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A client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client s baseline theophylline level was: Options: 1. 10 mcg/mL 2. 12 mcg/mL 3. 15 mcg/mL 4. 18 mcg/mL Answer: 1 Rationale: The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the disorder. Although all the options identify values within the therapeutic range, option 1 is the option that reflects a need for compliance with medication. 2. A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? Options: 1. Do nothing, because this is an expected finding. 2. Immediately clamp the chest tube and notify the physician. 3. Check for an air leak because the bubbling should be intermittent. 4. Increase the suction pressure so that the bubbling becomes vigorous. Answer: 1 Rationale: Continuous gentle bubbling should be noted in the suction control chamber. Option 2 is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option 3 is incorrect. Bubbling should be continuous and not intermittent. Option 4 is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. 3. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? Options: 1. Inform the physician. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep-breathe. Answer: 2

Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options 1, 3, and 4 are incorrect. 4. A nurse caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: Options: 1. Call the physician. 2. Place the tube in a bottle of sterile water. 3. Immediately replace the chest tube system. 4. Place a sterile dressing over the disconnection site. Answer: 2 Rationale: If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

5. A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: Options: 1. Exhale slowly. 2. Stay very still. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver. Answer: 4 Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options 1, 2, and 3 are incorrect client instructions. 6. While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. The initial nursing action is to: Options:

1. Call the physician to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection. Answer: 2 Rationale: If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options 1 and 3 will delay treatment in this emergency situation. 7. A nurse is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? Options: 1. Stridor 2. Occasional pink-tinged sputum 3. A few basilar lung crackles on the right 4. Respiratory rate of 24 breaths/min Answer: 1 Rationale: The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options 2, 3, and 4 are not signs that require immediate notification of the physician. Level of Cognitive Ability - Analysis 8. A nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Select all expected assessment findings. Options: 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. 50 mL of drainage in the drainage collection chamber 4. Drainage system maintained below the client s chest 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Answer: 3,4,5,6 Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is

seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more that 100 mL/hr is considered excessive and requires physician notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client s chest allows gravity to drain the pleural space. 9. An emergency room nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? Options: 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury Answer: 2 Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. 10. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? Options: 1. Hypocapnia 2. A hyperinflated chest noted on the chest x-ray 3. Increased oxygen saturation with exercise 4. A widened diaphragm noted on the chest x-ray Answer: 2 Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. 11. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would

the nurse anticipate to be prescribed? Options: 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar Answer: 2 Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity. 12. A nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following positions will the nurse instruct the client to assume? Options: 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed and leaning on an overbed table Answer: 4 Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

13. A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: Options: 1. Dyspnea 2. Chest pain 3. A bloody, productive cough 4. A cough with the expectoration of mucoid sputum Answer: 4 Rationale: One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options 1, 2, and 3 are late symptoms and signify cavitation and extensive lung involvement.

14. A nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? Options: 1. Bronchoscopy 2. Sputum culture 3. Chest x-ray 4. Tuberculin skin test Answer: 2 Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis . A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acidfast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy. 15. A nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this information if the student states that tuberculosis is transmitted by: Options: 1. Hand to mouth 2. The airborne route 3. The fecal-oral route 4. Blood and body fluids Answer: 2 Rationale: Tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis and is spread primarily by the airborne route. Options 1, 3, and 4 are incorrect.

16. A nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: Options: 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min Answer: 2 Rationale: Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased

