Respiratory System Test Bank

MULTIPLE CHOICE

1. A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to: Expel mucus from the airways.
2. Dilate the terminal bronchioles.
3. Provide for increased oxygen tension in the alveoli.

Respiratory Stimulus

Exercise the muscles of respiration. ANS: Rationale: Coughing is one of the protective reflexes.

Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client. Test-Taking Strategy: Focus on the subject, the purpose of coughing in a postoperative client. Recalling the effects of anesthesia on the respiratory system and the respiratory complications that can occur will direct you to option 1.

Review the purposes of coughing if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Linton, A. , & Maebius, N. (2007). Introduction to medical-surgical nursing (4th ed. ). Philadelphia: Saunders. 0B]: Client Needs: Physiological Integrity TOP: Content Area: Adult Health/Respiratory MSC: Integrated Process: Nursing Process/lmplementation 2. A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 uminute.

The nurse responds that this would be harmful because it could:

1. lncrease the risk of pneumonia from drier air passages.
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2. Be drying to nasal assages.
3. Decrease the client’s oxygen-based respiratory drive.
4. Decrease the client’s carbon dioxide-based respiratory drive.

Rationale: Normally respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen provides the respiratory stimulus.

The client with COPD cannot increase oxygen levels independently because it could deplete the respiratory drive, leading to respiratory failure. Test-Taking Strategy: Focus on the client’s diagnosis and recall hat in clients with COPD, the level of oxygen provides the respiratory stimulus. This will direct you to option 3. Review the importance of oxygen and carbon dioxide tensions in the bloodstream if you had difficulty with this question. MSC: Integrated Process: Teaching and Learning 3. The chest x-ray report for a client states that the client has a left apical pneumothorax.

The nurse would monitor the status of breath sounds in that area by placing the stethoscope:

1. Posteriorly under the left scapula.
2. Just under the left clavicle.
3. ln, the fifth intercostal space.
4. Near the lateral twelfth rib ANS:

Rationale: The apex of the lung is the rounded, uppermost part of the lung. To check breath sounds in a client with a left apical pneumothorax, the nurse would place the stethoscope Just under the left clavicle. The other options are incorrect. Test-Taking Strategy: Focus on the strategic words “left apical pneumothorax. ” This will assist in eliminating options 3 and 4.

Next, use anatomical landmarks of the lungs to direct you to option 2 from the remaining options. Review data collection techniques for the respiratory system if you had difficulty with this question. MSC: Integrated Process: Nursing Process/Data Collection . A nurse is observing a nursing student listening to the breath sounds ofa client. The nurse intervenes if the student performs which incorrect procedure?

1. Asks the client to sit upright.
2. Asks the client to breathe slowly and deeply through the mouth
3. Places the stethoscope on the client’s gown
4. Uses the diaphragm of the stethoscope ANS: 3.

Rationale: To listen to breath sounds, the stethoscope is always placed directly on the client’s skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using he diaphragm of the stethoscope, which is warmed prior to use. Test-Taking Strategy: Note the strategic words “incorrect procedure. ” Thinking about this data collection procedure and noting the words “on the client’s gown” in option 3 will direct you to this option.

Review the correct method for listening to breath sounds if you had difficulty with this question. DIF: Level of Cognitive Ability: Analysis ed. ). Philadelphia: Saunders. 0B]: Client Needs: Health Promotion and Maintenance TOP: Content Area: Adult Health/Respiratory 5. A nursing student prepares to instruct a client to expectorate a sample of putum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided? will use a sterile container from the supply area.

1. “l will send the specimen immediately to the laboratory.
2. “l will ask the client to brush the teeth and rinse the mouth before expectorating.
3.  “I will have the client take a shallow breath before coughing.

ANS: 4 Rationale: Because of the nature of the test, the sputum must be collected in a sterile not a clean) container. The client should brush the teeth and rinse the mouth to decrease the number of contaminating organisms. The client should take a few deep breaths, and then cough forcefully (not spit) into the container.

