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MS RESPI 1 1. A client with smoke inhalation singes the nasal hairs. The nurse knows that this is important because the nasal hairs do what for the body? A. The nasal hairs do not serve any purpose. B. The nasal hairs filter the air of foreign particles. C. The nasal hairs aid in the secretion of mucus. D. The nasal hairs warm the air that is inspired. Nasal hairs filter the air as it enters the nose. 2. A client arrives with fractured sinuses after an MVA. Based on what you know about the function of the sinuses, you can expect the client to have difficulty with what area of communication? A. Hearing B. Touch C. Speech D. Ocular The sinuses assist in speech. 3. A man sustains damage to the nasopharynx after a gunshot wound. This has significance as the nasopharynx serves what function in the body? A. Food passageway B. Air humidifier C. Air passageway D. No function The nasopharynx serves as only a passageway for air. 4. A client has frequent periods of aspiration while eating. The nurse understands that this is a result of which mechanism? A. Upward rise of the soft palate B. Closure of the nasopharynx C. Closure of the windpipe D. Upward rise of the tongue The upward rise of the soft palate prevents food from entering the nasopharynx during swallowing. 5. A client asks the nurse what keeps food from reaching the lungs. The nurse answers that it is which reflex? A. Gag reflex B. Cough reflex C. Larynx reflex D. Spastic reflex


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MS RESPI 11. A client with smoke inhalation singes the nasal hairs. The nurse knows that this is important because the nasal hairs do what for the body?A. The nasal hairs do not serve any purpose.B. The nasal hairs filter the air of foreign particles.C. The nasal hairs aid in the secretion of mucus.D. The nasal hairs warm the air that is inspired.Nasal hairs filter the air as it enters the nose.2. A client arrives with fractured sinuses after an MVA. Based on what you know about the function of the sinuses, you can expect the client to have difficulty with what area of communication?A. HearingB. TouchC. SpeechD. Ocular The sinuses assist in speech.3. A man sustains damage to the nasopharynx after a gunshot wound. This has significance as the nasopharynx serves what function in the body?A. Food passagewayB. Air humidifierC. Air passagewayD. No functionThe nasopharynx serves as only a passageway for air.4. A client has frequent periods of aspiration while eating. The nurse understands that this is a result of which mechanism?  A. Upward rise of the soft palateB. Closure of the nasopharynxC. Closure of the windpipeD. Upward rise of the tongueThe upward rise of the soft palate prevents food from entering the nasopharynx during swallowing.5. A client asks the nurse what keeps food from reaching the lungs. The nurse answers that it is which reflex?A. Gag reflexB. Cough reflexC. Larynx reflexD. Spastic reflexThe cough reflex prevents food from entering the lungs if it enters the larynx.6. When expiration is impaired, there will be a build up of which toxic substance?A. Carbon monoxideB. Carbon trioxideC. CarbonD. Carbon dioxideDuring expiration, the carbon dioxide is expelled.

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7. When the lungs of a premature infant collapse, it is generally the result of insufficient amounts of which lubricating substance?A. SurfactantB. MucousC. Epithelial D. SecretionsSurfactant, containing fluid, helps to prevent the collapse of the lungs.8. During assessment of the respiratory system, the client should be placed in which position?A. StandingB. ProneC. SupineD. SittingThe client should be placed in the sitting position for assessment of the respiratory system9. A client presents with a perforated septum. What is one question to ask this client?A. Use of nasal spraysB. Use of cocaineC. AllergiesD. Picking of nosePerforation of the septum may occur with chronic cocaine abuse.10. Many things may cause someone to have a deficiency in smell. Which mineral deficiency can cause this to occur? A. Iron B. Folic acid C. Niacin D. Zinc Zinc deficiency may cause a loss of the sense of smell.11. When giving home care instructions to a patient having episodes of epistaxis, which should be included?A. Instruct the patient to sneeze with mouth closedB. No limitations in moving or liftingC. Seek medical evaluation, if spontaneous nosebleed occurs D. Use a non-water soluble lubricant for anterior nose bleedsVomiting of swallowed blood will increase the risk of aspiration. Various interventions will decrease the risk for this complication.12. The nurse suspects CSF rhinorrhea. What assessment finding would confirm this data?A. Positive lab results for StaphylococcalB. Septal cartilage bulgingC. Nasal drainage test that is positive for glucoseD. Boney crepitusFractures in the nasoethmoidal or frontal region can disrupt the dura, causing CSF leakage or rhinorrhea. CSF rhinorrhea is suspected with a watery, nasal drainage that tests positive for glucose.

