Chapter 30: Acute Respiratory Disorders MULTIPLE CHOICE 1.

A patient asks the nurse about how air goes from the nose to the lung. The nurse draws the route according to which sequence? 1. Trachea, lar ynx, bronchi 2. Pharynx, trachea, bronchi, alveoli 3. Bronchi, trachea, bronchio les 4. Larynx, trachea, alveoli, bronchi ANS: 2 The route of inspired air is pha rynx, trachea, bronchi, alveoli. PTS: REF: TOP: MSC: 1 DIF: Cognitive Level: Kno wledge 509-510, Figure 30-1 OBJ: N/A Physiology of Ventilation KEY: Nursing Proc ess Step: Implementation NCLEX: Physiological Integrity 2. The nurse charts that the patient had periods of tachypnea during the night. This means that the respiration rate was: 1. below 12 breaths/minute. 2. uneven, with periods of apnea. 3. gradually deepening, then shallow, and then periods o f apnea. 4. above 20 breaths/minute. ANS: 4 Tachypnea is a respiration rate over 20 breaths/minute. Option 1 describes bradypnea, option 2 describes Biots respir ations, and option 3 describes Cheyne-Stokes respirations. PTS: 1 DIF: Cognitive Level: Comprehension REF: 512, Table 30-1 OBJ: 1 TOP: Respiration Rate KEY: Nur sing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A 90-year-old patient complains to the nurse of shortness of breath after wal king up a flight of stairs. The nurse explains that this problem is a result of age-related changes, such as a(n): 1. flexible rib cage. 2. high arched diaphrag m. 3. increased chest movement. 4. enlargement of bronchioles. ANS: 4 Enlarged b ronchioles require the inspiration of greater amounts of air. Other age-related changes make increased inspiration difficult. PTS: 1 DIF: Cognitive Level: Compr ehension OBJ: 2 TOP: Age-Related Changes KEY: Nursing Process Step: Implementati on REF: 512

MSC: NCLEX: Physiological Integrity 4. When documenting the findings in the functional assessment portion of the nursi ng assessment for a patient with a respiratory disorder, the nurse would exclude : 1. occupation. 2. usual diet. 3. smoking history. 4. previous respiratory diso rders. ANS: 4 Previous respiratory disorders are assessed in the medical history p ortion of the assessment. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehens ion 1 TOP: Respiratory Assessment Nursing Process Step: Assessment NCLEX: Health Promotion and Maintenance REF: 513 5. To auscultate breath sounds in the right middle lobe from the anterior aspect , the nurse would place the diaphragm of the stethoscope at the: 1. second inter costal space. 2. third intercostal space. 3. fourth intercostal space. 4. fifth intercostal space. ANS: 4 The fifth intercostal space is the optimum position fo r auscultating the right middle lobe. PTS: 1 DIF: Cognitive Level: Application R EF: 514, Figure 30-4 OBJ: 3 TOP: Breath Sounds KEY: Nursing Process Step: Assess ment MSC: NCLEX: Physiological Integrity 6. If the nurse can hear no breath sounds in the lower right lobe, the nurse wou ld assess that the bronchus is: 1. partially filled with fluid. 2. narrowed by s pasm. 3. partially filled with thick mucus. 4. completely obstructed. ANS: 4 Ina bility to hear air movement means that the bronchus is obstructed. Options 1, 2, and 3 would produce adventitious sounds. PTS: 1 DIF: Cognitive Level: Analysis REF: 514 OBJ: 1 TOP: Breath Sounds KEY: Nursing Process Step: Assessment MSC: NC LEX: Physiological Integrity 7. A worried patient asks the nurse what is the advantage of a fluoroscopy. The best response would be that a fluoroscopy: 1. shows respiratory function in mot ion.

