MedSurg ATI Respiratory System Prac7ce Ques7ons

1. A home health nurse is teaching a pa2ent who has ac2ve TB. The provider has prescribed the following
medica2on regiment: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO
daily, and ethambutol 1 mg PO daily. Which of the following pa2ent statements indicate the client
understands the teaching? (Select all that apply)

A. "I can subs2tute one medica2on for another if I run out because they all fight infec2on."
B. "I will wash my hands each 2me I cough."
C. "I will wear a mask when I am in a public area."
D. "I am glad I don't have to have any more sputum specimens."
E. "I don't need to worry where I go once I start taking my medica2ons."

Answer: B. "I will wash my hands each 7me I cough." – the client should wash her hands each 2me she
coughs to prevent spreading the infec2on. C. "I will wear a mask when I am in a public area." – The
pa2ent should wear a mask while in public areas to prevent spreading the infec2on. The client has ac2ve
TB, which is transmiTed through the airborne route.

2. A nurse in the emergency department is assessing a client who was in a MVA. Findings include absent
breath sounds in the leX lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min,
respira2ons 38/min, temperature 101.4 F, and SaO2 92% on room air. Which of the following ac2ons
should the nurse take first?

A. Obtain chest x-ray.

B. Prepare for chest tube inser2on.
C. Administer oxygen via a high-flow mask.
D. Ini2ate IV access.

Answer: C. Administer oxygen via a high-flow mask. According to the ABC process, the nurse should
place the priority on administering oxygen via high-flow mask to provide the client oxygen to restore
op2mal breathing.

3. A nurse in a clinic is providing teaching for a pa2ent who is to have a tuberculin skin test. Which of the
following informa2on should the nurse include:

A. If the test is posi2ve, then you have an ac2ve case of TB.

B. If the test is posi2ve, you should have another tuberculin skin test in 3 weeks.
C. You must return to the clinic to have the test read in 2 to 3 days.
D. A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin
substance.

Answer: C. You must return to the clinic to have the test read in 2 to 3 days. The pa2ent should have
the test read in 2 to 3 days. An area of indura2on aXer 48 to 72 hours indicates exposure to tubercle
bacillus. If the pa2ent does not return to have the test read within 72 hours, another skin test is
necessary
4. A nurse in the emergency department is assessing a pa2ent for a closed pneumothorax and significant
bruising of the leX chest following a MVA. The client reports severe leX chest pain on inspira2on. The
nurse should assess the pa2ent for which of the following manifesta2ons of a pneumothorax:

A. Absence of breath sounds

B. Expiratory wheezing
C. Inspiratory stridor
D. Rhonchi

Answer: A. Absence of breath sounds. A pa2ent who has pneumothorax experiences severely
diminished or absent breath sounds on the affected side.

5. A nurse in an urgent care clinical is collec2ng data from a pa2ent who reports exposure to anthrax. Which
of the following findings is an indica2on of the prodromal stage of inhala2on anthrax:

A. Dry cough
B. Rhini2s
C. Sore throat
D. Swollen lymph nodes

Answer: A. Dry cough. A dry cough is a clinical manifesta2on found in the prodromal stage of having
inhala2on anthrax. During this stage, it is difficult to dis2nguish from influenza or pneumonia because
there is no sore throat or rhini2s

6. A nurse in the emergency department is caring for a pa2ent who is having an acute asthma aTack. Which
of the following assessments indicates that the respiratory status is declining? (Select all that apply)

A. SaO2 95%
B. Wheezing
C. Retrac2on of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs)

Answer: B. Wheezing. Wheezing is a manifesta2on indica2ng the pa2ent's respiratory status is

declining. C. Retrac7on of sternal muscles. Retrac2on of sternal muscles is a manifesta2on that the
pa2ent's respiratory status is declining. E. Premature ventricular complexes (PVCs). PVCs are a
manifesta2on that the pa2ent's respiratory status is declining.

7. A nurse in a provider's office is assessing a pa2ent who states he was recently exposed to TB. Which of
the following findings is a clinical manifesta2on of pulmonary TB:

A. Pericardial fric2on rub

B. Weight gain
C. Night sweats
D. Cyanosis of the finger2ps

Answer: C. Night sweats. Night sweats and fevers are clinical manifesta2ons of TB.
8. A nurse is assessing a client following a gunshot wound to the chest. For which of the following
findings should the nurse monitor to detect a pneumothorax? (Select all that apply)

A. Tachypnea
B. Devia2on of the trachea
C. Bradycardia
D. Decreased use of accessory muscles
E. Pleuri2c pain

Answer: A. Tachypnea, B. Devia7on of the trachea, E. Pleuri7c pain

9. A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of
the following findings should the nurse expect? (Select all that apply)

A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement

Answer: B. Cyanosis, C. Hypotension, D. Dyspnea, E. Paradoxic chest movement

10. A nurse is assessing a client who has a PE. Which of the following manifesta2ons should the nurse
expect to find? (Select all that apply)

