test p0st r n bscn

time 60
minuts

1. Dr. Jones prescribes albuterol sulfate (Proventil) for a

patient with newly diagnose asthma. When teaching the
patient about this drug, the nurse should explain that it
may cause:

A. Nasal congestion
B. Nervousness
C. Lethargy
D. Hyperkalemia

2. Miriam, a college student with acute rhinitis sees the

campus nurse because of excessive nasal drainage. The
nurse asks the patient about the color of the drainage. In
acute rhinitis, nasal drainage normally is:

A. Yellow
B. Green
C. Clear
D. Gray

3. A male adult patient hospitalized for treatment of

a pulmonary embolism develops respiratory alkalosis.
Which clinical findings commonly accompany respiratory
alkalosis?

A. Nausea or vomiting
B. Abdominal pain or diarrhea
C. Hallucinations or tinnitus
D. Lightheadedness or paresthesia

4. Before administering ephedrine, Nurse Tony assesses

the patient’s history. Because of ephedrine’s
central nervous system (CNS) effects, it is not
recommended for:

A. Patients with an acute asthma attack

B. Patients with narcolepsy
C. Patients under age 6
D. Elderly patients

5. A female patient suffers adult respiratory distress

syndrome as a consequence of shock. The patient’s
condition deteriorates rapidly, and endotracheal
intubation and mechanical ventilation are initiated. When
the high-pressure alarm on the mechanical ventilator,
alarm sounds, the nurse starts to check for the cause.
Which condition triggers the high-pressure alarm?
A. Kinking of the ventilator tubing
B. A disconnected ventilator tube
C. An endotracheal cuff leak
D. A change in the oxygen concentration without resetting the
oxygen level alarm

6. A male adult patient on mechanical ventilation is

receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V.
as needed. Which assessment finding indicates that the
patient needs another pancuronium dose?

A. Leg movement
B. Finger movement
C. Lip movement
D. Fighting the ventilator

7. On auscultation, which finding suggests a

right pneumothorax?

A. Bilateral inspiratory and expiratory crackles

B. Absence of breaths sound in the right thorax
C. Inspiratory wheezes in the right thorax
D. Bilateral pleural friction rub.
8. Rhea, confused and short breath, is brought to the
emergency department by a family member. The medical
history reveals chronic bronchitis and hypertension. To
learn more about the current respiratory problem, the
doctor orders a chest x-ray and arterial blood gas (ABG)
analysis. When reviewing the ABG report, the nurses sees
many abbreviations. What does a lowercase “a” in ABG
value present?

A. Acid-base balance
B. Arterial Blood
C. Arterial oxygen saturation
D. Alveoli

9. A male patient is admitted to the healthcare facility for

treatment of chronic obstructive pulmonary disease.
Which nursing diagnosis is most important for this
patient?

A. Activity intolerance related to fatigue

B. Anxiety related to actual threat to health status
C. Risk for infection related to retained secretions
D. Impaired gas exchange related to airflow obstruction
10. Nurse Ruth assessing a patient for
tracheal displacement should know that the trachea will
deviate toward the:

A. Contralateral side in a simple pneumothorax

B. Affected side in a hemothorax
C. Affected side in a tension pneumothorax
D. Contralateral side in hemothorax

11. After undergoing a left pneumonectomy, a female

patient has a chest tube in place for drainage. When
caring for this patient, the nurse must:

A. Monitor fluctuations in the water-seal chamber

B. Clamp the chest tube once every shift
C. Encourage coughing and deep breathing
D. Milk the chest tube every 2 hours

12. When caring for a male patient who has just had a
total laryngectomy, the nurse should plan to:

A. Encourage oral feeding as soon as possible

B. Develop an alternative communication method
C. Keep the tracheostomy cuff fully inflated
D. Keep the patient flat in bed
13. A male patient has a sucking stab wound to the chest.
Which action should the nurse take first?

A. Drawing blood for a hematocrit and hemoglobin level

B. Applying a dressing over the wound and taping it on three
sides
C. Preparing a chest tube insertion tray
D. Preparing to start an I.V. line

14. For a patient with advanced chronic obstructive

pulmonary disease (COPD), which nursing action best
promotes adequate gas exchange?

A. Encouraging the patient to drink three glasses of fluid daily

B. Keeping the patient in semi-Fowler’s position
C. Using a high-flow venture mask to deliver oxygen as
prescribe
D. Administering a sedative, as prescribe

15. A male patient’s X-ray result reveals bilateral white-

outs, indicating adult respiratory distress syndrome
(ARDS). This syndrome results from:

A. Cardiogenic pulmonary edema
B. Respiratory alkalosis
C. Increased pulmonary capillary permeability
D. Renal failure

16. For a female patient with chronic obstructive

pulmonary disease, which nursing intervention would
help maintain a patent airway?

A. Restricting fluid intake to 1,000 ml per day

B. Enforcing absolute bed rest
C. Teaching the patient how to perform controlled coughing
D. Administering prescribe sedatives regularly and in large
amounts

17. Nurse Lei caring for a client with a pneumothorax and

who has had a chest tube inserted notes continues gentle
bubbling in the suction control chamber. What action is
appropriate?

A. Do nothing, because this is an expected finding

B. Immediately clamp the chest tube and notify the physician
C. Check for an air leak because the bubbling should be
intermittent
D. Increase the suction pressure so that the bubbling becomes
vigorous
18. Nurse Maureen has assisted a physician with the
insertion of a chest tube. The nurse monitors the client
and notes fluctuation of the fluid level in the water seal
chamber after the tube is inserted. Based on this
assessment, which action would be appropriate?