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13. When preparing a patient for rhinoplasty, the nurse should include in the pre-operative and post-operative instructions which important intervention?A. Surgery is performed immediately after the fracture.B. Prosthetic implants are always used to reshape the nose.C. Nasal packing will be in place for at least 72 hours.D. Swelling and bruising will subside within 3 to 4 days.Rhinoplasty is surgical reconstruction of the nose. It is done to relieve airway obstruction and repair any visible deformity of the nose following fracture. If edema is excessive after a nasal fracture, surgery is delayed for 7 to 10 days to allow the swelling to subside. Following surgery, nasal packing is left in place for up to 72 hours to minimize bleeding and provide tissue support.14. The nursing diagnosis that takes highest priority for the patient with a suspected nasal fracture would be?A. Ineffective Airway Clearance R/T to nasal fractureB. Chronic pain R/T recent nasal fractureC. Risk of Infection R/T recent nasal fractureD. Alteration in Body Requirements Less than R/T to recent nasal fractureNursing care for patient with nasal fracture focuses on controlling pain, bleeding, and swelling. Airway management is a priority. Immediately following nasal trauma and fracture, the airway is at risk for obstruction be bleeding and edema. Acute pain would be an appropriate nursing diagnosis for immediate post injury. Risk, for a nursing diagnosis does not take priority, when there is a potential for airway problems. Maintaining adequate hydration is important, but hydration is a secondary nursing diagnosis when airway problems are a potential.15. The nurse assesses the patient with a nasal fracture. Which assessment finding would be indicative of potential airway problems?A. TachycardiaB. Facial painC. Decreased 24-hour urinary outputD. Capillary refill > than 3 secondsAirway patency is extremely important in these patients. Edema and bleeding may obstruct the airway causing signs of respiratory distress. The heart tries to compensate for difficulty in breathing by initiating a sympathetic response. Pain is not a sign of respiratory distress. Urinary output would reflect hydration status.16. Which of the following nursing interventions is implemented for the patient with a nasal fracture to reduce the patient anxiety?A. Encourage deep, slow breathing through the mouthB. Application of ice compresses to the noseC. Administration of an analgesicD. Nasal suctioning of the nasopharynxPatients with nasal trauma become extremely panicky because of blood draining down their throat. Encouraging deep, slow breathing through the mouth to help relieve the patient's anxiety. Application of ice compresses to the nose will reduce swelling. Administration of an analgesic will reduce pain.

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17. When performing a sleep assessment on a middle-aged male, the most important finding confirming sleep apnea would be?  A. Day time headaches  B. Day time excessive sleepiness  C. Anxiety  D. Excess alcohol intakeSleep apnea is intermittent absence of airflow through the mouth and nose during sleep. It is a life threatening disorder effecting 2% of middle-aged women and 4 % of middle-aged men. Excessive daytime sleepiness is the leading cause of sleep apnea. Excess alcohol intake may contribute to sleep apnea but is not a result of sleep apnea.18. The nurse is assessing the ABG lab results of a patient admitted with severe sleep apnea. Which finding would be expected?A. pH 7.30, PCO2 50B. pH 7.40 , PCO2 30C. pH 7.37, PCO2 36D. pH 7.40 , PCO2 44Airflow obstruction causes oxygen saturation, PO2 & PCO2 changes with resultant pH changes. It manifests as respiratory acidosis. The values in answers 3 & 4 are normal. 19. During a polysomnography, the nurse would anticipate recording which activity?A. EEG B. Pulse oximeter C. Daily weightsD. Oral suctioningThe diagnosis of obstructive sleep apnea is based on polysomnography, an overnight sleep study. Several variables are recorded during the study. Continuous arterial oxygen saturation readings are measured by a pulse oximeter. EEG (electroencephalogram) can measure ocular activity and muscle tone. Weight loss may occur as a result of obstructive sleep apnea but would not be a continuous variable monitored.20. Which subjective data would be most indicative of supraglottic cancer in a patient admitted for C/O of a sore throat and difficult in swallowing?  A. Foul BreathB. Pain radiating to the earC. Palatable lump in the throatD. Enlarged cervical lymph nodesApproximately 35 % of laryngeal cancers develop in the supraglottic area, which includes the epiglottis, and false vocal cords. Symptoms often do not develop until the tumor is relatively large, delaying diagnosis. Pain is subjective data only obtained from the patient. Answers A, C & D are manifestations of supraglottic cancer but are objective data.21. A client has COPD. One way to improve lung function is to eliminate one of the risk factors. The most important, well-known risk factor is?

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A. Exposure to asbestosB. Cigarette smokingC. Exposure to allergensD. Exposure to wood smokeSmoking cessation will not only prevent COPD but may improve lung function once the disease has been diagnosed.22. When providing information about the client's respiratory condition, it is best not to present more information than the client is able to assimilate. This is because of what?A. The client will be too tired to listen.B. The client will want to spend time with the family.C. Anxiety will interfere with the ability to learn.D. Clients should be allowed to deny illness if necessary. Anxiety will interfere with the ability to learn. 23. During teaching for asthma, you tell the client that which diagnostic test is used to evaluate the day-to-day severity of disease?A. Arterial blood gasesB. Skin testingC. Peak expiratory flow rateD. Pulmonary function tests Peak expiratory flow rate is used to evaluate severity of bronchial hyperresponsiveness.24. An asthmatic patient asks about common acquired triggers for asthmatic attacks. The nurse tells the client that a common trigger is what?A. Environmental pollutantsB. Respiratory infectionsC. Loss of heat D. Bronchodilation Respiratory infections are a common internal stimulus for an asthmatic attack.25. An army nurse presents to the clinic with a question related to anthrax. In discussing the transmission of anthrax, it is known that anthrax is transmitted by which method?A. Inhalation into lungsB. Person to personC. Hand to mouthD. Contact Person to person transmission does not occur. Anthrax is airborn and is inhaled into the lungs.26. When teaching about tuberculosis (TB), it is known that which tests are needed to confirm the disease?A. Sputum and chest x-rayB. Four positive tests C. Chest x-ray onlyD. Skin test only

