. 1.

Question
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed 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

Correct Answer: B. Nervousness

Albuterol may cause nervousness. The primary adverse effects of albuterol therapy are
tremors and nervousness, mostly seen in children who are 2 to 6 years of age, though can be
seen at any age. Tremors are the result of activation of the beta-2 receptors found on the
motor nerve terminals which increases intracellular cAMP. These side effects occur in
approximately one in every five patients. Other adverse effects of albuterol include tremor,
dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and
muscle cramps.
. 2. Question
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

Correct Answer: C. Clear

Normally, nasal drainage in acute rhinitis is clear. Anterior rhinoscopy typically reveals
swelling of the nasal mucosa and thin, clear secretions. The inferior turbinates may take on a
bluish hue, and cobblestoning of the nasal mucosa may be present. On physical examination,
clinicians may notice mouth breathing, frequent sniffling and/or throat clearing, transverse
supra-tip nasal crease, and dark circles under the eyes (allergic shiners).
. 3. Question
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

Correct Answer: D. Lightheadedness or paresthesia

The patient with respiratory alkalosis may complain of lightheadedness or paresthesia
(numbness and tingling in the arms and legs). The exact history and physical exam findings
are highly variable as there are many pathologies that induce the pH disturbance. These may
include acute onset dyspnea, fever, chills, peripheral edema, orthopnea, weakness, confusion,
light-headedness, dizziness, anxiety, chest pain, wheezing, hemoptysis, trauma, history of
central line catheter, recent surgery, history of thromboembolic disease, history of asthma,
history of COPD, acute focal neurological signs, numbness, paresthesia, abdominal pain,
nausea, vomiting, tinnitus, or weight loss.
. 7. Question
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.

Correct 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. A pneumothorax is defined as a collection
of air outside the lung but within the pleural cavity. It occurs when air accumulates between
the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on
the lung and make it collapse. The degree of collapse determines the clinical presentation of
pneumothorax. None of the other options are associated with pneumothorax.
. 9. Question
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.

Correct 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. Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%.
Pulse oximetry reading of 87% below may indicate the need for oxygen administration while
a pulse oximetry reading of 92% or higher may require oxygen titration. The other options
also may apply to this patient but less important.
. 10. Question
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.

Correct Answer: D. Contralateral side in hemothorax.

The trachea will shift according to the pressure gradients within the thoracic cavity. If there is
no significant air or fluid accumulation, the trachea will not shift. The pressure gradient
inside the thorax changes with a pneumothorax. Normally the pressure of the pleural space is
negative when compared to atmospheric pressure. When the chest wall expands outwards, the
lung also expands outwards due to surface tension between parietal and visceral pleura.
. 11. Question
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.

Correct 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. Assist
the patient with splinting painful areas when coughing, deep breathing. Supporting chest and
abdominal muscles makes coughing more effective and less traumatic.
. 12. Question
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.

Correct 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. Assess the effectiveness
of nonverbal communication methods. The client may use hand signals, facial expressions,
and changes in body posture to communicate with others. However, others may have
difficulty in interpreting these nonverbal techniques. Each new method needs to be assessed
for effectiveness and altered as necessary.
. 13. Question
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.

Correct 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). The nurse may use a first aid device called a chest seal or
improvise with the packaging sterile dressings coming in. Peel open the packaging and tape
the entire plastic portion over the 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. Question
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 venturi mask to deliver oxygen as prescribed.
 D. Administering a sedative, as prescribed.

Correct Answer: C. Using a high-flow venturi 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.
. 16. Question
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 prescribed sedatives regularly and in large amounts.

Correct Answer: C. Teaching the patient how to perform controlled coughing.

Controlled coughing helps maintain a patent airway by helping to mobilize and remove
secretions. Cough can be persistent but ineffective, especially if the patient is elderly, acutely
ill, or debilitated. Coughing is most effective in an upright or in a head-down position after
chest percussion.
. 17. Question
Nurse Lei, caring for a client with a pneumothorax and who has had a chest tube inserted,
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.