A. Inform the physician

B. Continue to monitor the client
C. Reinforce the occlusive dressing
D. Encourage the client to deep breathe

19. Nurse Reynolds caring for a client with a chest tube

turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action is to:

A. Call the physician

B. Place the tube in bottle of sterile water
C. Immediately replace the chest tube system
D. Place a sterile dressing over the disconnection site

20. A nurse is assisting a physician with the removal of a

chest tube. The nurse should instruct the client to:

A. Exhale slowly
B. Stay very still
C. Inhale and exhale quickly
D. Perform the Valsalva maneuver

21. While changing the tapes on a tracheostomy tube, the

male client coughs and tube is dislodged. The initial
nursing action is to:

A. Call the physician to reinsert the tube

B. Grasp the retention sutures to spread the opening
C. Call the respiratory therapy department to reinsert the
tracheotomy
D. Cover the tracheostomy site with a sterile dressing to
prevent infection

22. Nurse Oliver is caring for a client immediately after

removal of the endotracheal tube. The nurse reports
which of the following signs immediately if experienced by
the client?

A. Stridor
B. Occasional pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate 24 breaths/min
23. An emergency room nurse is assessing a male client
who has sustained a blunt injury to the chest wall. Which
of these signs would indicate the presence of a
pneumothorax in this client?

A. A low respiratory rate

B. Diminished breath sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury

24. Nurse Reese is caring for a client hospitalized with

acute exacerbation of chronic obstructive pulmonary
disease. Which of the following would the nurse expect to
note on assessment of this client?

A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increased oxygen saturation with exercise
D. A widened diaphragm noted on the chest x-ray

25. An oxygen delivery system is prescribed for a male

client with chronic obstructive pulmonary disease to
deliver a precise oxygen concentration. Which of the
following types of oxygen delivery systems would the
nurse anticipate to be prescribed?
A. Face tent
B. Venturi mask
C. Aerosol mask
D. Tracheostomy collar

26. Blessy, a community health nurse is conducting an

educational session with community members
regarding tuberculosis. The nurse tells the group that one
of the first symptoms associated with tuberculosis is:

A. Dyspnea
B. Chest pain
C. A bloody, productive cough
D. A cough with the expectoration of mucoid sputum

27. A nurse performs an admission assessment on a

female client with a diagnosis of tuberculosis. The nurse
reviews the result of which diagnosis test that will
confirm this diagnosis?

A. Bronchoscopy
B. Sputum culture
C. Chest x-ray
D. Tuberculin skin test
28. A nurse is caring for a male client with emphysema
who is receiving oxygen. The nurse assesses the oxygen
flow rate to ensure that it does not exceed:

A. 1 L/min
B. 2 L/min
C. 6 L/min
D. 10 L/min

29. A nurse instructs a female client to use the pursed-lip

method of breathing and the client asks the nurse about
the purpose of this type of breathing. The nurse responds,
knowing that the primary purpose of pursed-lip breathing
is to:

A. Promote oxygen intake

B. Strengthen the diaphragm
C. Strengthen the intercostal muscles
D. Promote carbon dioxide elimination

30. A nurse is caring for a male client with acute

respiratory distress syndrome. Which of the following
would the nurse expect to note in the client?
A. Pallor
B. Low arterial PaO2
C. Elevated arterial PaO2
D. Decreased respiratory rate

31. A nurse is preparing to obtain a sputum specimen

from a male client. Which of the following nursing actions
will facilitate obtaining the specimen?

A. Limiting fluid
B. Having the client take deep breaths
C. Asking the client to spit into the collection container
D. Asking the client to obtain the specimen after eating

32. Nurse Joy is caring for a client after a bronchoscopy

and biopsy. Which of the following signs, if noticed in the
client, should be reported immediately to the physician?

A. Dry cough
B. Hematuria
C. Bronchospasm
D. Blood-streaked sputum
33. A nurse is suctioning fluids from a male client via a
tracheostomy tube. When suctioning, the nurse must limit
the suctioning time to a maximum of:

A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds

34. A nurse is suctioning fluids from a female client

through an endotracheal tube. During the suctioning
procedure, the nurse notes on the monitor that the heart
rate is decreasing. Which if the following is the
appropriate nursing intervention?

A. Continue to suction
B. Notify the physician immediately
C. Stop the procedure and reoxygenate the client
D. Ensure that the suction is limited to 15 seconds

35. A male adult client is suspected of having a

pulmonary embolus. A nurse assesses the client, knowing
that which of the following is a common clinical
manifestation of pulmonary embolism?
A. Dyspnea
B. Bradypnea
C. Bradycardia
D. Decreased respirations

36. A slightly obese female client with a history of allergy-

induced asthma, hypertension, and mitral valve prolapse
is admitted to an acute care facility for elective surgery.
The nurse obtains a complete history and performs a
thorough physical examination, paying special attention
to the cardiovascular and respiratory systems. When
percussing the client’s chest wall, the nurse expects to
elicit:

A. Resonant sounds.
B. Hyperresonant sounds.
C. Dull sounds.
D. Flat sounds.

37. A male client who weighs 175 lb (79.4 kg) is receiving

aminophylline (Aminophyllin) (400 mg in 500 ml) at 50
ml/hour. The theophylline level is reported as 6 mcg/ml.
The nurse calls the physician who instructs the nurse to
change the dosage to 0.45 mg/kg/hour. The nurse should:
A. Question the order because it’s too low.
B. Question the order because it’s too high.
C. Set the pump at 45 ml/hour.
D. Stop the infusion and have the laboratory repeat the
theophylline measurement.