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A positive TB test does not indicate active disease. Sputum tests and chest x-rays are routinely used to diagnosis the disease.27. Of the following persons, who is most likely to be at risk for tuberculosis? A. Tobacco farmerB. HousewifeC. Homeless manD. Day care workersOvercrowded shelters contribute to the spread of TB.28. Before giving the flu vaccine, it is necessary to assess for which allergy?A. Allergy to peanutsB. Allergy to soyC. Allergy to eggsD. Allergy to milkPersons allergic to egg proteins may have allergic reactions to the influenza vaccine.29. In order to loosen secretions in a patient with pneumonia, it may be necessary to increase fluid intake to how much per day?A. 1000 mLB. 2000 mL C. 2750 mL D. 6000 mL2500-3000mL/day help liquefy secretions.30. Which of the following should be given the pneumococcal vaccine?A. Healthy newbornsB. 70-year-old with COPDC. Toddlers at daycareD. Daycare workers The vaccine is recommended for people who are at risk for adverse outcomes from bacterial pneumonias.31. A client begins to have Cheyne-Stokes respirations. This type of breathing pattern is best explained as

1. Completely irregular breathing pattern with random deep and shallow respirations

2. Prolonged inspirations with inspiratory and/or expiratory pauses3. Rhythmic waxing and waning of both rate and depth of respiration with

brief periods of interspersed apnea4. Sustained, regular, rapid respirations of increased depth.

Rationale: Correct answer: CCheyne-Stokes respirations are a pattern of breathing in which phases of hyperpnea regularly alternates with apnea. The pattern waxes (crescendo) and wanes (decrescendo). Ataxic breathing is a completely irregular breathing pattern. Apneustic breathing is a pattern of prolonged inspiration with pauses. Central neurogenic hyperventilation is a sustained, regular, raid respiratory pattern of increased depth.

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 32. An 87 year old woman has come to the medical clinic for her annual physical examination. The nurse assessing her knows that pulmonary function in elderly clients often shows

1. A reduced vital capacity2. A decrease in residual volume3. An increase in functional alveoli4. Blood gases that reflect mild acidosis

Rationale: Correct answer: AResidual volume increases with age, probably related to the loss of elastic forces in the lung. This increased residual value reduces the vital capacity. Arterial pH does not change with age. The functional alveoli decrease in the elderly due to the thinning of alveolar walls, resulting in the loss of alveolar septal tissue. There are also fewer capillaries present.33. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?

1. Obtain a 12-lead EKG2. Place client in high Fowler’s position3. Lower the oxygen rate4. Take baseline vital signs

 Rationale: The correct answer is number: C A low oxygen level acts as a stimulus for respiration. A high concentrationof supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death. 34. The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis?

1. Respiratory rate2. Peak air flow volumes3. Pulse oximetry4. Skin color

Rationale: The correct answer is number: BThe peak airflow volume decreases about 24 hours before clinical manifestations.

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35. An adult who has general anesthesia for major surgery is in the PACU. One of the signs that may indicate that his artificial airway should be removed is

1. gagging2. restlessness3. an increase in pain4. clear lungs on auscultation

Rationale: Correct answer: AReturn of the gag reflex often indicates that the client is able to manage his own secretions and maintain a patent airway. Restlessness can indicate cerebral anoxia due to a blockage of the tube. Changes in the perception of pain are unrelated to intubation. It is expected that the client who is intubated will have clear lungs.36. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement?

1. Have the client cough into a tissue and dispose in a separate bag2. Instruct the client to cover the mouth with a tissue when coughing3. Reinforce for all to wash their hands before and after entering the

room4. Place client in a negative pressure private room and have all who enter

the room use masks with shields

Rationale: The correct answer is number: DA client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries (Africa, Asia, South America), transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled. 37. The nurse is assessing a client with chronic obstructive pulmonary disease receiving oxygen for low PaO2 levels. Which assessment is a nursing priority?

1. Evaluating SaO2 levels frequently2. Observing skin color changes3. Assessing for clubbing fingers4. Identifying tactile fremitus

Rationale: The correct answer is number: A

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The best method to evaluate a client’s oxygenation is to evaluate the SaO2. This is just as effective as an Arterial Blood Gas to evaluate the oxygenation, and is less traumatic and expensive.38. A client is admitted to the hospital with the medical diagnosis of traumatic brain injury. From the assessment finding of slow, shallow respirations, the nurse concludes that which area of the brain is affected by injury?a. Anterior pituitaryb. Hypothalamusc. Medullad. Cerebral cortexRationale: The answer is: CThe medulla and pons are the areas of brain tissue that control breathing. Injury to these tissues would produce alterations in the client’s breathing rate and pattern. The other options are incorrect areas of te brain. 39. In the client with right lung pneumonia, the nurse should encourage which position to facilitate optimal oxygenation?

1. Prone position2.  Supine position with head elevated 30 degrees3. Positioned with the right side dependent4.  Positioned with the left side dependent

 Rationale: The answer is: DWith unilateral disease, the example to remember is “good ling down.” Since ventilation and perfusion are gravity dependent, enhancing ventilation and perfusion to healthy lung tissue and alveoli with enhance oxygenation. Perfusion refers to the circulation of blood into the tissues and cells. Supine positioning would provide near equal ventilation and perfusion to both lungs. In the diseased lung, excess fluid and fibrosis inhibit gas exchange at the pulmonary capillary membrane, thereby diminishing oxygenation. 40. The nurse is making a home visit to a 70-year-old client with emphysema. Which assessment finding has the most serious implication for this client’s nursing care?

1. Increased anterior-posterior diameter of the chest2. Bilateral crackles throughout the lung fields3. Pursed-lip breathing4. Circumoral cyanosis

 Rationale: The answer is: BIncreased anterior-posterior diameter of the chest, pursed-lip breathing, and circumoral cynosis are chronic findings in clients with emphysema. They do not indicate acute changes in the client’s condition. Bilateral crackles

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throughout the lung fields indicate excessive pulmonary fluid requiring acute intervention. The etiology of the fluid excess in the lungs needs to be explored in-depth. 41. In developing the care plan for a client with pulmonary mycrobacterium tuberculosis, what primary precaution should be located?

