1. The nurse is caring for a male client with a chest
Hypoxia - As the respiratory center in the brain
tube. If the chest drainage system is accidentally
disconnected, what should the nurse plan to do?
a. Place the end of the chest tube in a container of
sterile saline. - If a chest drainage system is
disconnected, the nurse may place the end of the chest
tube in a container of sterile saline or water to prevent
air from entering the chest tube, thereby preventing
negative respiratory pressure.
2. A male elderly client is admitted to an acute care
facility with influenza. The nurse monitors the
client closely for complications. What is the most
common complication of influenza?
b. Pneumonia - Pneumonia is the most common
complication of influenza. It may be either primary
influenza viral pneumonia or pneumonia secondary to
a bacterial infection. Other complications of influenza
include myositis, exacerbation of chronic obstructive
pulmonary disease, and Reye's syndrome.
Myocarditis, pericarditis, transverse myelitis, and
encephalitis are rare complications of influenza.
3. A female 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:
b. 5 to 20 minutes. - Initially, the nurse should plug
the opening in the tracheostomy tube for 5 to 20
minutes, and then gradually lengthen this interval
according to the client's respiratory status.
4. Gina, a home health nurse is visiting a home
care client with advanced lung cancer. Upon
assessing the client, the nurse discovers wheezing,
bradycardia, and a respiratory rate of 10
breaths/minute. These signs are associated with
which condition?
a.
becomes depressed, hypoxia occurs, producing
wheezing, bradycardia, and a decreased respiratory
rate.
5. A male 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?
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.
6. A female client with interstitial lung disease is
prescribed prednisone (Deltasone) to control
inflammation. During client teaching, the nurse
stresses the importance of taking prednisone
exactly as prescribed and cautions against
discontinuing the drug abruptly. A client who
discontinues prednisone abruptly may experience:
b. acute adrenocortical insufficiency. -
Administration of a corticosteroid such as prednisone
suppresses the body's natural cortisol secretion, which
may take weeks or months to normalize after drug
discontinuation. Abruptly discontinuing such therapy
may cause the serum cortisol level to drop low
enough to trigger acute adrenocortical insufficiency.
Hyperglycemia, glycosuria, GI bleeding, restlessness,
and seizures are common adverse effects of
corticosteroid therapy, not its sudden cessation
7. A male client is admitted to the health care
facility for treatment of chronic obstructive
pulmonary disease. Which nursing diagnosis is
most important for this client?
d. Impaired gas exchange related to airflow
obstruction - A patent airway and an adequate
breathing pattern are the top priority for any client,
making impaired gas exchange related to airflow
obstruction the most important nursing diagnosis. The
other options also may apply to this client but are less
important.
8. 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?
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.
9. A male adult client with cystic fibrosis is
admitted to an acute care facility with an acute
respiratory infection. Prescribed respiratory
treatment includes chest physiotherapy. When
should the nurse perform this procedure?
b. At least 2 hours after a meal - The nurse should
perform chest physiotherapy at least 2 hours after a
meal to reduce the risk of vomiting and aspiration.
Performing it immediately before a meal may tire the
client and impair the ability to eat. Percussion and
vibration, components of chest physiotherapy, may
worsen bronchospasms; therefore, the procedure is
contraindicated in clients with bronchospasms.
Secretions that have mobilized (especially when
suction equipment isn't available) are contraindication
for postural drainage, another component of chest
physiotherapy
10. On arrival at the intensive care unit, a
critically ill female client suffers respiratory arrest
and is placed on mechanical ventilation. The
physician orders pulse oximetry to monitor the
client's arterial oxygen saturation (SaO2)
noninvasively. Which vital sign abnormality may
alter pulse oximetry values?
d. Hypotension - Hypotension, hypothermia, and
vasoconstriction may alter pulse oximetry values by
reducing arterial blood flow. Likewise, movement of
the finger to which the oximeter is applied may
interfere with interpretation of SaO2. All of these
conditions limit the usefulness of pulse oximetry.