38. The nurse is teaching a male client with chronic

bronchitis about breathing exercises. Which of the
following should the nurse include in the teaching?

A. Make inhalation longer than exhalation.

B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.

39. Which phrase is used to describe the volume of air

inspired and expired with a normal breath?

A. Total lung capacity

B. Forced vital capacity
C. Tidal volume
D. Residual volume

40. A male client abruptly sits up in bed, reports having

difficulty breathing and has an arterial oxygen saturation
of 88%. Which mode of oxygen delivery would most likely
reverse the manifestations?

A. Simple mask
B. Non-rebreather mask
C. Face tent
D. Nasal cannula

41. A female client must take streptomycin for

tuberculosis. Before therapy begins, the nurse should
instruct the client to notify the physician if which health
concern occurs?

A. Impaired color discrimination
B. Increased urinary frequency
C. Decreased hearing acuity
D. Increased appetite

42. A male client is asking the nurse a question regarding

the Mantoux test for tuberculosis. The nurse should base
her response on the fact that the:

A. Area of redness is measured in 3 days and determines

whether tuberculosis is present.
B. Skin test doesn’t differentiate between active and dormant
tuberculosis infection.
C. Presence of a wheal at the injection site in 2 days indicates
active tuberculosis.
D. Test stimulates a reddened response in some clients and
requires a second test in 3 months.

43. A female adult client has a tracheostomy but doesn’t

require continuous mechanical ventilation. When weaning
the client from the tracheostomy tube, the nurse initially
should plug the opening in the tube for:

A. 15 to 60 seconds.
B. 5 to 20 minutes.
C. 30 to 40 minutes.
D. 45 to 60 minutes.

44. Nurse Oliver observes constant bubbling in the water-

seal chamber of a closed chest drainage system. What
should the nurse conclude?

A. The system is functioning normally

B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed.
45. A black client with asthma seeks emergency care for
acute respiratory distress. Because of this client’s dark
skin, the nurse should assess for cyanosis by inspecting
the:

A. Lips.
B. Mucous membranes.
C. Nail beds.
D. Earlobes.

46. For a male client with an endotracheal (ET) tube, which

nursing action is most essential?

A. Auscultating the lungs for bilateral breath sounds

B. Turning the client from side to side every 2 hours
C. Monitoring serial blood gas values every 4 hours
D. Providing frequent oral hygiene

47. The nurse assesses a male client’s respiratory status.

Which observation indicates that the client is
experiencing difficulty breathing?

A. Diaphragmatic breathing
B. Use of accessory muscles
C. Pursed-lip breathing
D. Controlled breathing

48. A female client is undergoing a complete physical

examination as a requirement for college. When checking
the client’s respiratory status, the nurse observes
respiratory excursion to help assess:

A. Lung vibrations.
B. Vocal sounds.
C. Breath sounds.
D. Chest movements.

49. A male client comes to the emergency department

complaining of sudden onset of diarrhea, anorexia,
malaise, cough, headache, and recurrent chills. Based on
the client’s history and physical findings, the physician
suspects legionnaires’ disease. While awaiting diagnostic
test results, the client is admitted to the facility and
started on antibiotic therapy. What is the drug of choice
for treating legionnaires’ disease?

A. Erythromycin (Erythrocin)
B. Rifampin (Rifadin)
C. Amantadine (Symmetrel)
D. Amphotericin B (Fungizone)

50. A male client with chronic obstructive pulmonary

disease (COPD) is recovering from a myocardial infarction.
Because the client is extremely weak and can’t produce an
effective cough, the nurse should monitor closely for:

A. Pleural effusion.
B. Pulmonary edema.
C. Atelectasis.
D. Oxygen toxicity.

51. The nurse in charge is teaching a client with

emphysema how to perform pursed-lip breathing. The
client asks the nurse to explain the purpose of this
breathing technique. Which explanation should the nurse
provide?

A. It helps prevent early airway collapse.

B. It increases inspiratory muscle strength.
C. It decreases use of accessory breathing muscles.
D. It prolongs the inspiratory phase of respiration.
52. After receiving an oral dose of codeine for an
intractable cough, the male client asks the nurse, “How
long will it take for this drug to work?” How should the
nurse respond?

A. In 30 minutes
B. In 1 hour
C. In 2.5 hours
D. In 4 hours

53. A male client suffers adult respiratory distress

syndrome as a consequence of shock. The client’s
condition deteriorates rapidly, and endotracheal (ET)
intubation and mechanical ventilation are initiated. When
the high-pressure alarm on the mechanical ventilator
sounds, the nurse starts to check for the cause. Which
condition triggers the high-pressure alarm?

A. Kinking of the ventilator tubing

B. A disconnected ventilator tube
C. An ET cuff leak
D. A change in the oxygen concentration without resetting the
oxygen level alarm
54. A female client with chronic obstructive pulmonary
disease (COPD) takes anhydrous theophylline, 200 mg P.O.
every 8 hours. During a routine clinic visit, the client asks
the nurse how the drug works. What is the mechanism of
action of anhydrous theophylline in treating a
nonreversible obstructive airway disease such as COPD?

A. It makes the central respiratory center more sensitive to

carbon dioxide and stimulates the respiratory drive.
B. It inhibits the enzyme phosphodiesterase, decreasing
degradation of cyclic adenosine monophosphate, a
bronchodilator.
C. It stimulates adenosine receptors, causing bronchodilation.
D. It alters diaphragm movement, increasing chest expansion
and enhancing the lung’s capacity for gas exchange.