1. Contact skin precautions2. Use of special mask to avoid inhaling infected airborne droplets3. Avoidance of blood contamination4. Containment of draining wounds

 Rationale: The answer is: BMycobacterium tuberculosis is transmitted via airborne droplets so use of a properly fitted particulate filter mask is indicated to prevent its spread. The other options do not represent methods of preventing airborne transmission.42. The family of a client with emphysema asks the nurse about the disease process. The nurse explains that the disorder results from a decreased oxygen supply because of:

1. Paralysis of respiratory muscles2. Infectious obstruction3. Pleural effusion4. Loss of surface area for gas exchange

 Rationale: The answer is: DEmphysema is a chronic disease with progressive destruction of alveoli and loss of alveolar area available for gas exchange. Paralysis of respiratory muscles, airway obstructions, and pleural effusion would diminish ventilatory capacity that could ultimately lead to decreased oxygen supply.43. A client comes to the clinic with an acute asthma episode. Which breath sound characteristic does the nurse expect to find auscultation?

1. Bilateral crackles2. Wheezing3. Diminished breath sounds in the upper lobes4. Rhonchi

 Rationale: The answer is: BExpiratory wheezing is a characteristic finding in acute asthma due to airway constriction. Crackles are indicative of excess pulmonary fluid, which is not typical finding with acute asthma. Ronchi are related to mucus obstruction of large airways and are common finding in chronic obstructive pulmonary disease processes.

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44. Which of the following blood gas reports would the nurse expect in a client with progressive chronic obstructive pulmonary disease (COPD)?

1. pH 7.55, PaCO2 30 mmHg, PaCO2 80 mmHg, HCO3 24 mEq/L.2. pH 7.40, PaCO2 40 mmHg, PaCO2 94 mmHg, HCO3 22 mEq/L.3. pH 7.38, PaCO2 45 mmHg, PaCO2 88 mmHg, HCO3 26 mEq/L.4. pH 7.30, PaCO2 60 mmHg, PaCO2 70 mmHg, HCO3 30 mEq/L.

 Rationale: The answer is: DDuring the later stages of COPD, arterial blood gas findings indicate low pH, elevated pCO2 , LOW  pO2, and elevated HCO3, which indicate the body’s attempt to compensate for chronically low pH. Option A is indicative of respiratory alkalosis; option B and C are variations of normal ABG results.45. What instruction is most important for the nurse to provide during discharge teaching of a client who underwent a laryngectomy?

1. Operation of feeding pump2. Use of Passy Muir (speaking tracheostomy) valve3. Tracheostomy care4. Wound care

 Rationale: The answer is: CFor any client with a tracheostomy, maintenance of the airway is clearly the priority. Clients are taught to perform routine tracheostomy care to prevent airway obstruction. Only those clients discharged with a feeding tube will need instruction about operation of a feeding pump. Wound care and use of a Passy Muir valve for communication are important factors to include discharge teaching, but the airway is the clear priority.46. A client has a right chest tube following a thoracotomy. When assisting the client to ambulate what measure is appropriate to maintain the water seal?

1. Keep the collection device below the level of the chest2. Clamp the chest tube below assisting the client out of  bed3. Milk the chest tube when the client returns to bed to assess patency4. Connect the collection device to a portable suction machine

 Rationale: The answer is: AGravity helps maintain the water seal thereby preventing backflow of air and fluid into the chest. The chest tube should never be clamped as this may cause pneumothortax. The chest tube should not be milked unless ordered by the physician for clients with visible clots in the chest drainage tubing.

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Milking the chest tubes creates suction within the tubing and can cause pleural tissue damage.47. What is the priority nursing diagnosis for the finding of secondary polycythemia in a client with chronic obstructive pulmonary disease?

1. Risk for injury related to venous thrombi2. Risk for injury related to use of oxygen3. Impaired tissue perfusion related to chronic hypoxemia4. Impaired gas exchange related to factors other than hypoxia

 Rationale: The answer is: CSecondary polycythemia, or increased red blood cells count, develops as chronic obstructive pulmonary disease occurs, in response to chronic hypoxemia. Of the possible options, impaired tissue perfusion related to hypoxemia is the only factor related to development of secondary polycythemia. Risk for injury these clients related to venous thombi or use of oxygen may or may not be present. Impaired gas exchange may also be a factor; however, it is related hypoxemia. 48. When auscultating breath sounds in the client with an acute asthma episode, the nurse uses which of the following to guide interpretation of severity of findings?a. Severity of airway obstruction is associated with intensity of wheezingb. Wheezing may be absent with severe airway obstructionc. Unilateral wheezing indicates an origin for respiratory distress other than asthmad. Breath sounds are prolonged on expirationRationale: The answer is: BWheezing is a common finding during an acute asthma episode, however; the wheezing is not a consistent predictor of the severity of the attack. Airway obstruction may be so severe that the client is moving little or no air and is experiencing severe respiratory distress. Breath sounds are prolonged in expiration with asthma, but this factor does not alter the plan of care in any way.   49. First postoperative day after a right lower lobe (RLL) lobectomy, the client deep breathes and coughs but has difficulty raising mucus. What indicates that the client is not adequately clearing secretions?a. Chest x-ray film shows right-sided pleural fluid.b. A few scattered crackles on RLL on auscultation,c. PCO2   increases from 35 to 45 mm Hg.d. Decrease in forced vital capacityRatio: answer:  CRetained secretions may cause hypoventilation: this result in an increase in the PCO2   . The other options do not as effectively reflect a problem with clearing mucus.