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

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling during
expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as
the lung expands or may occur only during expiration or coughing as the pleural space
diminishes.
. 18. Question
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.

Correct 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 re-expanded.
. 19. Question
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 a bottle of sterile water.
 C. Immediately replace the chest tube system.
 D. Place a sterile dressing over the disconnection site.

Correct Answer: B. Place the tube in a 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. Anchor thoracic catheter to the chest wall and provide
an extra length of tubing before turning or moving the patient. Prevents thoracic catheter
dislodgement or tubing disconnection and reduces pain and discomfort associated with
pulling or jarring of tubing.
. 20. Question
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

Correct 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.
. 22. Question
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

Correct 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. Post-extubation stridor is uncommon and seen only
in less than 10% of unselected critically ill patients and correlates with increased rates of
reintubation, prolonged duration of mechanical ventilation, and longer length of ICU stay.
Options B, C, and D are not signs that require immediate notification of the physician.
.
. 23. Question
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.

Correct 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 pneumothorax is defined as a
collection of air outside the lung but within the pleural cavity. It occurs when air accumulates
between the parietal and visceral pleura inside the chest. The air accumulation can apply
pressure on the lung and make it collapse.
. 24. Question
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.

Correct 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. Hyperinflation of the lungs is often seen on
imaging studies and occurs due to air trapping from airway collapse during exhalation.
. 25. Question
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

Correct 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. An air-entrainment (also known as venturi) mask can provide a pre-set
oxygen to the patient using jet mixing. As the percent of inspired oxygen increases using such
a mask, the air to oxygen ratio decreases, causing the maximum concentration of oxygen
provided by an air-entrainment mask to be around 40%. 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. Question
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.

Correct 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. A chronic cough, hemoptysis, weight loss, low-grade fever, and night sweats are
some of the most common physical findings in pulmonary tuberculosis. Other options are late
symptoms and signify cavitation and extensive lung involvement.
. 27. Question
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

Correct Answer: B. Sputum culture

Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium
tuberculosis. Mycobacterial culture is the gold standard for diagnosis. Mycobacterial culture
should be performed on both the solid and liquid medium. Liquid media culture can detect
very low bacterial load and is considered a gold standard. Culture essential for drug
susceptibility testing. 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. Active tuberculosis is diagnosed by isolating
Mycobacterium tuberculosis complex bacilli from bodily secretions.
. 28. Question
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

Correct 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. Supplemental oxygen can successfully reach the alveoli in these lungs, which
prevents this vasoconstriction and thereby increases perfusion and improves gas exchange,
thus resulting in improvement of hypoxemia.
. 30. Question
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

Correct 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. Despite 100% oxygen, patients have low oxygen saturation.
. 31. Question
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.

Correct 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. To cough deeply from the
lungs, the client might need to take three deep breaths before he coughs forcefully.
. 32. Question
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

Correct Answer: C. Bronchospasm

If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for
several hours. The client should be assessed for signs of complications, which would include
cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and
dysrhythmias. Cardiac arrhythmias may also occur especially in patients with pre-existing
cardiac disease.
. 33. Question
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

Correct 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. It is of
particular importance for patients with mechanical ventilators, endotracheal tube (ET)
intubations, tracheostomies, or other airway adjuncts. Clearance of airway secretions is a
normal process and is critical to the prevention of respiratory infections, atelectasis, and
preservation of airway patency.
. 34. Question
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.

Correct 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. Question
A male adult client is suspected of having a pulmonary embolism. 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

Correct Answer: A. Dyspnea

The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia,
dyspnea, and chest pain. PE leads to impaired gas exchange due to obstruction of the
pulmonary vascular bed leading to a mismatch in the ventilation to perfusion ratio because
alveolar ventilation remains the same, but pulmonary capillary blood flow decreases,
effectively leading to dead space ventilation and hypoxemia.
. 38. Question
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.