55. A male client with pneumococcal pneumonia is

admitted to an acute care facility. The client in the next
room is being treated for mycoplasmal pneumonia.
Despite the different causes of the various types of
pneumonia, all of them share which feature?

A. Inflamed lung tissue

B. Sudden onset
C. Responsiveness to penicillin.
D. Elevated white blood cell (WBC) count

56. A client with Guillain-Barré syndrome develops

respiratory acidosis as a result of reduced alveolar
ventilation. Which combination of arterial blood gas (ABG)
values confirms respiratory acidosis?

A. pH, 5.0; PaCO2 30 mm Hg

B. pH, 7.40; PaCO2 35 mm Hg
C. pH, 7.35; PaCO2 40 mm Hg
D. pH, 7.25; PaCO2 50 mm Hg

57. A male client admitted to an acute care facility with

pneumonia is receiving supplemental oxygen, 2 L/minute
via nasal cannula. The client’s history includes chronic
obstructive pulmonary disease (COPD) and coronary
artery disease. Because of these history findings, the
nurse closely monitors the oxygen flow and the client’s
respiratory status. Which complication may arise if the
client receives a high oxygen concentration?

A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis

58. At 11 p.m., a male client is admitted to the emergency

department. He has a respiratory rate of 44
breaths/minute. He’s anxious, and wheezes are audible.
The client is immediately given oxygen by face mask
and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m.,
the client’s arterial blood oxygen saturation is 86% and
he’s still wheezing. The nurse should plan to administer:

A. Alprazolam (Xanax).
B. Propranolol (Inderal)
C. Morphine.
D. Albuterol (Proventil).

59. After undergoing a thoracotomy, a male client is

receiving epidural analgesia. Which assessment finding
indicates that the client has developed the most serious
complication of epidural analgesia?

A. Heightened alertness
B. Increased heart rate
C. Numbness and tingling of the extremities
D. Respiratory depression
60. The nurse in charge formulates a nursing diagnosis of
Activity intolerance related to inadequate oxygenation
and dyspnea for a client with chronic bronchitis. To
minimize this problem, the nurse instructs the client to
avoid conditions that increase oxygen demands. Such
conditions include:

A. Drinking more than 1,500 ml of fluid daily.

B. Being overweight.
C. Eating a high-protein snack at bedtime.
D. Eating more than three large meals a day.

Answers and Rationale

1. Answer: B. Nervousness

Albuterol may cause nervousness. The inhaled form of the

drug may cause dryness and irritation of the nose and throat,
not nasal congestion; insomnia, not lethargy; and hypokalemia
(with high doses), not hyperkalemia. Other adverse effects of
albuterol include tremor, dizziness, headache, tachycardia,
palpitations, hypertension, heartburn, nausea, vomiting and
muscle cramps.

2. Answer: C. Clear
Normally, nasal drainage in acute rhinitis is clear. Yellow or
green drainage indicates spread of the infection to the
sinuses. Gray drainage may indicate a secondary infection.

3. Answer: D. Lightheadedness or paresthesia

The patient with respiratory alkalosis may complain of

lightheadedness or paresthesia (numbness and tingling in the
arms and legs). Nausea, vomiting, abdominal pain, and
diarrhea may accompany respiratory acidosis. Hallucinations
and tinnitus rare are associated with respiratory alkalosis or
any other acid-base imbalance.

4. Answer: D. Elderly patients

Ephedrine is not recommended for elderly patients, who are

particularly susceptible to CNS reactions (such
as confusion and anxiety) and to cardiovascular reactions
(such as increased systolic blood pressure, coldness in the
extremities, and anginal pain). Ephedrine is used for its
bronchodilator effects with acute and chronic asthma and
occasionally for its CNS stimulant actions for narcolepsy. It can
be administered to children age 2 and older.

5. Answer: A. Kinking of the ventilator tubing

Conditions that trigger the high-pressure alarm include kinking
of the ventilator tubing, bronchospasm or pulmonary
embolus, mucus plugging, water in the tube, coughing or
biting on endotracheal tube, and the patient’s being out of
breathing rhythm with the ventilator. A disconnected
ventilator tube or an endotracheal cuff leak would trigger the
low pressure alarm. Changing the oxygen concentration
without resetting the oxygen level alarm would trigger the
oxygen alarm.

6. Answer: D. Fighting the ventilator

Pancuronium, a nondepolarizing blocking agent, is used for

muscle relaxation and paralysis. It assists mechanical
ventilation by promoting endotracheal intubation and
paralyzing the patient so that the mechanical ventilator can do
its work. Fighting the ventilator is a sign that the patient needs
another pancuronium dose. The nurse should administer 0.01
to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the
legs, or lips has no effect on the ventilator and therefore is not
used to determine the need for another dose.

7. Answer: B. Absence of breaths sound in the right thorax

In pneumothorax, the alveoli are deflated and no air exchange
occurs in the lungs. Therefore, breath sounds in the affected
lung field are absent. None of the other options are associated
with pneumothorax. Bilateral crackles may result from
pulmonary congestion, inspiratory wheezes may signal
asthma, and a pleural friction rub may indicate pleural
inflammation.

8. Answer: B. Arterial Blood

A lowercase “a” in an ABG value represents arterial blood. For

instance, the abbreviation PaO2 refers to the partial pressure
of oxygen in arterial blood. The pH value reflects the acid-base
balance in arterial blood. Sa02 indicates arterial oxygen
saturation. An uppercase “A” represents alveolar conditions:
for example, PA02 indicates the partial pressure of oxygen in
the alveoli.