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50. What nursing observation indicates that the cuff on an endotracheal tube is leaking?a. An increase in peak pressure on the ventilator.b. Client is able to speakc. Increased swallowing efforts by clientd. Increased crackles (rales) over left lung fieldRatio: answer: BA leak in the cuff would allow air to pass through the trachea and vocal cords, allowing the client to make a noise-to speak51. The client with COPD is to be discharged home while receiving continous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?a. Because of his need for oxygen, the client will have to limit    activity at home.b. The use of oxygen will eliminate the client’s shortness of breath c. Precautions are necessary because oxygen can spontaneously ignite and exploded. use oxygen during activity to relieve the strain on the client’s heart.Ratio: answer: DUse of oxygen may help to relieve shortness of breath but will not eliminate it. Oxygen supports combustion but is not decrease the workload of the heart in clients with chronic pulmonary disease and to assist in preventing right heart failure.52. What symptoms would the nurse expect to observe in a 19-month-old client with a diagnosis of laryngotracheo- bronchitis?a. Predominant stridor on inspirationb. Predominant expiratory wheezec. High feverd. Slow respiratory rateRatio: answer: ABecause croup causes upper airway obstruction, inspiratory stridor is a predominant symptom.53. The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information?a. “You should avoid emotional situations that increase his shortness of breath.”b. “Help your husband arrange activities so that he doles as little walking as possible.”c. “Arrange a schedule so your husband does all necessary activities before noon: then he can rest during the afternoon and evening.”d. “Your husband will be more short of breath when he walks but that will not hurt him.”Ratio: answer: DPhysical conditioning is important for clients with COPD; activity needs to be paced so that undue fatigue does not occur; some increase in shortness of breath damage with exercise is to be expected but will not damage the

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lungs, if client stops exercising before an increase in shortness of breath, he will not experience a training effect  54. While a client’s wife is visiting, she observes the client’s chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse?a. “Your husband has been really sick; this must be a very difficult time. Let’s sit down and talk about it.”b. “I have checked all of the equipment and it is working fine; you do not need to worry about it.”c. “The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding.”d. “The chest tube is draining the secretions from his chest; it is important for him to deep breath frequently.”Ratio: answer: CThis is important information to explain to the client’s wife regarding the bloody drainage in the chest tube collection system. Option A: After the nurse has been explained the reason for the drainage; it would then be appropriate to sit down and talk with the wife. Option B and D do not answer the question or address the wife’s concern.55. The nurse is assessing a client with an endrotracheal tube in place. What data confirm that the tube has migrated too far into the trachea? a. Decreases breath sounds over the left side of the chest b. Increase rhonchi at the lung bases bilaterally. c. Client is able to speak and coughs excessively. d. Ventilator alarm continues to sound, indicating decreased oxygen tension.Ratio: answer: AAn endotracheal tube, which is inserted too far – beyond the carina – is most likely to enter the right main stem bronchus. The volume of air from the ventilator is then only delivered to the right lung; breath sounds are decreased or absent over the left lung.56. A 6-year-old client is admitted to the postoperative recovery area after a tonsillectomy. In what position will the nurse place the client?a. Semi-Fowler’s position, with the head turned to the sideb. Prone position, with the head of the bed slightly elevatedc. On the back, with the head turned to the right side.d. On the abdomen, with the head turned to the side.Ratio: answer: DBefore the child is fully awake, he or she should be placed on the abdomen with the head turned to one side to facilitate the drainage of secretions and to prevent aspiration. When alert, the child may sit up or not appropriate because they do not allow for drainage of secretions from the mouth and throat after a tonsillectomy. 57. The nurse understands that clamping a chest tube may cause what problem?a. Atmosphere pressure will be allowed to enter the lung.

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b. Tension pneumothraxc. Bacterial infections in the pleural cavity.d. Decrease in the rate and depth of respiration.Ratio: answer: BTension pneumothorax occurs when air enters the pleural space with each inspiration, becomes trapped there, and is not expelled during expiration (i.e., one way valve effect). Pressure builds in the chest as the accumulation of air in the pleural space increases. This can lead to a mediastinal shift.58. On auscultation, the nurse hears wheezing in a client with asthma. What would the nurse identify as the primary cause of this type of lung sound?a. Increased inspiratory pressure in the upper airways.b. Dilation of the respiratory bronchioles and increased mucus.c. Movement of air through narrowed airwaysd. Increased pulmonary compliance.Ratio: answer: CThe wheezing is due to narrowing of the airway caused by bronchospasm. There is also increased mucus production that hinders the airway; this also results in trapping of air in the alveoli.59. What is the finding on the nursing assessment that is associated with a diagnosis of  pneumonia?a. Diminished breath sounds.b. Accessory use of thoracic muscles.c. Hematemesis in the morning.d. Dry hacking cough at night.Ratio: answer: ADiminished breath sounds are typically noted over the consolidated area. The cough is generally productive. The breathing is rapid and shallow without the use of accessory muscles. Hemoptysis may occur, nut not hematemesis.60. The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client’s condition?a. Respiratory rate of 18 breaths/min.b. Pulse oximetry of 88%.c. Pulse rate of 110 beats /min.d. Productive cough with rapid breathing.Ratio: answer: AThe respiratory rate is within normal limits at 18 breaths/min. The option for the pulse oximetry is too low. The pulse rate is too high, and the productive cough with rapid breathing is not as sign ificant as the decrease in respiratory rate.61. Clients with COPD usually receive low-dose oxygen via nasal cannula. The nurse understands that what problem may occur if the client receives too much oxygen?a. Hyperventilationb. Tachypnea