2. helps the physician evaluate ventilation-perfusion ratio. 3. allows the physi cian to take tissue samples. 4. facilitates the removal of fluid from the bronch i. ANS: 1 A fluoroscopy allows visualization of both lungs while the patient is in the process of ventilation. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Appli cation 3 TOP: Diagnostic Tests Nursing Process Step: Implementation NCLEX: Psych osocial Integrity REF: 515-516 8. The nursing intervention that would be inappropriate in the immediate postpro cedure care of a patient who has had a fiberoptic bronchoscopy would be to: 1. p lace the patient in a semi-Fowlers position. 2. offer fluids to assess swallowing ability. 3. assess for diminished breath sounds. 4. assess for stridor. ANS: 2 Patients are NPO until the gag reflex returns. PTS: REF: TOP: MSC: 1 DIF: Cognit ive Level: Application 517, Diagnostic Tests and Procedures table, 521 OBJ: 3 Di agnostic Tests KEY: Nursing Process Step: Implementation NCLEX: Physiological In tegrity 9. The nurse closely monitors bilateral breath sounds and chest movement followi ng a thoracentesis because: 1. fluid may quickly accumulate due to inflammation. 2. the lung may have been punctured during the procedure. 3. severe bronchospas m may cause atelectasis. 4. asthma may result postprocedure. ANS: 2 There is a p ossibility that the lung could be punctured during the procedure. Bronchospasm, fluid collection, and asthma are not concerns related to a thoracentesis. PTS: R EF: TOP: MSC: 1 DIF: Cognitive Level: Analysis 517, Diagnostic Tests and Procedu res table, 521 OBJ: 3 Diagnostic Tests KEY: Nursing Process Step: Assessment NCL EX: Safe, Effective Care Environment 10. The nurse will record a positive reading of a tuberculin skin test when it i s assessed: 1. 1 day postinjection with a 10-mm area of redness and swelling. 2. 2 days postinjection with an 8-mm area of redness and swelling. 3. 4 days posti njection with a 3-mm area of redness and swelling. 4. 5 days postinjection with a 2-mm area of redness and swelling. ANS: 2

A positive reading of a TB skin test is an area of redness and swelling of 5 mm or larger 24 to 48 hours postinjection. PTS: REF: TOP: MSC: 1 DIF: Cognitive Lev el: Comprehension 517, Diagnostic Tests and Procedures table, 521 OBJ: 3 Diagnos tic Tests KEY: Nursing Process Step: Assessment NCLEX: Physiological Integrity 11. Prior to doing the arterial stick for an arterial blood gas, the nurse perfo rms an Allen test. The purpose of this test is to assess the: 1. respiratory fun ction. 2. tidal volume. 3. concentration of oxygen. 4. perfusion of the hand. AN S: 4 The perfusion of the hand by the radial and ulnar arteries is assessed beca use the puncture of the radial artery might cause it to occlude. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 3 TOP: Diagnostic Tests Nursing Proce ss Step: Assessment NCLEX: Safe, Effective Care Environment REF: 519, Figure 307 12. Which of these interventions would be inappropriate in performing a tracheal suction? 1. Administer oxygen prior to procedure. 2. Leave thumb off the suctio n control on insertion. 3. Maintain suction pressure between 80 and 100 mm Hg. 4 . Limit suction pass to 20 seconds. ANS: 4 Suction pass should be limited to 10 seconds. All other implementations listed are appropriate. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 4 TOP: Tracheal Suction Nursing Process Step: Implementation NCLEX: Physiological Integrity REF: 524 13. A severely dyspneic and cyanotic patient enters the ER. The nurse gives the patient oxygen at: 1. 2 L to preserve the hypoxic drive. 2. 6 L to relieve the d yspnea. 3. 8 L, humidified, to liquefy secretions. 4. 10 L, humidified aerosol, to dilate bronchi. ANS: 1 Low-dose oxygen is a safe initial dose in case the hyp oxic drive must be preserved, especially for a patient whose history is unknown.

PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 4 TOP: Oxygen Administration Nursing Process Step: Implementation NCLEX: Safe, Effective Care Environment REF: 527 14. The discharge planning for a patient with sleep apnea includes a CPAP ventil ation device that: 1. delivers 100% oxygen during apneic periods. 2. delivers ox ygen per aerosol to dilate the alveoli. 3. activates a burst of pressure if the patients respiration drops below a preset rate. 4. maintains a continuous pressur e in the airway to avoid apnea. ANS: 4 CPAP machines maintain positive pressure delivered per nose mask to prevent apnea. PTS: 1 DIF: Cognitive Level: Applicati on REF: 528 OBJ: 4 TOP: CPAP KEY: Nursing Process Step: Planning MSC: NCLEX: Phy siological Integrity 15. The assessment that ensures the nurse that the chest tube in a water seal dr ainage device is working correctly is the: 1. constant bubbling in the suction c ontrol chamber. 2. decrease of accumulation in the drainage chamber. 3. fluctuat ion of the column of water in the water seal. 4. constant bubbling in the water seal chamber. ANS: 3 The fluctuation of the level in the water seal indicates pa tency of the tubes with the reinflating lung. Constant bubbling in the wet sucti on control is normal. Constant bubbling in the water seal indicates an air leak. Decreasing drainage is normal. PTS: 1 DIF: Cognitive Level: Application REF: 52 9 OBJ: 4 TOP: Water Seal Drainage KEY: Nursing Process Step: Assessment MSC: NCL EX: Physiological Integrity 16. The assessment by the nurse at the bedside of a patient with a chest tube at tached to a water seal drainage that would require intervention is: 1. dependent loops in the chest tube. 2. the patient is in a semi-Fowlers position. 3. changi ng level of water in the water seal chamber. 4. level of drainage increase of 20 mL in 8 hours. ANS: 1 Dependent loops in the chest tube can collect drainage an d occlude the system. PTS: 1 DIF: Cognitive Level: Application REF: 529 OBJ: 4 T OP: Water Seal Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physio logical Integrity