Fever, tachypnea, and tachycardia don't affect pulse
oximetry values directly
11. The nurse is caring for a male client who
recently underwent a tracheostomy. The first
priority when caring for a client with a
tracheostomy is:
b. keeping his airway patent. - Maintaining a patent
airway is the most basic and critical human need. All
other interventions are important to the client's well-
being but not as important as having sufficient oxygen
to breathe.
12. For a male client with chronic obstructive
pulmonary disease, which nursing intervention
would help maintain a patent airway?
c. Teaching the client 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 client's ability to maintain a patent airway, causing
a high risk of infection from pooled secretions.
13. The amount of air inspired and expired with
each breath is called:
a. tidal volume. - Tidal volume is the amount of air
inspired and expired with each breath. Residual
volume is the amount of air remaining in the lungs
after forcibly exhaling. Vital capacity is the maximum
amount of air that can be moved out of the lungs after
maximal inspiration and expiration. Dead-space
volume is the amount of air remaining in the upper
airways that never reaches the alveoli. In pathologic
conditions, dead space may also exist in the lower
airway
14. A male client with pneumonia develops
respiratory failure and has a partial pressure of
arterial oxygen of 55 mm Hg. He's placed on
mechanical ventilation with a fraction of inspired
oxygen (FIO2) of 0.9. The nursing goal should be
to reduce the FIO2 to no greater than:
c. 0.5 - An FO2 greater than 0.5 for as little as 16 to
24 hours can be toxic and can lead to decreased gas
diffusion and surfactant activity. The ideal oxygen
source is room air F IO 2 0.18 to 0.21.
15. Nurse Mickey is administering a purified
protein derivative (PPD) test to a homeless client.
Which of the following statements concerning PPD
testing is true?
b. A positive reaction indicates that the client has
been exposed to the disease. - A positive reaction
means the client has been exposed to TB; it isn't
conclusive of the presence of active disease. A
positive reaction consists of palpable swelling and
induration of 5 to 15 mm. It can be read 48 to 72
hours after the injection. In clients with positive
reactions, further studies are usually done to rule out
active disease. In immunosuppressed clients, a
negative reaction doesn't exclude the presence of
active disease.
16. Before weaning a male client from a ventilator,
which assessment parameter is most important for
the nurse to review?
b. Baseline arterial blood gas (ABG) levels - Before
weaning a client from mechanical ventilation, it's
most important to have baseline ABG levels. During
the weaning process, ABG levels will be checked to
assess how the client is tolerating the procedure.
Other assessment parameters are less critical.
Measuring fluid volume intake and output is always
important when a client is being mechanically
ventilated. Prior attempts at weaning and ECG results
are documented on the client's record, and the nurse
can refer to them before the weaning process begins.
17. Which of the following would be most
appropriate for a male client with an arterial
blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2
saturation 96%, HCO3 24 mEq/L, and PaO2 94
mm Hg?
b. Instruct the client to breathe into a paper bag. -
The ABG results reveal respiratory alkalosis. The best
intervention to raise the PaCO2 level would be to
have the client breathe into a paper bag.
18. A female client is receiving supplemental
oxygen. When determining the effectiveness of
oxygen therapy, which arterial blood gas value is
most important?
c. Partial pressure of arterial oxygen (PaO2) - The
most significant and direct indicator of the
effectiveness of oxygen therapy is the PaO2 value.
Based on the PaO2 value, the nurse may adjust the
type of oxygen delivery (cannula, venturi mask, or
mechanical ventilator), flow rate, and oxygen
percentage. The other options reflect the client's
ventilation status, not oxygenation.
19. Nurse Julia is caring for a client who has a
tracheostomy and temperature of 103° F (39.4° C).