A. Bradypnea
B. Pleural fric2on rub
C. Hypertension
D. Petechiae
E. Tachycardia

Answer: B. Pleural fric7on rub, D. Petechiae, E. Tachycardia

11. A nurse is assessing a pa2ent following a bronchoscopy. Which of the following findings should the
nurse report to the provider:

A. Blood-2nged sputum
B. Dry, nonproduc2ve cough
C. Sore throat
D. Bronchospasms

Answer: D. Bronchospasms. Bronchospasms can indicate the pa2ent is having difficulty maintaining
a patent airway. The nurse should no2fy the provider immediately.
12. A nurse is assis2ng a provider with the removal of a chest tube. Which of the following should the
nurse instruct the pa2ent to do?

A. Lie on his leX side

B. Use the incen2ve spirometer
C. Cough at regular intervals
D. Perform the Valsalva maneuver

Answer: D. Perform the Valsalva maneuver. The pa2ent should be instructed to take a deep breath,
exhale, and bear down as the chest tube is being removed. This increases intrathroacic pressure and
reduces the risk of an air embolism.

13. A nurse is assessing a pa2ent who has a chest tube and drainage system in place. Which of the
following are expected findings? (Select all that apply)

A. Con2nuous bubbling in the water seal chamber

B. Gentle constant bubbling in the suc2on control chamber
C. Rise and fall in the level of water in the water seal chamber with inspira2on and expira2on
D. Exposed sutures without dressing
E. Drainage system upright at chest level

Answer: B. Gentle constant bubbling in the suc7on control chamber. Gentle bubbling in the suc2on
control chamber is an expected finding as air is being removed. C. Rise and fall in the level of water
in the water seal chamber with inspira7on and expira7on. A rise and fall of the fluid level in the
water seal chamber upon inspira2on and expira2on indicates that the drainage system is func2oning
properly.

14. A nurse is assis2ng with a thoracentesis. Which of the following ac2ons is appropriate for the nurse
to take when assis2ng with this procedure: (Select all that apply)

A. Wear goggles and mask during the procedure

B. Cleanse the area with an an2sep2c solu2on
C. Instruct the pa2ent to take deep breaths during inser2on of the needle
D. Posi2on the pa2ent laterally on the affected side
E. Apply pressure to the site aXer the needle is withdrawn

Answer: A. Wear goggles and mask during the procedure B. Cleanse the area with an an7sep7c
solu7on E. Apply pressure to the site a`er the needle is withdrawn

15. A nurse is assessing a pa2ent who has a chest tube in place following a thoracic surgery. Which of the
following findings indicates a need for interven2on:

A. Fluctua2on of drainage in the tubing with inspira2on.

B. Con2nuous bubbling in the water seal chamber.
C. Drainage of 75 mL in the first hour aXer surgery.
D. Several small, dark-red blood clots in the tubing.

Answer: B. Con7nuous bubbling in the water seal chamber. Con2nuous bubbling in the water seal
chamber suggests an air leak.
16. A nurse is caring for a client who has a new prescrip2on for heparin therapy. Which of the following
statements by the client should indicate an immediate concern for the nurse?

A. "I am allergic to morphine."

B. "I take antacids several 2me a day."
C. "I had a blood clot in my leg several years ago."
D. It hurts to take a deep breath."

Answer: B. "I take antacids several 7me a day." The greatest risk to the client is the possibility of
bleeding from a pep2c ulcer. The priority interven2on is to no2fy the provider of the finding

17. A nurse is assessing a pa2ent who has a history of asthma. Which of the following factors should the
nurse iden2fy as a risk for asthma?

A. Gender
B. Environmental allergies
C. Alcohol use
D. Race

Answer: B. Environmental allergies. Environmental allergies are a risk factor associated with asthma.
A pa2ent who has environmental allergies typically has other allergic problems, such as rhini2s or a
skin rash.

18. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome.
Which of the following medica2ons should the nurse an2cipate administering with this medica2on?
(Select all that apply)

A. Fentanyl
B. Furosemide
C. Midazolam
D. Famo2dine
E. Dexamethasone

Answer: A. Fentanyl, C. Midazolam

19. A nurse is assessing a pa2ent who has emphysema. The nurse should report which of the following
assessment findings:

A. Digital clubbing
B. Elevated temperature
C. Barrel-shaped chest
D. Diminished breath sounds

Answer: B. Elevated temperature. Pa2ents who have emphysema are at risk for development of
pneumonia and other respiratory infec2ons. A nurse should report an elevated temperature to the
provider.
20. A nurse is caring for a client who is to receive thromboly2c therapy. Which of the following factors
should the nurse recognize as a contraindica2on to the therapy?