9. Answer: D. Impaired gas exchange related to airflow

obstruction

A patient airway and an adequate breathing pattern are the

top priority for any patient, making “impaired gas exchange
related to airflow obstruction” the most important nursing
diagnosis. The other options also may apply to this patient but
less important.

10. Answer: D. Contralateral side in hemothorax

The trachea will shift according to the pressure gradients

within the thoracic cavity. In tension pneumothorax and
hemothorax, accumulation of air or fluid causes a shift away
from the injured side. If there is no significant air or fluid
accumulation, the trachea will not shift. Tracheal deviation
toward the contralateral side in simple pneumothorax is seen
when the thoracic contents shift in response to the release of
normal thoracic pressure gradients on the injured side.

11. Answer: C. Encourage coughing and deep breathing

When caring for a patient who is recovering from a

pneumonectomy, the nurse should encourage coughing and
deep breathing to prevent pneumonia in the unaffected lung.
Because the lung has been removed, the water-seal chamber
should display no fluctuations. Reinflation is not the purpose
of chest tube. Chest tube milking is controversial and should
be done only to remove blood clots that obstruct the flow of
drainage.
12. Answer: B. Develop an alternative communication
method

A patient with a laryngectomy cannot speak, yet still needs to

communicate. Therefore, the nurse should plan to develop an
alternative communication method. After a laryngectomy,
edema interferes with the ability to swallow and necessitates
tube (enteral) feedings. To prevent injury to the tracheal
mucosa, the nurse should deflate the tracheostomy cuff or
use the minimal leak technique. To decrease edema, the nurse
should place the patient in semi-Fowler’s position.

13. Answer: B. Applying a dressing over the wound and

taping it on three sides

The nurse immediately should apply a dressing over the stab

wound and tape it on three sides to allow air to escape and to
prevent tension pneumothorax (which is more life-threatening
than an open chest wound). Only after covering and taping the
wound should the nurse draw blood for laboratory tests,
assist with chest tube insertion, and start an I.V. line.

14. Answer: C. Using a high-flow venture mask to deliver

oxygen as prescribe
The patient with COPD retains carbon dioxide, which inhibits
stimulation of breathing by the medullary center in the brain.
As a result, low oxygen levels in the blood stimulate
respiration, and administering unspecified, unmonitored
amounts of oxygen may depress ventilation. To promote
adequate gas exchange, the nurse should use a Venturi mask
to deliver a specified, controlled amount of oxygen
consistently and accurately. Drinking three glasses of fluid
daily would not affect gas exchange or be sufficient to liquefy
secretions, which are common in COPD. Patients with COPD
and respiratory distress should be places in high-Fowler’s
position and should not receive sedatives or other drugs that
may further depress the respiratory center.

15. Answer: C. Increased pulmonary capillary permeability

ARDS results from increased pulmonary capillary permeability,

which leads to noncardiogenic pulmonary edema.
In cardiogenic pulmonary edema, pulmonary congestion
occurs secondary to heart failure. In the initial stage of ARDS,
respiratory alkalosis may arise secondary to hyperventilation;
however, it does not cause ARDS. Renal failure does not cause
ARDS, either.
16. Answer: C. Teaching the patient how to perform
controlled coughing

Controlled coughing helps maintain a patent airway by helping

to mobilize and remove secretions. A moderate fluid intake
(usually 2 L or more daily) and moderate activity help liquefy
and mobilize secretions. Bed rest and sedatives may limit the
patient’s ability to maintain a patent airway, causing a high risk
for infection from pooled secretions.

17. Answer: A. Do nothing, because this is an expected

finding

Continuous gentle bubbling should be noted in the suction

control chamber. Option b is incorrect. Chest tubes should
only be clamped to check for an air leak or when changing
drainage devices (according to agency policy). Option c is
incorrect. Bubbling should be continuous and not intermittent.
Option d is incorrect because bubbling should be gentle.
Increasing the suction pressure only increases the rate of
evaporation of water in the drainage system.

18. Answer: B. Continue to monitor the client

The presence of fluctuation of the fluid level in the water seal
chamber indicates a patent drainage system. With normal
breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if a
dependent loop exists, if the suction is not working properly,
or if the lung has reexpanded. Options A, C, and D are
incorrect.

19. Answer: B. Place the tube in bottle of sterile water

If the chest drainage system is disconnected, the end of the

tube is placed in a bottle of sterile water held below the level
of the chest. The system is replaced if it breaks or cracks or if
the collection chamber is full. Placing a sterile dressing over
the disconnection site will not prevent complications resulting
from the disconnection. The physician may need to be
notified, but this is not the initial action.

20. Answer: D. Perform the Valsalva maneuver

When the chest tube is removed, the client is asked to perform

the Valsalva maneuver (take a deep breath, exhale, and bear
down). The tube is quickly withdrawn, and an airtight dressing
is taped in place. An alternative instruction is to ask the client
to take a deep breath and hold the breath while the tube is
removed. Options A, B, and C are incorrect client instructions.

21. Answer: B. Grasp the retention sutures to spread the

opening

If the tube is dislodged accidentally, the initial nursing action is

to grasp the retention sutures and spread the opening. If
agency policy permits, the nurse then attempts immediately to
replace the tube. Covering the tracheostomy site will block the
airway. Options A and C will delay treatment in this emergency
situation.