The specimen should be sent directly to the laboratory. It should not be allowed to stand for long periods at room temperature to prevent overgrowth of contaminating organisms. Test-Taking Strategy: Note the strategic words “incorrect description. ” These words indicate a negative event query and ask you to select the incorrect procedure for collecting the sputum sample. Noting the words “shallow breath” in option 4 will direct you to this option. Review the procedure for collecting a sputum sample if you had difficulty with this question.

DIF: Level of Cognitive Ability: Comprehension 6. A nurse is caring for the client who is at risk for lung cancer due to an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most trequent early symptom ot lung cancer?

1. Hoarseness.
2. Pleuritic pain.
3. Hemoptysis.
4. Nonproductive hacking cough.

Rationale: Cough is the most frequent early symptom of lung cancer, which begins as onproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs.

Hoarseness and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature. Test-Taking Strategy: Focus on the strategic words “most frequent early symptom. ” This will assist in eliminating options 2 and 3, which obviously are later signs. To select between cough and hoarseness, remember that hoarseness would indicate a problem with the larynx, whereas cough would indicate a lower airway problem. Review the common early signs of lung cancer if you had difficulty with this question. 7.

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?

1.  Disconnection from the ventilator.
2. Endotracheal tube cuff leak.
3. Loose connection in the system.
4. Accumulation of secretions in the client’s lungs

Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely due to an obstruction. The obstruction can be caused by the client biting on the tube, inking of the tubing, or mucus in the lungs that requires suctioning.

It is also important to assess the tubing for the presence of any water and determine if the client is out of rhythm with breathing with the ventilator. The incorrect options list items that may be responsible for a low-pressure alarm on the ventilator. Test-Taking Strategy: Note the strategic words “high-pressure alarm” in the question. Recall that the high-pressure alarm indicates a possible obstruction to help guide you to the correct option. Review the causes of the high-pressure alarm on a ventilator if you had difficulty with this question.

A nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. The nurse should:

1. Stop the procedure and oxygenate the client.
2.  Notify the registered nurse immediately.
3. Continue to suction the client at a quicker pace.
4. Ensure that the suction is limited to 15 seconds.

Rationale: During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing.

If complications develop (especially cardiac irregularities), the nurse should stop the procedure and oxygenate the client. Test-Taking Strategy: Use the process of elimination, recalling that suction can cause cardiac rate or rhythm changes. Also use the ABCs?”airway, breathing, and circulation?”to guide you to the correct option. The correct option is the only one that protects the client’s airway and breathing. If you had difficulty with this question, review the complications and interventions associated with suctioning procedure. 9. A client has a closed-chest tube drainage system in place.

The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets that:

1. The tube is patent.
2. The client is retaining airway secretions.
3. Hemothorax is not resolving.
4. Suction should be added to the system.

Rationale: With normal breathing, the water level rises with inspiration and falls with expiration if the chest tube is patent. The system should not be affected by airway secretions, because the chest tube drains fluid in the pleural space. Options 3 and 4 are incorrect interpretations also. Test-Taking Strategy: Focus on the data in the uestion.

Recalling that the fluctuating water level in the water seal chamber is expected will assist in directing you to the correct option. Review chest tube drainage systems if you had difficulty with this question. MSC: Integrated Process: Nursing Process/Evaluation 10. A nurse is reviewing the record of a client with acute respiratory distress syndrome ( ) The nurse determines that which finding documented in the client’s record is consistent with the most expected characteristic of this disorder?

1.  Arterial Pa02 of 48
2. Arterial Pa02 of 81
3. Respiratory rate of 10 breaths per minute
4. Central cyanosis

Rationale: The most characteristic sign of ARDS is increasing hypoxemia with a Pa02 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client’s earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis. Test-Taking Strategy: Focus on the client’s diagnosis. Recalling that increasing hypoxemia occurs in this disorder will direct you to option 1 . Review the characteristics of ARDS if you had difficulty with this question.