17. A home health nurse who is following an 88-year-old patient with severe hype rtension in addition to his respiratory problem notices several drugs on the bed side table. The medication that the nurse would suggest the patient avoid is: 1. aspirin. 2. antitussive. 3. expectorant. 4. decongestant. ANS: 4 Decongestants increase the blood pressure. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysi s 5 TOP: Respiratory Drugs Nursing Process Step: Assessment NCLEX: Safe, Effecti ve Care Environment REF: 531 18. To enhance gas exchange, the nurse would position a patient who had a left p neumonectomy this morning: 1. on the right side. 2. on the left side. 3. in a se mi-Fowlers position. 4. flat, with a small pillow. ANS: 3 Elevation of the head h elps gas exchange in a new pneumonectomy. Complete side-lying on the unaffected side may cause mediastinal shift. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Ap plication 5 TOP: Postpneumonectomy Nursing Process Step: Implementation NCLEX: P hysiological Integrity REF: 530 19. A patient with acute bronchitis is being discharged with a prescription for an antimicrobial to be taken for the next 14 days. In the discharge teaching, th e nurse will stress: 1. taking the drug on an empty stomach before meals. 2. com pleting the entire course prescribed. 3. the need for thorough oral hygiene. 4. keeping the fluid intake of 500 mL/day. ANS: 2 The entire course of the prescrip tion should be taken to destroy the pathogen completely; otherwise, the pathogen may become resistant to the drug. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: C omprehension 6 TOP: Acute Bronchitis Nursing Process Step: Planning NCLEX: Healt h Promotion and Maintenance REF: 536 20. The group that the nurse would advise to have a vaccination with conjugated pneumococcal vaccine is:

1. 2. 3. 4. adult diabetics. persons 65 years or older. children younger than 24 months. per sons with cardiovascular disorders. ANS: 3 The conjugated product is especially designed for young children. Unconju gated vaccine is recommended for older adults and persons with cardiovascular di sorders. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 5 TOP: Pneumo nia Vaccine Nursing Process Step: Implementation NCLEX: Health Promotion and Mai ntenance REF: 536 21. To reduce the risk of aspiration in a patient who is receiving enteral feedi ngs running at 70 mL/hour, the nurse should: 1. check the position of the tube e very shift. 2. notify the charge nurse or physician about a residual of 15 mL. 3 . elevate the head during and for 10 minutes following the feeding. 4. position the patient on the left side after the feeding. ANS: 2 A residual of over 20% of the hourly rate should be reported so that the rate can be reduced. PTS: OBJ: K EY: MSC: 1 DIF: Cognitive Level: Application 5 TOP: Aspiration Pneumonia Nursing Process Step: Implementation NCLEX: Safe, Effective Care Environment REF: 537 22. The symptoms of hypoxemia for which the nurse should be alert are: 1. restle ssness, tachycardia, and tachypnea. 2. bradycardia, cyanosis, and restlessness. 3. dyspnea, flushed face, and tachycardia. 4. cyanosis, nausea, and bradycardia. ANS: 1 The universal symptoms of hypoxemia, regardless of cause, are restlessne ss, tachycardia, and tachypnea. PTS: 1 DIF: Cognitive Level: Comprehension REF: 538 OBJ: 6 TOP: Hypoxemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Phys iological Integrity 23. A patient comes to the ER with a sucking chest wound. Wh ich type of dressing should the nurse apply to begin the process of lung reinfla tion? 1. A petroleum dressing covered with an airtight bandage 2. No dressing at all 3. A pillow weighted down with a sandbag 4. An air-occlusive dressing taped on three sides (flutter dressing) ANS: 4