A. Hip arthroplasty 2 weeks ago

B. Elevated sedimenta2on rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count

Answer: A. Hip arthroplasty 2 weeks ago. The client who has undergone a major surgical procedure
within the last 3 weeks should not receive thromboly2c therapy because of the risk of hemorrhage
from the surgical site.

21. A nurse is caring for a group of clients. Which of the following clients are at risk for a PE? (Select all
that apply)

A. A client who has a BMI of 30

B. A female client who is postmenopausal.
C. A client who has a fractured femur.
D. A client who is a marathon runner.
E. A client who has chronic atrial fibrilla2on

Answer: A. A client who has a BMI of 30, B. A client who has a fractured femur, E. A client who has
chronic atrial fibrilla7on

22. A nurse is caring for a pa2ent receiving mechanical ven2la2on. The low pressure alarm sounds. Which
of the following should the nurse recognize as a cause for the alarm:

A. Excess secre2ons
B. Kinks in the tubing
C. Ar2ficial airway cuff leak
D. Bi2ng on the endotracheal tube

Answer: C. Ar7ficial airway cuff leak. An ar2ficial airway cuff leak interferes with oxygena2on and
causes the low pressure alarm to sound.

23. A nurse is caring for an elderly pa2ent who suffers from COPD with pneumonia. The nurse should
monitor the pa2ent for which of the following acidbase imbalances?

A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

Answer: Respiratory acidosis. Respiratory acidosis is a common complica2on of COPD. This

complica2on occurs because pa2ents who have COPD are unable to exhale carbon dioxide due to a
loss of elas2c recoil in the lungs
24. A nurse is caring for a pa2ent who has a chest tube and drainage system in place. The nurse observes
that the chest tube was accidentally removed. Which of the following ac2ons should the nurse take
first?

A. Obtain chest x-ray

B. Apply sterile gauze to the inser2on site
C. Place tape around the inser2on site
D. Assess respiratory status

Answer: B. Apply sterile gauze to the inser7on site. Using ABC, applica2on of a sterile gauze to the
site should be the first ac2on for the nurse to take. This allows air to escape and reduces the risk for
development of a tension pneumothorax.

25. A nurse is caring for a pa2ent 2 hours aXer admission. The pa2ent has an SaO2 of 91% exhibits audible
wheezes, and is using accessory muscles when breathing. Which of the following classes of
medica2ons should the nurse expect to administer?

A. An2bio2c
B. Beta-blocker
C. An2viral
D. Beta 2 agonist

Answer: D. Beta 2 agonist. The nurse should administer a beta2 agonist, which causes dila2on of the
bronchioles to relieve symptoms.

26. A nurse is caring for a pa2ent who has acute respiratory distress syndrome. Which of the following
assessment findings indicates a decline in the pa2ent's condi2on:

A. Increase in respiratory rate

B. Increase in oxygen satura2on
C. Decrease in carbon dioxide reten2on
D. Decrease in intercostal retrac2ons

Answer: B. Increase in respiratory rate. An increase is respiratory rate indicates increased work of
breathing and the need for improvement in oxygen delivery.

27. A nurse is caring for a pa2ent following a thoracentesis. Which of the following manifesta2ons should
the nurse recognize as risks for complica2ons? (Select all that apply)

A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the puncture site

Answer: A. Dyspnea. Dyspnea can indicate a pneumothorax or a reaccumula2on of fluid. The nurse
should no2fy the provider immediately
28. A nurse is caring for a pa2ent who has acute respiratory failure. Which of the following laboratory
findings should the nurse expect:

A. Arterial pH 7.50
B. PaCO2 25 mm Hg
C. SaO2 92%
D. PaO2 58 mm Hg

Answer: D. PaO2 58 mm Hg. The nurse should expect a pa2ent who has acute respiratory failure to
have lower par2al pressures of oxygen.

29. A nurse is caring for a pa2ent following the inser2on of a chest tube. The nurse should plan to have
which of the following items in the pa2ent's room:

A. Extra drainage system

B. Suture removal set
C. Container of sterile water
D. Nonadherent pads

Answer: C. Container of sterile water. The nurse should plan to place the open end of tubing if it
becomes disconnected into the sterile water to prevent a pneumothorax

30. A nurse is caring for a pa2ent who has a new diagnosis of TB and has been placed on a
mul2medica2on regimen. Which of the following instruc2ons should the nurse give the pa2ent
related to ethambutol?

A. "Your urine can turn a dark orange."

B. "Watch for a change in the sclera of your eyes."
C. "Watch for any changes in vision."
D. "Take vitamin B6 daily."

Answer: C. "Watch for any changes in vision.". The client who is receiving ethambutol will need to
watch for visual changes due to op2c neuri2s, which can result from taking this medica2on

31. A nurse is caring for a pa2ent who has a tracheostomy with an inflated cuff in place. Which of the
following findings indicates that the nurse should suc2on the pa2ent's airway secre2ons:

A. The pa2ent is unable to speak.

B. The pa2ent's airway secre2ons were last suc2oned 2 hours ago.
C. The pa2ent coughs and expectorates a large mucous plug.
D. The nurse auscultates course crackles in the lung field.