Which of the following interventions will most
likely lower the client's arterial blood oxygen
saturation?
a. Endotracheal suctioning - Endotracheal
suctioning removes secretions as well as gases from
the airway and lowers the arterial oxygen saturation
(SaO2) level. Coughing and incentive spirometry
improves oxygenation and should raise or maintain
oxygen saturation. Because of superficial
vasoconstriction, using a cooling blanket can lower
peripheral oxygen saturation readings, but SaO2
levels wouldn't be affected
20. For a male client who has a chest tube
connected to a closed water-seal drainage system,
the nurse should include which action in the plan
of care?
a. Measuring and documenting the drainage in the
collection chamber - The nurse should measure and
document the amount of chest tube drainage regularly
to detect abnormal drainage patterns, such as may
occur with a hemorrhage (if excessive) or a blockage
(if decreased). Continuous bubbling in the water-seal
chamber indicates a leak in the closed chest drainage
system, which must be corrected. The nurse should
keep the collection chamber below chest level to
allow fluids to drain into it. The nurse should not strip
chest tubes because doing so may traumatize the
tissue or dislodge the tube.
21. Nurse Eve 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:
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 highprotein 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)
22. A black male 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:
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.
23. A female client with asthma is receiving a
theophylline preparation to promote
bronchodilation. Because of the risk of drug
toxicity, the nurse must monitor the client's serum
theophylline level closely. The nurse knows that
the therapeutic theophylline concentration falls
within which range?
d. 10 to 20 mcg/ml - The therapeutic serum
theophylline concentration ranges from 10 to 20
mcg/ml. Values below 10 mcg/ml aren't therapeutic
24. A male client is to receive I.V. vancomycin
(Vancocin). When preparing to administer this
drug, the nurse should keep in mind that:
a. vancomycin should be infused over 60 to 90
minutes in a large volume of fluid. - To avoid a
hypotensive reaction from rapid I.V. administration,
the nurse should infuse vancomycin slowly, over 60
to 90 minutes, in a large volume of fluid. Although
neutropenia may occur in approximately 5% to 10%
of clients receiving vancomycin, this adverse effect
reverses rapidly when the drug is discontinued
25. Before seeing a newly assigned female client
with respiratory alkalosis, the nurse quickly
reviews the client's medical history. Which
condition is a predisposing factor for respiratory
alkalosis?
c. Extreme anxiety - Extreme anxiety may lead to
respiratory alkalosis by causing hyperventilation,
which results in excessive carbon dioxide (CO2) loss.
Other conditions that may set the stage for respiratory
alkalosis include fever, heart failure, and injury to the
brain's respiratory center, overventilation with a
mechanical ventilator, pulmonary embolism, and
early salicylate intoxication. Type 1 diabetes mellitus
may lead to diabetic ketoacidosis; the deep, rapid
respirations occurring in this disorder (Kussmaul's
respirations) don't cause excessive CO2 loss.
Myasthenia gravis and narcotic overdose suppress the
respiratory drive, causing CO2 retention, not CO2
loss; this may lead to respiratory acidosis, not
alkalosis.
25. 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:
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.
27. Pulmonary disease (COPD), which nursing
action best promotes adequate gas exchange?
c. Using a high-flow Venturi mask to deliver
oxygen as prescribed - The client 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
wouldn't affect gas exchange or be sufficient to
liquefy secretions, which are common in COPD.
Clients with COPD and respiratory distress should be
placed in high Fowler's position and shouldn't receive
sedatives or other drugs that may further depress the
respiratory center
28. Nurse Joana 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. - 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.)
29. A male client who takes theophylline for
chronic obstructive pulmonary disease is seen in
the urgent care center for respiratory distress.
Once the client is stabilized, the nurse begins
discharge teaching. The nurse would be especially
vigilant to include information about complying
with medication therapy if the client's baseline
theophylline level was:
a. 10 mcg/mL - The therapeutic range for the serum
theophylline level is 10 to 20 mcg/mL. If the level is
below the therapeutic range, the client
experience
frequent exacerbations of the disorder.
30. Nurse Kim is caring for a client with a
pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the
suction control chamber. What action
appropriate?
a. Do nothing, because this is an expected finding. -
Continuous gentle bubbling should be noted in the
suction control chamber.
31. A nurse has assisted a physician with the
insertion of a chest tube. The nurse monitors the
adult 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?
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.
32. The nurse caring for a male client with a chest
tube turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action
is to:
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. 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,
may but this is not the initial action.
