Deck 29: Respiratory System Function, Assessment, and Therapeutic Measures

Question 1

The nurse recognizes that the elderly patient's poor perfusion of body tissues is due to the patient's diagnosis of a blood disorder. Which of the following would best explain the patient's issue?

A)The patient's dehydration prevents circulation of free oxygen in the blood plasma.
B)The patient's low red blood cell (RBC) count prevents oxygen from adhering to the membranes.
C)The patient's low hemoglobin count provides less surface for the adherence of oxygen.
D)The patient's high white blood cell (RBC) count signifies an infection and need for more oxygen.

Answer 1

The patient's low hemoglobin count provides less surface for the adherence of oxygen.

Question 2

The nurse is caring for a patient who becomes dyspneic, which the patient states is a "6 out of 10" on the dyspnea scale. Which action should the nurse do first?

A)Contact the health care provider (HCP) for an order for supplemental oxygen.
B)Assist the patient to sit at the edge of the bed to lean over the bedside table.
C)Apply nasopharyngeal suction intermittently until the airway is cleared.
D)Apply supplemental oxygen and notify the HCP of this action.

Answer 2

Assist the patient to sit at the edge of the bed to lean over the bedside table.

Question 3

The nurse instructs the patient with chronic obstructive pulmonary disease (COPD) on methods to lower the risk of lung complications. One technique is the "long huff" cough. What is the rationale for this type of coughing exercise?

A)Increases oxygenation
B)Removes excess carbon dioxide
C)Ensures thorough lung expansion
D)Helps to open and clear smaller airways

Answer 3

Helps to open and clear smaller airways

Question 4

A patient's arterial blood gas analysis shows a PaCO₂ of 68 mm Hg. What action should the nurse take first?

A)Notify the HCP.
B)Remove the patient's oxygen mask.
C)Have the patient breathe into a paper bag.
D)Place the patient in a Fowler's position.

Question 5

The nurse is caring for patients in a respiratory unit and hears a ventilator alarm from the hallway. Which action should the nurse take first?

A)Assess the patient.
B)Call a code blue.
C)Check the machine.
D)Suction the patient.

Question 6

The nurse is caring for the patient who is experiencing uncontrolled diabetes mellitus. The patient is exhibiting Kussmaul's respirations. What best describes the compensatory action for the respirations?

A)The body is compensating for the metabolic acidosis by releasing CO₂ via the lungs.
B)The body is compensating for the metabolic alkalosis by retaining CO₂ via the lungs.
C)The body is compensating for the respiratory acidosis by retaining the CO₂ in the lungs.
D)The body is compensating for the respiratory alkalosis by releasing the CO₂ in the lungs.

Question 7

The nurse is reviewing a patient's pulmonary function tests. Which of the following best describes functional residual capacity?

A)It is the air inspired and expired in one breath.
B)It is the maximum amount of air beyond tidal volume.
C)It is the air remaining in the lungs after normal expiration.
D)It is the amount of air expired forcefully after maximum inspiration.

Question 8

A patient with a chest drainage system is admitted to the medical-surgical unit. The nurse notes vigorous bubbling in the water seal chamber of the system. What should the nurse do?

A)Decrease the level of suction until bubbling ceases.
B)Ask the patient to splint the site and cough forcefully.
C)No action is necessary; this is an expected finding.
D)Examine the entire system and tubing for air leaks.

Question 9

The nurse is preparing to suction a patient's tracheostomy. What is the maximum of time that the nurse can suction safely with each pass of the catheter? 1.3 to 5 seconds

A)10 to 15 seconds
B)15 to 25 seconds
C)25 to 45 seconds

Question 10

The patient arrives to the emergency department with a stab wound to the chest. The HCP places two chest tubes to drain air and blood from the patient's thoracic cavity. The nurse sets up the chest tube drainage system. Where should the nurse place the system?

A)Attached to the foot of the bed
B)Along the side of the patient's knee
C)Below the level of the patient's chest
D)At the level of the patient's clavicle

Question 11

The nurse is caring for a patient with chronic lung disease who is receiving oxygen via a nonrebreathing mask. Which observation indicates to the nurse that the system is functioning as expected?

A)Both side vents open on expiration, reservoir bag inflated
B)Both side vents open on inspiration, reservoir bag deflated
C)Both side vents closed on inspiration, reservoir bag inflated
D)Both side vents closed on expiration, reservoir bag deflated

Question 12

The nurse is providing discharge instructions for a patient who is to use an adrenergic bronchodilator. Which of the following responses would best demonstrate the patient's understanding?