The flutter dressing occludes air from entering but allows air to escape, avoidi ng a tension pneumothorax and mediastinal shift. PTS: OBJ: KEY: MSC: 1 DIF: Cogn itive Level: Analysis 6 TOP: Pneumothorax Care Nursing Process Step: Implementat ion NCLEX: Safe, Effective Care Environment REF: 543 24. When the nurse observes the paradoxical movement in a patient with a flail c hest who has marked dyspnea, the nurse should prepare for: 1. a thoracotomy. 2. an intubation. 3. a thoracentesis. 4. a body cast. ANS: 2 A patient with an unst able chest usually requires intubation and mechanical ventilation. PTS: 1 DIF: C ognitive Level: Analysis REF: 545 OBJ: 6 TOP: Flail Chest KEY: Nursing Process S tep: Planning MSC: NCLEX: Physiological Integrity 25. The intervention that would be inappropriate for decreasing the risk of fur ther emboli in a patient with a pulmonary embolism is: 1. carefully applying com pression stockings. 2. passive range of motion, especially the lower limbs. 3. p lacing pillows under the knees to elevate the legs. 4. ambulating frequently. AN S: 3 Nothing should be placed under the knees, where circulation might be impair ed. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 6 TOP: Pulmonary Emb olism Nursing Process Step: Implementation NCLEX: Physiological Integrity REF: 6 47 MULTIPLE RESPONSE 1. When a patient complains of tachypnea, the nurse explains t hat the breathing pattern has altered because the (select all that apply): 1. in creased pH levels stimulate chemoreceptors in the aorta and carotid, which stimu lates the phrenic nerve. 2. decreased O2 level signals the phrenic nerve to alte r the respiration rate. 3. muscles of respiration respond to the stimulus. 4. br ain has become hypoxic and causes an alteration in the respiration rate. 5. defl ated lung tissue results in an altered respiration rate. ANS: 2, 3

A decreased O2 level stimulates the phrenic nerve to signal the muscles of respi ration to do the work of breathing. A decreasing pH level is the stimulus to the chemoreceptors. Neither the brain nor the lungs signal for tachypnea. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 1 TOP: Respiration Center Nursi ng Process Step: Implementation NCLEX: Health Promotion and Maintenance REF: 512 2. During the physical examination of a patient with respiratory difficulty, the nurse notices other clues to respiratory dysfunction, which are (select all tha t apply): 1. flushed facial skin. 2. cyanotic nailbeds. 3. protruding abdomen. 4 . curved spine. 5. clubbed fingers. ANS: 2, 5 Clues to respiratory dysfunction a re cyanotic nailbeds and clubbed fingers from inadequate oxygenation. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 1 TOP: Clues to Respiratory Dysf unction Nursing Process Step: Assessment NCLEX: Health Promotion and Maintenance REF: 515 3. Just prior to the scheduled spirometry test, the nurse instructs a patient to (select all that apply): 1. not smoke. 2. use bronchodilator inhaler. 3. exerci se a few minutes. 4. drink two glasses of fluid. 5. avoid eating. ANS: 1 Patient s should not smoke, use bronchodilators, or exercise just prior to the test. Nor malsized meals and drinking fluid do not affect the test adversely. PTS: 1 DIF: Cognitive Level: Application REF: 519 OBJ: 3 TOP: Spirometry KEY: Nursing Proces s Step: Implementation MSC: NCLEX: Health Promotion and Maintenance OTHER 1. The nurse instructing a patient in deep breathing and coughing directs the patient to (place the options in the appropriate sequence): 1. place the hand on the abd omen to check rise and fall. 2. inhale through the nose, pause 1 to 3 seconds, a nd then exhale. 3. assume a high Fowlers position.

4. take 4 to 6 deep breaths. 5. cough deeply. ANS: 3, 1, 2, 4, 5 The exercise is done in a sequence to ensure open bronchioles and good deep cough. PTS: OBJ: KE Y: MSC: 1 DIF: Cognitive Level: Analysis 3 TOP: Deep Breathing and Coughing Nurs ing Process Step: Implementation NCLEX: Health Promotion and Maintenance REF: 52 2