Answer: D. The nurse auscultates course crackles in the lung field. The nurse should auscultate
coarse crackles of rhonchi, iden2fy a moist cough, hear or see secre2ons in the tracheostomy tube,
and then suc2on the pa2ent's airway secre2ons.
32. A nurse is caring for a pa2ent who is scheduled for a thoracentesis. Prior to the procedure, which of
the following ac2ons should the nurse take:

A. Posi2on the client in an upright posi2on, leaning over the bedside table.
B. Explain the procedure.
C. Obtain ABGs.
D. Administer benzocaine spray.

Answer: A. Posi7on the client in an upright posi7on, leaning over the bedside table. Posi2oning the
pa2ent in an upright posi2on and bent over the bedside table widens the intercostal space for the
provider to access the pleural fluid.

33. A nurse is caring for a pa2ent who has bacterial pneumonia. The nurse should expect which of the
following assessment findings:

A. Decreased fremitus
B. SaO2 95% on room air
C. Temperature 38.8 C ( 101.8 F)
D. Bradypnea

Answer: C. Temperature 38.8 C ( 101.8 F). An elevated temperature is an expected finding for a
pa2ent who has bacterial pneumonia.

34. A nurse is caring for a pa2ent who is scheduled for a throacentesis. Which of the folowing supplies
should the nurse ensure are in the pa2ent's room? (Select all that apply)

A. Oxygen equipment
B. Incen2ve spirometer
C. Pulse oximeter
D. Sterile dressing
E. Suture removal kit

Answer: A. Oxygen equipment. Oxygen equipment is necessary to have in the pa2ent's room if the
pa2ent becomes short of breath following the procedure. C. Pulse oximeter. Pulse oximetry is
necessary to monitor oxygen satura2on level during the procedure. D. Sterile dressing. A sterile
dressing is necessary to apply to the puncture site following the procedure.

35. A nurse is caring for a pa2ent who has COPD. Which of the following findings should the nurse report
to the provider:

A. Oxygen satura2on 89%

B. Produc2ve cough with green sputum
C. Clubbing of fingers
D. Pursed lipped breathing with exer2on

Answer: B. Produc7ve cough with green sputum. A nurse should report a produc2ve cough with
green sputum to the provider as it indicates an infec2on
36. A nurse is caring for a pa2ent with a PE. Which of the following interven2ons is the priority:

A. Provide a quiet environment

B. Encourage use of incen2ve spirometry ever 1 to 2 hours
C. Ini2ate con2nuous cardiac monitoring
D. Administer heparin via con2nuous IV fusion

Answer: D. Administer heparin via con7nuous IV fusion. Using the ABC approach, the nurse should
place priority on stabilizing circula2on to the lungs by administering heparin to prevent further clot
forma2on

37. A nurse is caring for a pa2ent who is in respiratory distress and requires endotracheal suc2oning.
Which of the following ac2ons should the nurse take:

A. Use clean technique to suc2on the pa2ent's endotracheal tube

B. Use a rota2ng mo2on to remove the suc2on catheter
C. Suc2on the oropharyngeal cavity prior to suc2oning the endotracheal tube
D. Suc2on the pa2ent's endotracheal tube every 2 hours

Answer: B. Use a rota7ng mo7on to remove the suc7on catheter. The nurse should rotate the
suc2on catheter during withdrawal to reduce the risk of 2ssue trauma.

38. A nurse is developing a teaching plan for a pa2ent about preven2ng acute asthma aTacks. Which of
the following points should the nurse plan to discuss first:

A. How to eliminate environmental triggers that precipitate aTacks

B. The pa2ent's percep2on of the disease process and what might have triggered aTacks in the past
C. The pa2ent's medica2on regimen
D. Manifesta2ons of respiratory infec2ons

Answer: B. The pa7ent's percep7on of the disease process and what might have triggered ahacks
in the past. The nurse should apply the nursing process priority-seong framework. The nurse can use
the nursing process to plan pa2ent care and priori2ze nursing ac2ons. Each step of the nursing
process builds on the previous step, beginning with assessment. Before the nurse can formulate a
plan of ac2on, implement a nursing interven2on, or no2fy a provider of a change in a pa2ent's status,
the nurse must first collect adequate data from the pa2ent. Assessing the pa2ent will provide the
nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should
take is to assess the pa2ent's current knowledge.