A)"The metered-dose inhaler (MDI) may keep me up at night, so I will avoid using the MDI at night."
B)"If my symptoms are not relieved, I may take one puff every 5 minutes until I feel better."
C)"Using the MDI more often than prescribed can result in worsening symptoms."
D)"Whenever I feel short of breath, I will take 2 puffs, but no more than 12 puffs a day."

Question 13

The nurse is reviewing the results of a patient's pulmonary function studies. Which result indicates the patient's resting tidal volume is within normal limits? 1.200 to 400 mL

A)400 to 600 mL
B)600 to 800 mL
C)800 to 1,000 mL

Question 14

The nurse recognizes that the patient is experiencing a respiratory emergency when the patient has wheezes and stridor. What do these sounds indicate?

A)This is an indication of bronchospasm.
B)This is an indication of a foreign body in the alveoli.
C)This is an indication of fluid in the bases of the lungs.
D)This is an indication of a crepitus in the thoracic area.

Question 15

The nurse places a patient who is experiencing dyspnea in the Fowler's position. What is the rationale for the nurse to use this position?

A)Fowler's position moves the tonsils from the back of the throat.
B)Fowler's position allows maximum lung expansion.
C)Fowler's position augments the use of accessory muscles.
D)Fowler's position relieves stress on the abdominal cavity.

Question 16

The nurse is caring for a patient who has been diagnosed with respiratory acidosis. Which of the following medical condition would be the contributing factor?

A)Acetaminophen overdose
B)Chronic obstructive pulmonary disease
C)End-stage renal disease
D)Acute hypoxemia due to high altitudes

Question 17

The nurse is assessing the patient diagnosed with pulmonary edema and hears lung sounds, and moist bubbling sounds are heard on inspiration and expiration. What medical term best defines the sound?

A)Coarse crackles
B)Fine crackles
C)Pleural friction rub
D)Wheezing

Question 18

The nurse is auscultating a patient's chest and hears an adventitious sound in the left lower lobe. What is the first step in determining whether this is an abnormality?

A)Ask the patient to cough and note the characteristics of secretions.
B)Ask the patient to drink some water and then reassess the breath sounds.
C)Have the HCP listen and verify what the nurse is hearing.
D)Listen to the corresponding area in the patient's right lower lobe.

Question 19

The nurse is caring for a patient who is on a ventilator and the high-pressure alarm sounds. What should the nurse consider as the cause for this alarm?

A)The patient is being weaned.
B)The tubing is disconnected.
C)The electricity is interrupted.
D)The tubing is obstructed.

Question 20

The patient returns to the medical unit after a pulmonary angiography. Which instructions by the nurse would help prevent complications from the test?

A)"Lie flat for 8 hours so the injection site does not bleed."
B)"You may sit up for short periods of time, such as mealtime."
C)"To prevent irritation to your throat, try not to cough for 6 hours."
D)"Don't drink anything for 6 hours after the test, as you may choke."

Question 21

The nurse is caring for the patient who has recently recovered from a spontaneous pneumothorax. The nurse palpates the patient's left shoulder area and feels a "Rice Krispies" presence under the skin. What best describes this symptom?

A)It is a sign of recovery from a pneumothorax.
B)It occurs when air leaks into the subcutaneous tissues.
C)It is a symptom of a pending recurrence of a pneumothorax.
D)It is a sign that the chest tube was removed too soon.

Question 22

The nurse is assessing a patient who has a history of COPD. What are some of the expected findings during the assessment? (Select all that apply.)

A)Barrel chest
B)Bradypnea
C)Chronic cough
D)Nail clubbing
E)Weight loss

Question 23

The LPN/LVN is caring for a patient with COPD who is using oxygen therapy at 2 L/min. The patient becomes short of breath and requests that the oxygen flow rate to be increased. What is the LPN/LVN's next step?

A)Increase the flow rate by 2 L.
B)Increase the flow rate by 1 L.
C)Contact the respiratory therapist (RT) for guidance.
D)Instruct the patient on huff coughing.

Question 24

The nurse is administering a pneumococcal vaccine to an older patient. What is the rationale for this vaccine?

A)There is a decline in effectiveness of lung defense mechanisms.
B)Many older adults are exposed to more pathogens as they age.
C)Many older adults develop immunity to viral pneumonia, not bacterial.
D)Many older adults become residents in extended-care facilities (ECFs).

Question 25

The LPN/LVN is caring for a patient with a chest tube and notices that the tubing appears to be occluded with clots. What is the LPN/LVN's next step with this issue?