22. Answer: A. Stridor

The nurse reports stridor to the physician immediately. This is

a high-pitched, coarse sound that is heard with the
stethoscope over the trachea. Stridor indicates airway edema
and places the client at risk for airway obstruction. Options B,
C, and D are not signs that require immediate notification of
the physician.

23. Answer: B. Diminished breath sounds

This client has sustained a blunt or a closed chest injury. Basic
symptoms of a closed pneumothorax are shortness of breath
and chest pain. A larger pneumothorax may cause tachypnea,
cyanosis, diminished breath sounds, and subcutaneous
emphysema. Hyperresonance also may occur on the affected
side. A sucking sound at the site of injury would be noted with
an open chest injury.

24. Answer: B. A hyperinflated chest noted on the chest x-

ray

Clinical manifestations of chronic obstructive pulmonary

disease (COPD) include hypoxemia, hypercapnia, dyspnea on
exertion and at rest, oxygen desaturation with exercise, and
the use of accessory muscles of respiration. Chest x-rays
reveal a hyperinflated chest and a flattened diaphragm if the
disease is advanced.

25. Answer: B. Venturi mask

The Venturi mask delivers the most accurate oxygen

concentration. It is the best oxygen delivery system for the
client with chronic airflow limitation because it delivers a
precise oxygen concentration. The face tent, aerosol mask,
and tracheostomy collar are also high-flow oxygen delivery
systems but most often are used to administer high humidity.

26. Answer: D. A cough with the expectoration of mucoid

sputum

One of the first pulmonary symptoms is a slight cough with

the expectoration of mucoid sputum. Options A, B, and C are
late symptoms and signify cavitation and extensive lung
involvement.

27. Answer: B. Sputum culture

Tuberculosis is definitively diagnosed through culture and

isolation of Mycobacterium tuberculosis. A presumptive
diagnosis is made based on a tuberculin skin test, a sputum
smear that is positive for acid-fast bacteria, a chest x-ray, and
histological evidence of granulomatous disease on biopsy.

28. Answer: B. 2 L/min

Oxygen is used cautiously and should not exceed 2 L/min.

Because of the long-standing hypercapnia that occurs in
emphysema, the respiratory drive is triggered by low oxygen
levels rather than increased carbon dioxide levels, as is the
case in a normal respiratory system.

29. Answer: D. Promote carbon dioxide elimination

Pursed-lip breathing facilitates maximal expiration for clients

with obstructive lung disease. This type of breathing allows
better expiration by increasing airway pressure that keeps air
passages open during exhalation. Options A, B, and C are not
the purposes of this type of breathing.

30. Answer: B. Low arterial PaO2

The earliest clinical sign of acute respiratory distress syndrome

is an increased respiratory rate. Breathing becomes labored,
and the client may exhibit air hunger, retractions, and
cyanosis. Arterial blood gas analysis reveals increasing
hypoxemia, with a PaO2 lower than 60 mm Hg.

31.  Answer: B. Having the client take deep breaths

To obtain a sputum specimen, the client should rinse the

mouth to reduce contamination, breathe deeply, and then
cough into a sputum specimen container. The client should be
encouraged to cough and not spit so as to obtain sputum.
Sputum can be thinned by fluids or by a respiratory treatment
such as inhalation of nebulized saline or water. The optimal
time to obtain a specimen is on arising in the morning.

32.  Answer: C. Bronchospasm

If a biopsy was performed during a bronchoscopy, blood-

streaked sputum is expected for several hours. Frank blood
indicates hemorrhage. A dry cough may be expected. The
client should be assessed for signs of complications, which
would include cyanosis, dyspnea, stridor, bronchospasm,
hemoptysis, hypotension, tachycardia, and dysrhythmias.
Hematuria is unrelated to this procedure.

33.  Answer: C. 10 seconds

Hypoxemia can be caused by prolonged suctioning, which

stimulates the pacemaker cells in the heart. A vasovagal
response may occur, causing bradycardia. The nurse must
preoxygenate the client before suctioning and limit the
suctioning pass to 10 seconds.

34.  Answer: C. Stop the procedure and reoxygenate the

client
During suctioning, the nurse should monitor the client closely
for side effects, including hypoxemia, cardiac irregularities
such as a decrease in heart rate resulting from vagal
stimulation, mucosal trauma, hypotension, and paroxysmal
coughing. If side effects develop, especially cardiac
irregularities, the procedure is stopped and the client is
reoxygenated.

35.  Answer: A. Dyspnea

The common clinical manifestations of pulmonary embolism

are tachypnea, tachycardia, dyspnea, and chest pain.

36.  Answer: A. Resonant sounds.

When percussing the chest wall, the nurse expects to elicit

resonant sounds — low-pitched, hollow sounds heard over
normal lung tissue. Hyperresonant sounds indicate increased
air in the lungs or pleural space; they’re louder and lower
pitched than resonant sounds. Although hyperresonant
sounds occur in such disorders as emphysema and
pneumothorax, they may be normal in children and very thin
adults. Dull sounds, normally heard only over the liver and
heart, may occur over dense lung tissue, such as from
consolidation or a tumor. Dull sounds are thudlike and of
medium pitch. Flat sounds, soft and high-pitched, are heard
over airless tissue and can be replicated by percussing the
thigh or a bony structure.

37.  Answer: A. Question the order because it’s too low.

A therapeutic theophylline level is 10 to 20 mcg/ml. The client

is currently receiving 0.5 mg/kg/hour of aminophylline.
Because the client’s theophylline level is sub-therapeutic,
reducing the dose (which is what the physician’s order would
do) would be inappropriate. Therefore, the nurse should
question the order.