33. Nurse Paul is assisting a physician with the
removal of a chest tube. The nurse should instruct
the client to:
d. Perform the Valsalva maneuver. - When the
chest tube is removed, the client is asked to perform
is 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
34. While changing the tapes on a tracheostomy
tube, the male client coughs and the tube is
dislodged. The initial nursing action is to:
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
35. A nurse is caring for a male client immediately
after removal of the endotracheal tube. The nurse
reports which of the following signs immediately if
experienced by the client?
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.
36. An emergency room nurse is assessing a female
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?
b. Diminished breathe 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
37. A nurse is caring for a male 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?
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.
38. 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:
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.
39. A nurse performs an admission assessment on
a female client with a diagnosis of tuberculosis.
The nurse reviews the results of which diagnostic
test that will confirm this diagnosis?
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
40. The nursing instructor asks a nursing student to
describe the route of transmission of tuberculosis. The
instructor concludes that the student understands this
information if the student states that the tuberculosis
is transmitted by:
b. The airborne route - Tuberculosis is an infectious
disease caused by the bacillus Mycobacterium
tuberculosis and is spread primarily by the airborne
route.
41. 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:
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.
42. 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:
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.
43. Nurse Hannah is preparing to obtain a sputum
specimen from a client. Which of the following
nursing actions will facilitate obtaining the
specimen?
b. Having the clients take three 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.
44. A nurse is caring for a female client after a
bronchoscope and biopsy. Which of the following
signs, if noted in the client, should be reported
immediately to the physicians?
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.
45. 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:
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.
46. 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 of
the following is the appropriate
nursing intervention?
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.

47. An unconscious male client is admitted to an
emergency room. Arterial blood gas measurements
reveal a pH of 7.30, a low bicarbonate level, a
normal carbon dioxide level, a normal oxygen
level, and an elevated potassium level. These
results indicate the presence of:
a. Metabolic acidosis - In an acidotic condition, the
pH would be low, indicating the acidosis. In addition,
a low bicarbonate level along with the low pH would
indicate a metabolic state.
48. A female 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 - The common clinical manifestations of
pulmonary embolism are tachypnea, tachycardia,
dyspnea, and chest pain.
49. A nurse teaches a male client about the use of a
respiratory inhaler. Which action by the client
indicates a need for further teaching?
a. Inhales the mist and quickly exhales - The client
should be instructed to hold his or her breath for at
least 10 to 15 seconds before exhaling the mist. O
50. A female client has just returned to a nursing
unit following bronchoscopy. A nurse would
implement which of the following nursing
interventions for this client?
d. Ensuring the return of the gag reflex before
offering food or fluids - After bronchoscopy, the
nurse keeps the client on NPO status until the gag
reflex returns because the preoperative sedation and
local anesthesia impair swallowing and the protective
laryngeal reflexes for a number of hours. Additional
fluids are unnecessary because no contrast dye is used
that would need flushing from the system. Atropine
and midazolam would be administered before the
procedure, not after.
51. A nurse is assessing the respiratory status of a
male client who has suffered a fractured rib. The
nurse would expect to note which of the following?
d. Pain, especially with inspiration - Rib fractures
are a common injury, especially in the older client,
and result from a blunt injury or a fall. Typical signs
and symptoms include pain and tenderness localized
at the fracture site and exacerbated by inspiration and
palpation, shallow respirations, splinting or guarding
the chest protectively to minimize chest movement,
and possible bruising at the fracture site. Paradoxical
respirations are seen with flail chest.
52. A female client with chest injury has suffered
flail chest. A nurse assesses the client for which
most distinctive sign of flail chest?
c. Paradoxical chest movement - Flail chest results
from fracture of two or more ribs in at least two
places each. This results in a "floating" section of ribs.