A)Gently squeeze portions of the tubing form the patient to the system until the clots are moved to the system.
B)Hold the proximal end of the tubing between two fingers while sliding the fingers toward the system.
C)Document the findings and prepare to assist the HCP for removal of the chest tube.
D)If tubing appears to be occluded, consult with the HCP for specific orders.

Question 26

Which of the following are effects of aging on the respiratory system? (Select all that apply.)

A)Decrease in peak airflow and gas exchange
B)Weakening of respiratory muscles
C)Increased lung surfactant levels
D)Decline of effectiveness of lung defense mechanisms
E)Increased tidal lung capacity

Question 27

The LPN/LVN is caring for a patient with a chest tube. The nurse notes that the dressing over the insertion site is soiled. What is the most appropriate step for the nurse to take?

A)Change the dressing with sterile petroleum gauze and label the dressing with date and initials.
B)Cleanse the area after removing the old dressing and apply a sterile petroleum gauze over the site.
C)Reinforce the dressing and contact the HCP and assist with the changing of the dressing.
D)Apply the two padded clamps at the bedside and change the dressing using sterile technique.

Question 28

The nurse is using the nursing diagnosis of ineffective airway clearance. The nurse is implementing the intervention of ambulating or turning the patient every 2 hours. What is the rationale for this intervention?

A)Movement helps mobilize secretions.
B)Movement facilitates intestinal motility.
C)Movement facilitates circulation of the extremities.
D)Movement protects the patient from pressure ulcers.

Question 29

The nurse is assessing a patient's respiratory system and notices upon auscultation bibasilar crackles. How would the nurse explain these findings to the patient?

A)"When you said '99' during my assessment, I heard some unusual vibrations."
B)"When you said 'ee' during my assessment, it sounded like 'ay.'"
C)"When you took a deep breath, I heard sounds like cellophane being crumpled."
D)"When I placed my hands on your back during a deep breath, I felt unusual movement."

Question 30

The nurse is providing care to a patient who has been receiving high oxygen concentration therapy for 36 hours. Which of the following symptoms, if exhibited by the patient, should the nurse contact the HCP for suspected lung damage from this therapy? (Select all that apply.)

A)Numbness in the extremities
B)Hypoactive bowel sounds
C)Crepitus in the scapular area
D)Dry cough, and chest pain
E)PaO₂ greater than 100 mm Hg

Question 31

The HCP ordered azithromycin 500 mg for the first day, then 250 mg a day for 4 days for a patient with pneumonia. The pharmacy has azithromycin 250-mg tablets in stock. How many tablets will be sent to the facility for the patient's medication?

Question 32

The nurse is preparing to perform a routine cleaning of the patient's cuffed tracheostomy. The nurse notes that the cuff has been deflated since the patient's weaning off of the mechanical ventilator. What is the nursing intervention at this time?

A)Contact the HCP for further orders.
B)Do not start the cleaning until the cuff is properly inflated.
C)Continue with the cleaning of the tracheostomy.
D)Contact the RT to have the cuff inflated.

Question 33

The nurse is caring for the patient receiving oxygen therapy. Which of the following is correct regarding a simple face mask?

A)Is can deliver a precise percentage of oxygen therapy.
B)It can be worn while the patient is eating or drinking.
C)It is less claustrophobic for the patient than the other masks.
D)It can deliver oxygen at a concentration from 40 to 60 percent.

Question 34

The nurse has obtained a noninvasive measurement of the patient's oxygen saturation. What is this test called?

A)Arterial blood gas (ABG)
B)Incentive spirometer
C)Peak flow meter
D)Pulse oximetry

Question 35

The nurse is coaching a patient who is using a transtracheal catheter. The nurse recognizes that the patient understands the care for the catheter by which of the following statements?

A)"I will clean the catheter once a day to prevent mucous obstructions."
B)"I will be able cover the site with a loose scarf or collar."
C)"I will use a nasal cannula when I want to eat or drink."
D)"I will not remove the catheter until the site is healed."

Question 36

The nurse is preparing a patient for a spirometer test to diagnose COPD. The patient asks how to prepare for this test. How should the nurse respond?

A)"Refrain from using a short-acting inhaler 6 to 8 hours prior to testing."
B)"Do not eat or drink anything for 6 to 8 hours prior to the testing."
C)"Refrain from vigorous exercise 6 to 8 hours prior to the testing."
D)"Take all medications, including inhalers prior to the testing."

Question 37

A patient is diagnosed with respiratory acidosis. Which health problems should the nurse consider as causing this patient's diagnosis? (Select all that apply.)

A)Acute aspirin overdose
B)Kidney failure
C)Hyperventilation
D)Shallow respirations
E)Chronic lung disease