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c. Hypoventilation or apnead. Increased snoring.Ratio: answer: CIn clients with chronic high Pco2 level (COPD), the administration of oxygen at a flow rate that is too high will cause carbon dioxide narcosis, which leads to apnea and the need for use of an Ambu bag to ventilate the client. 62. A client has a diagnosis of right-sided empyema. Thoracentesis is to be performed in the client’s room. The nurse will place the client in what position for this procedure?a. Prone position with feet elevated.b. Sitting with upper torso over bedside table.c. Lying on left side with right knee bent.d. Semi-Fowler’s position with lower torso flat.Ratio: answer: BPositioning over the bedside table allows the ribs to separate, which assists the physician in positioning the needle into the pleural cavity. If the client is unable to assume a sitting position, the client is placed on the affected side with head of bed slightly elevated. The area containing the fluid should be dependent.63. For a client with COPD, what is the main risk factor pulmonary infection?   a. Fluid imbalance with pitting edema.   b. Pooling of respiratory secretions.   c. Decreased fluid intake and loss of body weight.   d. Decreased anterior-posterior diameter of the chest.Ratio: answer: BThe ineffective clearing of secretions with resultant pooling can lead to an increased risk of infection. The client’s appetite is usually decreased, and the client has an increased anteroposterior diameter of the chest.64. Basilar crackles are present in a client’s lungs on auscultation. The nurse knows that these are discrete, noncontinuous sounds that area. Caused by the sudden opening of alveolib. Usually more prominent during expirationc. Produced by air flow across passages narrowed by secretionsd. Found primarily in the pleuraRatio: answer: ABasilar crackles are usually heard during inspiration and are caused by sudden opening of alveoli.65. A client requires that a bronchoscopy procedure be done. Due to his physical condition, he will be awake during the procedure. As part of the pretest teaching, the nurse will instruct him that before the scope insertion, his neck will be positioned so that it isa. In a flexed positionb. In an extended positionc. In a neutral positiond. Hyperextended

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Ratio: answer: DHyperextension brings the pharynx into alignment with the trachea and allows the scope to be inserted without trauma.66. A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be toa. Wait until the client’s lab work is done.b. Not administer oxygen unless ordered by the physician.c. Administer oxygen at 2L flow per minuted. Administer oxygen at 10L flow per minute and check the client’s nailbeds.Ratio: answer: CAdminister oxygen at 2L/min. and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2   narcosis and the respiratory system will cease to function.67. Care for a client following a brochoscopy will include a. Withholding food and liquids until the gag reflex returns.b. Providing throat irrigations every 4 hoursc. Having the client refrain from talking for several daysd. Suctioning frequently, as orderedRatio: answer: AUntil the gag reflex return, the client cannot handle foods or liquids, and may aspirate. Suctioning (d) is not usually ordered. The client does not require throat irrigations (b) and can talk (c) whenevr he or she is ready.68. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?a. Serosanguineous drainage from the puncture siteb. Increased temperature and blood pressure.c. Increased pulse and pallord. Hypotension and hypothermiaRatio: answer: CIncreased pulse and pallor are symptoms associated with shock. A compromised venous return any occur if there is mediastinal shift as a result of excessive fluid removal. Usually no more than 1L of fluid is removed at one time to prevent this from occurring.69. If a client continues to hypoventilate, the nurse will continually assess for a complication ofa. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosisRatio: answer: ARespiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. It differs from the metabolic acidosis (c) in that it is caused by defective functioning of the lungs.

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70. Which one of the following rules for charting narrative notes does not fit into acceptable charting procedures?a. Each entry should be signed with the nurse’s name and professional status.b. Objective facts are more relevant than nursing interpretationc. Behaviors rather than feelings should be charted.d. Use of word client or patient is important to designate particular entries.Ratio: answer: DThe word patient or client should not be used, as the chart belongs to the client; thus, adding is to the chart is redundant. 71. Auscultation of a client’s lungs reveals rales (crackles) in the left posterior base. The nursing intervention is toa. Repeat auscultation after asking the client to deep breathe and coughb. Instruct the client to limit fluid intake to less than 2000 mL/day.c. Place the client’s ankles and sacrum for the presence of edema.d. Place the client on bedrest in a semi-Fowler’s position.  Ratio: answer: AAlthough crackles often indicate fluid in the alveoli, they may also be related to hypoventilation and     will clear after a deep breath or a cough. It is therefore, premature to impose fluid (b) or activity (d) restrictions. Inspection for edema (c) would be appropriate after reauscultation.72. The physician has schedule a client for a left pneumonectomy. The position that will most likely be ordered postoperatively for him is the a. Unoperative side or backb. Operative side or backc. Back onlyd. Back or either sideRatio: answer: BPositioning the client on the operative side facilitates the accumulation of sersanguineous fluid. The fluid forms a solid mass, which prevents the remaining lung from being drawn into the space.73. A client who has had a lobectomy for cancer of the left lower lobe of the lung complaining of severe pain on inspiration. The drug the nurse expects the physician to order to relieve the pain isa. Codeine sulfateb. Demerolc. Morphine sulfated. Tylenol with codeineRatio: answer: BDemorol is the drug of choice. Morphine (c) is usually contraindicated due to its depressing action on respirations. Codeine (a) and Tylenol (d) are usually not sufficient pain relievers; therefore, the use of these drugs could interfere with other nursing inventions, such as deep breathing and coughing.74. A client has been diagnosed with a pulmonary embolism. The nurse would anticipate medical orders for the immediate administration of