38.  Answer: C. Use diaphragmatic breathing.

In chronic bronchitis the diaphragm is flat and weak.

Diaphragmatic breathing helps to strengthen the diaphragm
and maximizes ventilation. Exhalation should be longer than
inhalation to prevent collapse of the bronchioles. The client
with chronic bronchitis should exhale through pursed lips to
prolong exhalation, keep the bronchioles from collapsing, and
prevent air trapping. Diaphragmatic breathing — not chest
breathing — increases lung expansion.

39.  Answer: C. Tidal volume

Tidal volume refers to the volume of air inspired and expired
with a normal breath. Total lung capacity is the maximal
amount of air the lungs and respiratory passages can hold
after a forced inspiration. Forced vital capacity is the vital
capacity performed with a maximally forced expiration.
Residual volume is the maximal amount of air left in the lung
after a maximal expiration.

40.  Answer: B. Non-rebreather mask

A non-rebreather mask can deliver levels of the fraction of

inspired oxygen (FIO2) as high as 100%. Other modes —
simple mask, face tent, and nasal cannula — deliver lower
levels of FIO2.

41.  Answer: C. Decreased hearing acuity

Decreased hearing acuity indicates ototoxicity, a serious

adverse effect of streptomycin therapy. The client should
notify the physician immediately if it occurs so that
streptomycin can be discontinued and an alternative drug can
be prescribed. The other options aren’t associated with
streptomycin. Impaired color discrimination indicates color
blindness; increased urinary frequency and increased appetite
accompany diabetes mellitus.
42.  Answer: B. Skin test doesn’t differentiate between
active and dormant tuberculosis infection.

The Mantoux test doesn’t differentiate between active and

dormant infections. If a positive reaction occurs, a sputum
smear and culture as well as a chest X-ray are necessary to
provide more information. Although the area of redness is
measured in 3 days, a second test may be needed; neither test
indicates that tuberculosis is active. In the Mantoux test, an
induration 5 to 9 mm in diameter indicates a borderline
reaction; a larger induration indicates a positive reaction. The
presence of a wheal within 2 days doesn’t indicate active
tuberculosis.

43.  Answer: B. B. 5 to 20 minutes.

Initially, the nurse should plug the opening in the

tracheostomy tube for 5 to 20 minutes, then gradually
lengthen this interval according to the client’s respiratory
status. A client who doesn’t require continuous mechanical
ventilation already is breathing without assistance, at least for
short periods; therefore, plugging the opening of the tube for
only 15 to 60 seconds wouldn’t be long enough to reveal the
client’s true tolerance to the procedure. Plugging the opening
for more than 20 minutes would increase the risk of acute
respiratory distress because the client requires an adjustment
period to start breathing normally.

44.  Answer: C. The system has an air leak.

Constant bubbling in the chamber indicates an air leak and

requires immediate intervention. The client with a
pneumothorax will have intermittent bubbling in the water-
seal chamber. Clients without a pneumothorax should have no
evidence of bubbling in the chamber. If the tube is obstructed,
the nurse should notice that the fluid has stopped fluctuating
in the water-seal chamber.

45.  Answer: B. Mucous membranes.

Skin color doesn’t affect the mucous membranes. The lips, nail
beds, and earlobes are less reliable indicators of cyanosis
because they’re affected by skin color.

46.  Answer: A. Auscultating the lungs for bilateral breath

sounds

For a client with an ET tube, the most important nursing action

is auscultating the lungs regularly for bilateral breath sounds
to ensure proper tube placement and effective oxygen
delivery. Although the other options are appropriate for this
client, they’re secondary to ensuring adequate oxygenation.

47.  Answer: B. Use of accessory muscles

The use of accessory muscles for respiration indicates the

client is having difficulty breathing. Diaphragmatic and pursed-
lip breathing are two controlled breathing techniques that
help the client conserve energy.

48.  Answer: D. Chest movements.

The nurse observes respiratory excursion to help assess chest

movements. Normally, thoracic expansion is symmetrical;
unequal expansion may indicate pleural effusion, atelectasis,
pulmonary embolus, or a rib or sternum fracture. The nurse
assesses vocal sounds to evaluate air flow when checking for
tactile fremitus; after asking the client to say “99,” the nurse
palpates the vibrations transmitted from the
bronchopulmonary system along the solid surfaces of the
chest wall to the nurse’s palms. The nurse assesses breath
sounds during auscultation.

49.  Answer: A. Erythromycin (Erythrocin)

Erythromycin is the drug of choice for treating legionnaires’
disease. Rifampin may be added to the regimen if
erythromycin alone is ineffective; however, it isn’t
administered first. Amantadine, an antiviral agent, and
amphotericin B, an antifungal agent, are ineffective against
legionnaires’ disease, which is caused by bacterial infection.

50.  Answer: C. Atelectasis.

In a client with COPD, an ineffective cough impedes secretion

removal. This, in turn, causes mucus plugging, which leads to
localized airway obstruction — a known cause of atelectasis.
An ineffective cough doesn’t cause pleural effusion (fluid
accumulation in the pleural space). Pulmonary edema usually
results from left-sided heart failure, not an ineffective cough.
Although many noncardiac conditions may cause pulmonary
edema, an ineffective cough isn’t one of them. Oxygen toxicity
results from prolonged administration of high oxygen
concentrations, not an ineffective cough.

51.  Answer: A. It helps prevent early airway collapse.

Pursed-lip breathing helps prevent early airway collapse.