Correct Answer: C. Use diaphragmatic breathing.

In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to
strengthen the diaphragm and maximizes ventilation. When the client has COPD, air often
becomes trapped in the lungs, pushing down on the diaphragm. The neck and chest muscles
must then assume an increased share of the work of breathing. This can leave the diaphragm
weakened and flattened, causing it to work less efficiently.
. 39. Question
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

Correct Answer: C. Tidal volume

Tidal volume refers to the volume of air inspired and expired with a normal breath. Tidal
volume is the amount of air that moves in or out of the lungs with each respiratory cycle. It
measures around 500 mL in an average healthy adult male and approximately 400 mL in a
healthy female. It is a vital clinical parameter that allows for proper ventilation to take place.

. 40. Question
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

Correct 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. Non-rebreathing masks have a bag attached to the mask known as a reservoir bag,
which inhalation draws from to fill the mask through a one-way valve and features ports at
each side for exhalation, resulting in an ability to provide the patient with 100% oxygen at a
higher LPM flow rate.
. 41. Question
A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse
should instruct the client to notify the physician if a health concern occurs?
 A. Impaired color discrimination
 B. Increased urinary frequency
 C. Decreased hearing acuity
 D. Increased appetite

Correct 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. Ototoxicity and vestibular
impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases,
deafness may occur due to ototoxicity, thus caution must be exercised when combining
streptomycin with other potentially ototoxic drugs. The other options aren’t associated with
streptomycin.
. 42. Question
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.

Correct 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. According to CDC, this test is performed using the ‘Mantoux technique,’
which is injecting 0.1 mL of a solution containing 5 units of tuberculin purified protein
derivative into the inner surface of the forearm through the intradermal route. It should be
administered two or more than 2 inches from the elbow, wrist, or any other injection site.
. 43. Question
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.

Correct 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. Tracheal plugging
is ordered by the doctor to help the client wean off an artificial airway. Plugging covers the
opening of the trach tube in the throat, and allowing her to breathe through her nose mouth.
Plugging will also help make the sound of her voice stronger.
. 44. Question
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.

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

Constant bubbling in the chamber indicates an air leak and requires immediate intervention.
With suction applied, this indicates a persistent air leak that may be from a large
pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (system-
centered).
. 45. Question
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

Correct Answer: B. Mucous membranes

Skin color doesn’t affect the mucous membranes. When the oxygen level has dropped only a
small amount, cyanosis may be hard to detect. In dark-skinned people, cyanosis may be
easier to see in the mucous membranes (lips, gums, around the eyes) and nails. The lips, nail
beds, and earlobes are less reliable indicators of cyanosis because they’re affected by skin
color.
. 46. Question
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.

Correct 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. Adventitious breath sounds such as wheezes and crackles are an indication of
respiratory difficulties. Quick assessment allows for early detection of deterioration or
improvement. Although the other options are appropriate for this client, they’re secondary to
ensuring adequate oxygenation.
. 47. Question
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

Correct Answer: B. Use of accessory muscles

The use of accessory muscles for respiration indicates the client is having difficulty
breathing. Accessory muscles of respiration are muscles other than the diaphragm and
intercostal muscles that may be used for labored breathing. The sternocleidomastoid, spinal,
and neck muscles may be used as accessory muscles of respiration; their use is a sign of an
abnormal or labored breathing pattern. Diaphragmatic and pursed-lip breathing are two
controlled breathing techniques that help the client conserve energy.
. 50. Question
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

Correct 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.
Adults with COPD have extensive collateral ventilation secondary to airway destruction and
thus are less likely to develop resorption atelectasis in the presence of an obstructing lesion
(i.e., intrathoracic tumor). The use of high inspiratory oxygen concentration (high FiO2)
during induction and maintenance of general anesthesia also contributes to atelectasis via
absorption atelectasis.