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a. Warfin (Coumadin)b. Dexamethasone (Decadron)c. Heparind. Protamine sulfateRatio: answer: CHeparin acts rapidly to prevent extension of emboli and the formation of thrombi. Warfin is a slow-acting anticoagulant. Protamine sulfate inactivates heparin. Dexamethasone, a corticosteroid, is not indicated for the immediate treatment of pulmonary embolism.75. The nurse would assess that a client is experiencing Cheyne-Strokes respiration when he hasa. Periods of hyperpnea alternating with periods of apnea.b. Periods of tachypnea alternating with periods of apnea.c. An increase in both rate and depth of respiration.d. Deep, regular, sighing respiration. Ratio: answer: AA period of hyperpnea alternating with apnea is a breathing pattern that is easily missed if the client’s respirations are not observed for a few minutes. It may indicate disorders of cerebral circulation, increased cerebral pressure, and/or injury to the brain tissue.76. When assessing a client who has experienced a pulmonary embolism, the nurse would expect to see what type of respiratory pattern?a. Rate >30 per minuteb. Apneac. Accessory muscle used. Rapid and shallowRatio: answer: DThe best answer in this group is rapid, shallow respirations. The pain of pulmonary embolism will cause the client to not want to breathe deeply, but will have to breathe more rapidly to maintain oxygenation. 77. A client with newly symptomatic COPD is being started on a bronchodilator. The nurse’s understanding of the action of this drug will help the nurse to understand that the expected effect in this client will bea. Decreased respiratory rateb. Increased work of breathingc. Help in clearing secretionsd. Help in liquefying secretionsRatio: answer: ABronchodilators enlarge the diameter of the airways which allows for easier passage of air, and thus indirectly will decrease respiratory rate and decreased work of breathing.78. A common assessment finding associated with pneumonia isa. Accessory muscle useb. Bronchial breath sounds over area of pneumoniac. Dry, hacking cough

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d. Night sweatsRatio: answer: BBronchial breath sounds, normally heard over the trachea, can be heard over the area of consolidation in a client with pneumonia. They are sounds transmitted fro the trachea mainstem bronchus over the area filled with exudates. This client typically will not be using accessory muscles, but breathing rapidly and shallowly from pain. A productive cough is usual finding. Night sweats are seen in clients with tuberculosis, AIDS, Hodgkin’s, or menopause. 79. The nurse would expect a client with a tension pneumothorax to display what types of assessment findings?a. Chronic cyanosis and hypotensionb. Sustained bradypnea and hypotensionc. Boring chest pain and diaphoresisd. Acute dyspnea and tachycardiaRatio: answer: DThe best answer is acute dyspnea and shortness of breath; chest pain is not that common, nor is diaphoresis; cyanosis is a very late sign, and  bradypnea would not be seen; rather tachypnea and tachycardia are more commonly seen.    80. A client with pulmonary edema is started on furosemide (Lasix). What would the nurse include in the discharge teaching?a. A decrease in urine output is to be expected.b. The client should eat foods with plenty of potassium.c. The client should expect an increase in swelling in the hands and feet.d. The client should take the medication at bedtime.Ratio: answer: BFurosemide (Lasix) is a loop diuretic that will increase urine output and decrease edema. Give furosemide early in the day so that the increased urination will not disturb the client’s sleep. Arrange for a potassium rich diet or potassium supplements as needed due to the loss of potassium with the increased diuresis.81. If airflow is obstructed while attempting to ventilate a victim during CPR, what should the rescuer do?a. Give two slow breathes followed by 15 chest compressions.b. Perform a finger sweep.c. Perform five chest compressions.d. Reposition the victim’s head and reattempt to ventilate.Ratio: answer: DIf the victim cannot be ventilated the first time, reposition the head and try to ventilate again. If the victim cannot be ventilated after respositioning the head, the rescuer should proceed with maneuverse to remove any foreign bodies that may be obstructing the airway.82.  A client is wearing a nasal cannula. The flow rate is set at 2 L/min. The nurse understands the O2 concentration that the client is receiving is:a. 28%

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b. 45%c. 50%d. 60%Ratio: answer: AA flow rate of 2 L/min gives an O2 concentration of approximately 28%. Face masks will deliver O2 concentrations of 35-50% with flow rates of 6-12 L/min. A nonrebreathing mask, which delivers high concentrations of O2 and deliver O2 concentrations of 60-90%.83. Analysis of arterial blood gasses (ABGs) and oxymetry are the best methods to assess which of the following?a. Acid-base balance.b. Adequate oxygenation.c. The efficiency of gas transfer in the lungs.d. Mixed venous gas sample.Ratio: answer: CTwo methods that are used to assess the efficiency of gas transfer in the lungs are analysis of ABGs and oxymetry. ABGs are used to measure acid-base balance,but oxymetry is not. An assessment of PaO2 or SaO2 is usually sufficient to determine adequate oxygenation. Blood drawn from a pulmonary artery catheter is termed a mixed venous blood gas sample because it consists of venous blood that has returned to the heart from tissue beds and “mixed” in the right ventricle.84. A 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:a. lung vibrations.b. vocal sounds.c. breath sounds.d. chest movements.Correct Answer: DRATIONALES: The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, 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 the word "ninety-nine" 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. 85. A 47-year-old male client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:a.  lobar pneumonia.b.  empyema.c.  Pneumocystis carinii pneumonia.d.  infected chest tube wound site. Correct Answer: B