39. A nurse is caring for a pa2ent who is postopera2ve and is hypoven2la2ng secondary to general
anesthesia effects and incisional pain. Which of the following ABG values support the nurse's
suspicion of respiratory acidosis:

A. pH 7.50, PO2 99 mm Hg, PaCO2 25 mm Hg, HCO3 22 mEq/L

B. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3 30 mEq/L
C. pH 3.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3 20 mEq/L
D. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L

Answer: D. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L. These ABG values indicate
respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates
respiratory acidosis.
40. A nurse is discharging a pa2ent who has COPD. Upon discharge, the pa2ent is concerned that he will
never be able to leave his house now that he is on con2nuous oxygen. Which of the following is an
appropriate response by the nurse?

A. "There are portable oxygen delivery systems that you can take with you."
B. "When you go out, you can remove the oxygen and then reapply it when you get home."
C. "You probably will not be able to go out as much as you used to."
D. "Home health services will come to you so you will not need to get out."

Answer: A. "There are portable oxygen delivery systems that you can take with you." The nurse
should inform the pa2ent that there are portable oxygen systems that he can use to leave the house.
This should alleviate the pa2ent's anxiety.

41. A nurse is discharging a pa2ent who has pulmonary TB and is to start therapy with rifampin. The nurse
should plan to include which of the following in the pa2ent's teaching plan:

A. Ringing in the ears is expected.

B. Purified protein deriva2ve skin test results will improve in 4 months.
C. Urine and other secre2ons will be orange.
D. Take the medica2on with meals.

Answer: C. Urine and other secre7ons will be orange. Rifampin will turn urine and other secre2ons
orange.

42. A nurse is planning care for a pa2ent following the inser2on of a chest tube and drainage system.
Which of the following should be included in the plan of care? (Select all that apply)

A. Encourage the pa2ent to cough every 2 hours

B. Check for con2nuous bubbling in the suc2on chamber
C. Strip the drainage tubing every 4 hours
D. Clamp the tube once a day
E. Obtain a chest x-ray

Answer: A. Encourage the pa7ent to cough every 2 hours. The nurse should instruct the pa2ent to
cough every 2 hours. This promotes oxygena2on and lung reexpansion. B. Check for con7nuous
bubbling in the suc7on chamber. The nurse should check for con2nuous bubbling in the suc2on
chamber to verify that suc2on is being maintained at the appropriate level. E. Obtain a chest x-ray. A
chest x-ray is obtained following the procedure to verify chest tube placement.

43. A nurse is instruc2ng a pa2ent on the use of an incen2ve spirometer. Which of the following
statements by the client indicates an understanding of the teaching."

A. "I will place the adapter on my finger to read my blood oxygen satura2on level."
B. "I will lie on my back with my knees bent."
C. "I will rest my hand over my abdomen to create resistance.
D. "I will take in a deep breath and hold it before exhaling."

Answer: D. "I will take in a deep breath and hold it before exhaling." The pa2ent who is using the
spirometer should take in a deep breath and hold it for 3 to 5 seconds before exhaling. As the pa2ent
exhales, the needle of the spirometer rises. This promotes lung expansion.
44. A nurse is planning care for a pa2ent who has COPD and is malnourished. Which of the following
recommenda2ons to promote nutri2onal intake should the nurse include in the plan:

A. Eat high-calorie foods first

B. Increase intake of water at meal 2mes
C. Perform ac2ve range of mo2on exercises before meals
D. Keep sal2ne crackers nearby for snacking

Answer: A. Eat high-calorie foods first. The client who has COPD oXen experiences early sa2ety.
Therefore, the pa2ent should eat high-calorie foods first.

45. A nurse is orien2ng a newly licensed nurse on the purpose of administering vecuronium to a client
who has ARDS. Which of the following statements by the newly licensed nurse indicates
understanding of the teaching?

A. "This medica2on is given to treat infec2on."

B. "This medica2on is given to facilitate ven2la2on."
C. "This medica2on is given to decrease inflamma2on."
D. "This medica2on is given to reduce anxiety."

Answer: B. "This medica7on is given to facilitate ven7la7on." Vecuronium is a neuromuscular

blocking agent given to facilitate ven2la2on and decrease oxygen consump2on.

46. A nurse is planning care for a pa2ent who has COPD. Which of the following interven2ons should the
nurse include in the plan of care:

A. Schedule respiratory treatments aXer meals

B. Have the pa2ent sit in a chair for 2-hour periods 3x a day
C. Provide a diet high in calories and protein
D. Combine ac2vi2es to allow for longer rest periods between ac2vi2es

Answer: C. Provide a diet high in calories and protein. The nurse should provide a pa2ent who has
COPD with a diet that is high in protein and low on carbs

47. A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which
of the following ac2ons should be included in the plan of care for this client? (Select all that apply)

A. Administer an2bio2cs.
B. Provide supplemental oxygen
C. Administer an2viral medica2on
D. Administer of bronchodilators
E. Maintain ven2latory support

Answer: B. Provide supplemental oxygen, D. Administer of bronchodilators, E. Maintain ven7latory

support
48. A nurse is planning to instruct a pa2ent on how to perform pursed-lip breathing. Which of the
following should the nurse include in the plan of care?

