyspnea, flushed face, and tachycardia
D) Cyanosis, nausea, and bradycardia