Learning this technique helps the client control respiration
during periods of excitement, anxiety, exercise, and
respiratory distress. To increase inspiratory muscle strength
and endurance, the client may need to learn inspiratory
resistive breathing. To decrease accessory muscle use and
thus reduce the work of breathing, the client may need to
learn diaphragmatic (abdominal) breathing. In pursed-lip
breathing, the client mimics a normal inspiratory-expiratory
(I:E) ratio of 1:2. (A client with emphysema may have an I:E
ratio as high as 1:4.)

52.  Answer: A. In 30 minutes

Codeine’s onset of action is 30 minutes. Its peak concentration

occurs in about 1 hour; its half-life, in 2.5 hours; and its
duration of action is 4 to 6 hours.

53.  Answer: A. Kinking of the ventilator tubing

Conditions that trigger the high-pressure alarm include kinking

of the ventilator tubing, bronchospasm or pulmonary
embolus, mucus plugging, water in the tube, coughing or
biting on the ET tube, and the client’s being out of breathing
rhythm with the ventilator. A disconnected ventilator tube or
an ET cuff leak would trigger the low-pressure alarm. Changing
the oxygen concentration without resetting the oxygen level
alarm would trigger the oxygen alarm.
54.  Answer: A. It makes the central respiratory center
more sensitive to carbon dioxide and stimulates the
respiratory drive.

Anhydrous theophylline and other methylxanthine agents

make the central respiratory center more sensitive to CO2 and
stimulate the respiratory drive. Inhibition of
phosphodiesterase is the drug’s mechanism of action in
treating asthma and other reversible obstructive airway
diseases — not COPD. Methylxanthine agents inhibit rather
than stimulate adenosine receptors. Although these agents
reduce diaphragmatic fatigue in clients with chronic bronchitis
or emphysema, they don’t alter diaphragm movement to
increase chest expansion and enhance gas exchange.

55.  Answer: A. Inflamed lung tissue

The common feature of all types of pneumonia is an

inflammatory pulmonary response to the offending organism
or agent. Although most types of pneumonia have a sudden
onset, a few (such as anaerobic bacterial pneumonia and
mycoplasmal pneumonia) have an insidious onset. Antibiotic
therapy is the primary treatment for most types of
pneumonia; however, the antibiotic must be specific for the
causative agent, which may not be responsive to penicillin. A
few types of pneumonia, such as viral pneumonia, aren’t
treated with antibiotics. Although pneumonia usually causes
an elevated WBC count, some types, such as mycoplasmal
pneumonia, don’t.

56.  Answer: D. pH, 7.25; PaCO2 50 mm Hg

In respiratory acidosis, ABG analysis reveals an arterial pH

below 7.35 and partial pressure of arterial carbon dioxide
(PaCO2) above 45 mm Hg. Therefore, the combination of a pH
value of 7.25 and a PaCO2 value of 50 mm Hg confirms
respiratory acidosis. A pH value of 5.0 with a PaCO2 value of
30 mm Hg indicates respiratory alkalosis. Options B and C
represent normal ABG values, reflecting normal gas exchange
in the lungs.

57.  Answer: A. Apnea

Hypoxia is the main breathing stimulus for a client with COPD.

Excessive oxygen administration may lead to apnea by
removing that stimulus. Anginal pain results from a reduced
myocardial oxygen supply. A client with COPD may have
anginal pain from generalized vasoconstriction secondary to
hypoxia; however, administering oxygen at any concentration
dilates blood vessels, easing anginal pain. Respiratory alkalosis
results from alveolar hyperventilation, not excessive oxygen
administration. In a client with COPD, high oxygen
concentrations decrease the ventilatory drive, leading to
respiratory acidosis, not alkalosis. High oxygen concentrations
don’t cause metabolic acidosis.

58.  Answer: D. Albuterol (Proventil).

The client is hypoxemic because of bronchoconstriction as

evidenced by wheezes and a subnormal arterial oxygen
saturation level. The client’s greatest need is bronchodilation,
which can be accomplished by administering bronchodilators.
Albuterol is a beta2 adrenergic agonist, which causes dilation
of the bronchioles. It’s given by nebulization or metered-dose
inhalation and may be given as often as every 30 to 60
minutes until relief is accomplished. Alprazolam is
an anxiolytic and central nervous system depressant, which
could suppress the client’s breathing. Propranolol is
contraindicated in a client who’s wheezing because it’s a beta2
adrenergic antagonist. Morphine is a respiratory center
depressant and is contraindicated in this situation.

59.  Answer: D. Respiratory depression

Respiratory depression is the most serious complication of
epidural analgesia. Other potential complications include
hypotension, decreased sensation and movement of the
extremities, allergic reactions, and urine retention. Typically,
epidural analgesia causes central nervous system depression
(indicated by drowsiness) as well as a decreased heart rate
and blood pressure.

60.  Answer: B. Being overweight.

Conditions that increase oxygen demands include

obesity, smoking, exposure to temperature extremes, and
stress. A client with chronic bronchitis should drink at least
2,000 ml of fluid daily to thin mucus secretions; restricting fluid
intake may be harmful. The nurse should encourage the client
to eat a high-protein snack at bedtime because protein
digestion produces an amino acid with sedating effects that
may ease the insomnia associated with chronic bronchitis.
Eating more than three large meals a day may cause fullness,
making breathing uncomfortable and difficult; however, it
doesn’t increase oxygen demands. To help maintain adequate
nutritional intake, the client with chronic bronchitis should eat
small, frequent meals (up to six a day).