A. Take quick breaths upon inhala2on.

B. Place your hand over your stomach.
C. Take a deep breath in through your nose.
D. Puff your cheeks upon exhala2on.

Answer: C. Take a deep breath in through your nose. The pa2ent should take a deep breath is
through her nose while performing pursed-lip breathing. This controls the pa2ent's breathing

49. A nurse is planning care for a pa2ent following placement of a chest tube 1 hour ago. Which of the
following ac2ons should the nurse include in the plan of care:

A. Clamp the chest tube if there is con2nuously bubbling in the water seal chamber
B. Keep the chest tube drainage system at the level of the right atrium
C. Tape all of the connec2ons between the chest tube and the drainage system
D. Empty the collec2on chamber and record the amount of drainage every 8 hours

Answer: C. Tape all of the connec7ons between the chest tube and the drainage system. The nurse
should tape all of the connec2ons to ensure that the system is air2ght and prevent the chest tubing
from accidentally disconnec2ng.

50. A nurse is preparing a pa2ent for a thoracentesis. In which of the following posi2ons should the nurse
place the pa2ent:

A. Lying flat on the affected site

B. Prone with arms raised over the head
C. Supine with the head of the bed elevated
D. Siong while leaning forward over the bedside table

Answer: D. Sikng while leaning forward over the bedside table. When preparing a pa2ent for a
thoracentesis, the nurse should have the pa2ent sit on the edge of the bed and lean forward over the
bedside table because this posi2on maximizes the space between the pa2ent's ribs and allows for
aspira2on of accumulated fluid and air.

51. A nurse is preparing discharge teaching to a pa2ent who is postopera2ve following a rhinoplasty.
Which of the following instruc2ons should the nurse include:

A. Apply warm compresses to the face

B. Take aspirin 650mg by mouth for mild pain
C. Close your mouth while sneezing
D. Lie on your back with your head elevated 30 degrees while res2ng

Answer: D. Lie on your back with your head elevated 30 degrees while res7ng. The nurse should
instruct the pa2ent to rest in the semi-fowlers posi2on to prevent aspira2on of nasal secre2ons.
52. A nurse is preparing to care for a pa2ent following chest tube placement. Which of the following
items should be available in the pa2ent's room? (Select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing

Answer: A. Oxygen. Oxygen should be readily available in case the pa2ent develops respiratory
distress following chest tube placement B. Sterile water. If the chest tubing becomes disconnected,
the end of the tubing should be placed in sterile water to restore the water seal. C. Occlusive dressing.
If the chest tubing becomes disconnected, the nurse should immediately place a gauze dressing of
the site. An occlusive dressing can also be necessary to prevent the redevelopment of a
pneumothrorax.

53. A nurse is preparing to administer a dose of a new prescrip2on of prednisone to a pa2ent who has
COPD. The nurse should monitor for which of the following adverse effects of this medica2on? (Select
all that apply)

A. Hypokalemia
B. Tachycardia
C. Fluid reten2on
D. Nausea
E. Black, tarry stools

Answer: C. Fluid reten7on. The nurse should observe for fluid reten2on. This is an adverse effect of
prednisone. E. Black, tarry stools. The nurse should monitor for black, tarry stools.

54. A nurse is providing discharge teaching to a pa2ent who has a new prescrip2on for prednisone for
asthma. Which of the following pa2ent statements indicates an understanding of the teaching:

A. "I will decrease my fluid intake while taking this medica2on."

B. "I will expect to have black, tarry stools."
C. "I will take my medica2on with meals."
D. "I will monitor for weight loss while on this medica2on."

Answer: C. "I will take my medica7on with meals." The pa2ent should take this medica2on with
food. Taking prednisone on an empty stomach can cause gastrointes2nal distress.

55. A nurse is preparing to administer a new prescrip2on for isoniazid to a pa2ent who has TB. The nurse
should instruct the pa2ent to report which of the following findings as an adverse effect of the
medica2on?

A. "You might no2ce yellowing of your skin."

B. "You might experience pain in your joints."
C. "You might no2ce 2ngling of your hands."
D. "You might experience a loss of appe2te."

Answer: C. "You might no7ce 7ngling of your hands." Tingling of the hands is an adverse effect of
isoniazid.
56. A nurse is providing discharge teaching to a pa2ent who has COPD and a new prescrip2on for
albuterol. Which of the following statements by the pa2ent indicates an understanding of the
teaching?

A. "This medica2on can increase my blood sugar levels."

B. "This medica2on can decrease my immune response."
C. "I can have an increase in my heart rate while taking this medica2on. "
D. "I can have mouth sores while taking this medica2on."

Answer: C. "I can have an increase in my heart rate while taking this medica7on. " Bronchodilators,
such as albuterol, can cause tachycardia.