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RATIONALES: Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. In this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough and an infected chest tube wound, not turbid drainage. 86. A slightly obese 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.b.  hyperresonant sounds.c.  dull sounds.d.  flat sounds.Correct Answer: ARATIONALES: 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.87. A client with chronic obstructive pulmonary disease tells the nurse that he feels short of breath. The client's respiratory rate is 36 breaths/min and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm done, I'll come assess the client." The nurse's most appropriate action is to:a.  notify the primary physician immediately.b.  stay with the client until the therapist arrives. c.  administer the treatment by metered-dose inhaler. d.  give the nebulizer treatment herself. Correct Answer: DRATIONALES: The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is

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stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment so the nurse can't change the route without a new order from the physician. 88. A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? a.  Head tilt-chin liftb.  Jaw-thrustc.  Heimlichd.  SeldingerCorrect Answer: B RATIONALES: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw near the corners of the mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The Heimlich maneuver is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel. 89. A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a.  The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.b.  The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.c.  The client exhibits restlessness and confusion.d.  The client exhibits bronchial breath sounds over the affected area.Correct Answer: ARATIONALES: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation. 90. For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?a.  Restricting fluid intake to 1,000 ml/dayb.  Enforcing absolute bed restc.  Teaching the client how to perform controlled coughing

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d.  Administering prescribed sedatives regularly and in large amountsCorrect Answer: CRATIONALES: 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.91. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?a.  Fluid intake for the past 24 hoursb.  Baseline arterial blood gas (ABG) levelsc.  Prior outcomes of weaningd.  Electrocardiogram (ECG) resultsCorrect Answer: BRATIONALES: 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.92. The physician prescribes albuterol (Proventil) for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause:a.  nasal congestion.b.  nervousness.c.  lethargy.d.  hyperkalemia.  Correct Answer: BRATIONALES: Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting, and muscle cramps. 93. A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take?a.  Notify the physician immediately so he can determine client competency.b.  Have the client sign a do-not-resuscitate (DNR) form.c.  Determine whether the client's family was consulted about his decision.d.  Consult the palliative care group to direct care for the client. Correct Answer: A

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RATIONALES: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. Therefore, the physician should be notified immediately so he can determine client competency. The physician is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client the right to make decisions about his care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Option 4 isn't appropriate at this time and must be initiated by a physician order.94. The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?a.  The system is functioning normally.b.  The client has a pneumothorax.c.  The system has an air leak.d.  The chest tube is obstructed. Correct Answer: CRATIONALES: Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a 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. 95. A client undergoes a purified protein derivative (PPD) test for tuberculosis. After injecting PPD, the nurse should plan to read the test results after waiting:a.  12 hours.b.  24 hours.c.  36 hours.d.  48 hours. Correct Answer: DRATIONALES: Skin tests for tuberculosis require a delay in reading the reaction to allow sufficient time for antibodies to respond to the injected antigen. The nurse should read the client's PPD test for size of induration 48 hours after injection. Reading it earlier may lead to a false-negative result. 96. The nurse determines that a mechanically ventilated client requires restraints. Which restraint device is most appropriate for this client? a.  Belt b.  Elbow c.  Limb d.  VestCorrect Answer: CRATIONALES: The limb restraint is the best choice for this client. Applied to the wrists, the limb restraints prevent the client from inadvertently

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dislodging the endotracheal tube. Correctly applied, the limb restraints provide protection while allowing some movement of the limbs. Elbow restraints prevent flexion of the elbows and are commonly used in infants and small children. Belt and vest restraints are used to remind clients to remain seated or in bed. These restraints don't prevent limb movement.97. A college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the client about the color of the drainage. In acute rhinitis, nasal drainage normally is:a.  yellow.b.  green.c.  clear.d.  gray.Correct Answer: CRATIONALES: Normally, nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.98. A client is receiving conscious sedation while undergoing bronchoscopy. Which assessment finding should receive the nurse's immediate attention?a.  Absent cough and gag reflexesb.  Blood-tinged secretionsc.  Oxygen saturation of 90%d.  Respiratory rate of 13 breaths/minCorrect Answer: CRATIONALES: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of conscious sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after a bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits. 99. The nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome (SARS). Which action by the employee requires immediate intervention by the nurse? a.  The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room.b.  The employee doesn't remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room.c.  The employee removes all personal protective equipment and washes her hands before leaving the client's room.d.  The employee enters the room wearing a gown, gloves, and a mask.  Correct Answer: DRATIONALES: The nurse should tell the employee to wear the proper personal protective equipment including a gown, gloves, N95 respirator, and

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eye protection when entering the room. In option 1, the employee is wearing the correct personal protective equipment. To prevent the spread of infection, clients who require isolation should have a stethoscope, blood pressure cuff, and thermometer kept in the room for single client use, as is the case in option 2. In option 3, the employee followed the correct procedure for exiting the client's room.100. A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?a.  Administering oxygen, coughing, breathing deeply, and maintaining bed restb.  Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometerc.  Coughing, breathing deeply, frequent repositioning, and using an incentive spirometerd.  Administering pain medications, frequent repositioning, and limiting fluid intakeCorrect Answer: C RATIONALES: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will increase the risk of pneumonia.