Because this section is unattached to the rest of the
bony rib cage, this segment results in paradoxical
chest movement. This means that the force of
inspiration pulls the fractured segment inward, while
the rest of the chest expands. Similarly, during
exhalation, the segment balloons outward while the
rest of the chest moves inward. This is a telltale sig
53. A male client has been admitted with chest
trauma after a motor vehicle accident and has
undergone subsequent intubation. A nurse checks
the client when the high-pressure alarm on the
ventilator sounds, and notes that the client has
absence of breathe sounds in right upper lobe of
the lung. The nurse immediately assesses for other
signs of:
a. Right pneumothorax - Pneumothorax is
characterized by restlessness, tachycardia, dyspnea,
pain with respiration, asymmetrical chest expansion,
and diminished or absent breath sounds on the
affected side. Pneumothorax can cause increased
airway pressure because of resistance to lung
inflation. Acute respiratory distress syndrome and
pulmonary embolism are not characterized by absent
breath sounds. An endotracheal tube that is inserted
too far can cause absent breath sounds, but the lack
of breath sounds most likely would be on the left side
because of the degree of curvature of the right and left
main stem bronchi.
54. A nurse is teaching a male client with chronic
respiratory failure how to use a metered-dose
inhaler correctly. The nurse instructs the client to:
c. Hold the breath after inhalation - Instructions for
using a metered-dose inhaler include shaking the
canister, holding it right side up, inhaling slowly and
evenly through the mouth, delivering one spray per
breath, and holding the breath after inhalation.
55. A nurse is assessing a female client with
multiple trauma who is at risk for developing
acute respiratory distress syndrome. The nurse
assesses for which earliest sign of acute respiratory
distress syndrome?
d. Increased respiratory rate - The earliest
detectable sign of acute respiratory distress syndrome
is an increased respiratory rate, which can begin from
1 to 96 hours after the initial insult to the body. This is
followed by increasing dyspnea, air hunger, retraction
of accessory muscles, and cyanosis. Breath sounds
may be clear or consist of fine inspiratory crackles or
diffuse coarse crackles.
56. A nurse is taking pulmonary artery catheter
measurements of a male client with acute
respiratory distress syndrome. The pulmonary
capillary wedge pressure reading is 12mm Hg. The
nurse interprets that this readings is:
c. Normal and expected - The normal pulmonary
capillary wedge pressure (PCWP) is 8 to 13 mmHg,
and the client is considered to have high readings if
they exceed 18 to 20 mmHg. The client with acute
respiratory distress syndrome has a normal PCWP,
which is an expected finding because the edema is in
the interstitium of the lung and is noncardiac
57. A nurse is assessing a male client with chronic
airflow limitations and notes that the client has a
"barrel chest." The nurse interprets that this
client has which of the following forms of chronic
airflow limitations?
a. Emphysema - The client with emphysema has
hyperinflation of the alveoli and flattening of the
diaphragm. These lead to increased anteroposterior
diameter, referred to as "barrel chest." The client also
has dyspnea with prolonged expiration and has
hyperresonant lungs to percussion
58. A nurse is caring for a female client diagnosed
with tuberculosis. Which assessment, if made by
the nurse, is inconsistent with the usual clinical
presentation of tuberculosis and may indicate the
development of a concurrent
problem?
b. High-grade fever - The client with tuberculosis
usually experiences cough (productive or
nonproductive), fatigue, anorexia, weight loss,
dyspnea, hemoptysis, chest discomfort or pain, chills
and sweats (which may occur at night), and a low
grade fever.

59. 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. - 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
60. Nurse Oliver observes constant bubbling in the
water-seal chamber of a closed chest drainage
system. What should the nurse conclude?
c. The system has an air leak. - Constant bubbling in
the chamber indicates an air leak and requires
immediate intervention. The client with a expansion may indicate pleural effusion, atelectasis,
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.
61. For a male client with an endotracheal (ET)
tube, which nursing action is most essential?
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.
62. The nurse assesses a male client's respiratory
status. Which observation indicates that the client
is experiencing difficulty breathing?
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.
63. 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:
d. Chest movements. - The nurse observes
respiratory excursion to help assess chest movements.
Normally, thoracic expansion is symmetrical; unequal
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.
64. 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:
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.
65. 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 - 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.
66. 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 - 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.
67. 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?
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.