57. A nurse is preparing to administer cispla2n IV to a pa2ent with lung cancer. The nurse should iden2fy
that which of the following findings is an adverse effect of this medica2on?

A. Hallucina2ons
B. Pruri2s
C. Hand and foot syndrome
D. Tinni2s

Answer: D. Tinni7s. An adverse effect of cispla2n is ototoxicity, which can cause 2nni2s.

58. A nurse is providing informa2on about TB to a group of pa2ents at a local community center. Which
of the following manifesta2ons should the nurse include in the teaching? (Select all that apply)

A. Persistent cough
B. Weight gain
C. Fa2gue
D. Night sweats
E. Purulent sputum

Answer: A. Persistent cough, C. Fa7gue, D. Night sweats, E. Purulent sputum

59. A nurse is preparing to assist a provider to withdraw arterial blood from a pa2ent's radial artery for
measurement of ABG. Which of the following ac2ons should the nurse plan to take?

A. Hyperven2late the pa2ent with 100% oxygen prior to obtaining the specimen.
B. Apply ice to the site aXer obtaining the specimen.
C. Perform an Allen's test prior to obtaining the specimen.
D. Release pressure applied to the puncture site 1 minute aXer the needle is withdrawn

Answer: C. Perform an Allen's test prior to obtaining the specimen. The nurse should ensure that
circula2on to the hand is adequate from the ulnar artery in case the radial artery is injured from the
blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
60. A nurse is providing instruc2ons about pursed-lip breathing for a pa2ent who has COPD with
emphysema. The nurse should explain that this breathing technique accomplishes which of the
following:

A. Increases oxygen intake

B. Promotes carbon dioxide elimina2on
C. Uses the intercostal muscles
D. Strengthens the diaphragm

Answer: B. Promotes carbon dioxide elimina7on. A pa2ent who has COPD with emphysema should
use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control
dyspnea. It slows the pa2ent's pace of breathing, making each breath more effec2ve. Pursed-lip
breathing releases trapped air in the lungs and prolongs exhala2on to slow the breathing rate. This
improved breathing paTern moves carbon dioxide out of the lungs more efficiently.

61. A nurse is providing preopera2ve teaching to a pa2ent who is to undergo a pneumonectomy. The
pa2ent states "I am afraid it will hurt to cough aXer surgery." Which of the following statements by
the nurse is appropriate:

A. AXer the surgeon removes your lung you will not need to cough.
B. I'll make sure you get a cough suppressant to keep you from straining the incision when you cough.
C. Don't worry. You will have a pump that delivers pain medica2on as you need it, so you will have
very liTle pain.
D. I will show you how to splint your incision while you cough.

Answer: D. I will show you how to splint your incision while you cough. The pa2ent who had a
pneumonectomy should cough to clear secre2ons from the remaining lung. The nurse should show
how to splint the incision to reduce pain while coughing.

62. A nurse is reviewing prescrip2ons for a client who has acute dyspnea and diaphoresis. The client
states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respira2ons
38/min, temperature 101.2 F, and blood pressure 100/54 mm Hg. Which of the following nursing
ac2ons is the priority?

A. No2fy the provider.

B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.

Answer: C. Administer oxygen therapy. When using the ABC approach to care, the nurse determines
that the priority finding is related to the respiratory status. Mee2ng oxygena2on needs by
administering oxygen therapy is the priority ac2on.
63. A nurse is providing teaching to a pa2ent about pulmonary func2on tests. Which of the following
tests measures the volume of air the lungs can hold at the end maximum inhala2on:

A. Total lung capacity

B. Vital lung capacity
C. Func2onal residual capacity
D. Residual volume

Answer: A. Total lung capacity. Pulmonary func2on tests are used to examine the effec2veness of
the lungs and iden2fy lung problems. Total lung capacity measures the amount of air the lungs can
hold aXer maximum inhala2on

64. A nurse is reviewing the health records of five clients. Which of the following clients are at risk for
developing respiratory distress syndrome? (Select all that apply)

A. A client who experienced a near-drowning incident.

B. A client following coronary artery bypass graX surgery.
C. A client who has a hemoglobin of 15.1 mg/dL
D. A client who has dyphagia.
E. A client who experienced a drug overdose.

Answer: A. A client who experienced a near-drowning incident. B. A client following coronary artery
bypass gra` surgery. D. A client who has dysphagia. E. A client who experienced a drug overdose.

65. A nurse is reinforcing teaching with a pa2ent on the purpose of taking a bronchodilator. Which of the
following pa2ent statements indicates an understanding of the teaching?

A. "This medica2on can decrease my immune response."

B. "I take this medica2on to prevent asthma aTacks."
C. "I need to take this medica2on with food."
D. "This medica2on has a slow onset to treat my symptoms."

Answer: B. "I take this medica7on to prevent asthma ahacks." A bronchodilator can prevent asthma
aTacks from occurring.

66. A nurse is reviewing the prescrip2ons for a client who has a pneumothorax. Which of the following
ac2ons should the nurse perform first?

A. Assess the client's pain.

B. Obtain a large-bore IV needle for decompression.
C. Administer lorazepam.
D. Prepare for chest tube inser2on.

Answer: B. Obtain a large-bore IV needle for decompression. The priority ac2on the nurse should
take when using the ABC approach to client care is to establish and maintain the client's respiratory
func2on. Obtaining a large-bore IV needle for decompression is the priority ac2on by the nurse.
67. A nurse is reviewing ABG laboratory results of a pa2ent who is in respiratory distress. The results are
pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing
which of the following acid-base imbalances:

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

Answer: B. Respiratory alkalosis. A pa2ent who is experiencing respiratory alkalosis will have an
increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include
hyperven2la2on, fever, and respiratory infec2ons.

68. A nurse is teaching about daily chest physiotherapy with a pa2ent who has cys2c fibrosis. The nurse
should instruct the pa2ent that which of the following is the purpose of the treatments:

A. To encourage deep breaths

B. To mobilize secre2ons in the airways
C. To dilate the bronchioles
D. To s2mulate the cough reflex

Answer: B. To mobilize secre7ons in the airways. The purpose of chest physiotherapy is to loosen
the pa2ent's secre2ons and promote drainage of secre2ons from the lungs. Chest physiotherapy
includes percussion, vibra2on, and promo2on of drainage by gravity.

69. A nurse is reviewing discharge instruc2ons for a client who experienced a pneumothorax. Which of
the following statements should the nurse use when teaching the client?

A. "No2fy your provider if you experience weakness."

B. "You should be able to return to work in 1 week."
C. "You need to wear a mask when in crowded areas."
D. "No2fy your provider if you experience a produc2ve cough."

Answer: D. "No7fy your provider if you experience a produc7ve cough." The client should no2fy the
provider of a produc2ve or persistent cough. This can indicate that the client might need treatment
of a respiratory infec2on.

70. A nurse is teaching a pa2ent who has TB. Which of the following statements should the nurse include
in the teaching?

A. "You will need to con2nue to take the mul2medica2on regimen for 4 months."
B. "You will need to provide sputum samples every 4 weeks to monitor the effec2veness of the
medica2on."
C. "You will need to remain hospitalized for treatment."
D. "You will need to wear a mask at all 2mes."

Answer: B. "You will need to provide sputum samples every 4 weeks to monitor the effec7veness
of the medica7on." The client who has tuberculosis needs to provide sputum samples every 2 to 4
weeks to monitor the effec2veness of the medica2on.
71. A nurse on a medical unit is caring for a pa2ent who apirated gastric contents prior to admission. The
nurse administers 100% oxygen by nonbreather mask aXer the pa2ent reports severe dyspnea. Which
of the following findings is a clinical manifesta2on of acute respiratory distress syndrome (ARDS):

A. Tympanic temperature of 38 C (100.4 F)

B. PaO2 50 mm Hg
C. Rhonchi
D. Hypopnea

Answer: B. PaO2 50 mm Hg. The pa2ent who has manifesta2ons of ARDS has a low PaO2 level even
with the administra2on of oxygen. Hypoxemia aXer treatment with oxygen is a manifesta2on of
ARDS.

72. A nurse on a med-surg unit is caring for a pa2ent who is postopera2ve following a hip replacement
surgery. The pa2ent reports feeling apprehensive and restless. Which of the follow findings should
the nurse recognize as an indica2on of a PE:

A. Sudden onset of dyspnea

B. Tracheal devia2on
C. Bradycardia
D. Difficulty swallowing

Answer: A. Sudden onset of dyspnea. Clinical manifesta2ons of a PE have a rapid onset. Dyspnea
occurs due to reduced blood flow to the lungs.

73. A nurse working in the ED is caring for a pa2ent following a chest trauma. Which of the following
findings indicates a tension pneumothorax:

A. Collapsed neck veins on the affected side

B. Collapsed neck veins on the unaffected side
C. Tracheal devia2on to the affected side
D. Tracheal devia2on to the unaffected side

Answer: D. Tracheal devia7on to the unaffected side. A tension pneumothorax results from free air
filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected
side.

74. A pa2ent is admiTed to the emergency department following a motorcycle crash. The nurse notes a
crackling sensa2on upon palpa2on on the right side of the pa2ent's chest. AXer no2fying the
provider, the nurse should document the finding as which of the following:

A. Fric2on rub
B. Crackles
C. Crepitus
D. Tac2le fremen2s

Answer: C. Crepitus. Crepitus, also called subcutaneous emphysema, is a coarse crackling sensa2on
that the nurse can feel when palpa2ng the skin surface over the pa2ent's chest. Crepitus indicates an
air leak into the subcutaneous 2ssue, which is oXen a clinical manifesta2on of a pneumothorax.