carbon dioxide levels, as is the case in a normal respiratory system. 17. Which of the following arterial blood gas results indicates metabolic alkalosis? Options: 1. pH of 7.34, PCO2 of 50 mm Hg, HCO3 of 32 mEq/L, PO2 of 70 mm Hg 2. pH of 7.46, PCO2 of 30 mm Hg, HCO3 of 26 mEq/L, PO2 of 80 mm Hg 3. pH of 7.38, PCO2 of 45 mm Hg, HCO3 of 22 mEq/L, PO2 of 50 mm Hg 4. pH of 7.47, PCO2 of 40 mm Hg, HCO3 of 36 mEq/L, PO2 of 78 mm Hg Answer: 4 Rationale: In a metabolic alkalosis, the pH is elevated, along with the bicarbonate level (HCO3). Option 4 is the only option that reflects these values. 18. Which of the following arterial blood gas results indicates metabolic alkalosis? Options: 1. pH of 7.34, PCO2 of 50 mm Hg, HCO3 of 32 mEq/L, PO2 of 70 mm Hg 2. pH of 7.46, PCO2 of 30 mm Hg, HCO3 of 26 mEq/L, PO2 of 80 mm Hg 3. pH of 7.38, PCO2 of 45 mm Hg, HCO3 of 22 mEq/L, PO2 of 50 mm Hg 4. pH of 7.47, PCO2 of 40 mm Hg, HCO3 of 36 mEq/L, PO2 of 78 mm Hg Answer: 4 Rationale: In a metabolic alkalosis, the pH is elevated, along with the bicarbonate level (HCO3). Option 4 is the only option that reflects these values. 19. A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed- lip breathing is to: Options: 1. Promote oxygen intake. 2. Strengthen the diaphragm. 3. Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination. Answer: 4 Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. 20. A nurse reviews the arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an

HCO3 of 25 mEq/L. The nurse interprets these values as indicating: Options: 1. Metabolic acidosis, uncompensated 2. Respiratory acidosis, uncompensated 3. Respiratory alkalosis, uncompensated 4. Metabolic acidosis, partially compensated Answer: 3 Rationale: In respiratory alkalosis, the pH will be higher than normal and the Pco2 will be low. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. The only option that reflects these conditions is option 3. 21. A nurse is caring for a client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? Options: 1. Pallor 2. Low arterial PaO2 3. Elevated arterial PaO2 4. Decreased respiratory rate Answer: 2 Rationale: The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg. 22. A nurse is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? Options: 1. Limiting fluids 2. Having the client take three deep breaths 3. Asking the client to spit into the collection container 4. Asking the client to obtain the specimen after eating Answer: 2 Rationale: To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

23. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physician? Options: 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum Answer: 3 Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. 24. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: Options: 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds Answer: 3 Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds. 25. A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? Options: 1. Continue to suction. 2. Notify the physician immediately. 3. Stop the procedure and reoxygenate the client. 4. Ensure that the suction is limited to 15 seconds. Answer: 3 Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia,

cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated. 26. An unconscious client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: Options: 1. Metabolic acidosis 2. Respiratory acidosis 3. Overcompensated respiratory acidosis 4. Combined respiratory and metabolic acidosis Answer: 1 Rationale: In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options 2, 3, and 4 are incorrect. 27. An unconscious client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: Options: 1. Metabolic acidosis 2. Respiratory acidosis 3. Overcompensated respiratory acidosis 4. Combined respiratory and metabolic acidosis Answer: 1. Rationale: In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options 2, 3, and 4 are incorrect. 28. A client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? Options: 1. Dyspnea 2. Bradypnea 3. Bradycardia 4. Decreased respirations Answer: 1

Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. 29. A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? Options: 1. Inhales the mist and quickly exhales 2. Removes the cap and shakes the inhaler well before use 3. Presses the canister down with the finger as he breathes in 4. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed Answer: 1 Rationale: The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options 2, 3, and 4 are accurate instructions regarding the use of the inhaler. 30. A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? Options: 1. Administering atropine intravenously 2. Administering small doses of midazolam (Versed) 3. Encouraging additional fluids for the next 24 hours 4. Ensuring the return of the gag reflex before offering food or fluids Answer: 4 Rationale: After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after. 31. A client has an order to have radial arterial blood gases drawn. Before drawing the sample, a nurse occludes the: Options: 1. Ulnar artery and observes for color changes in the affected hand 2. Radial artery and observes for color changes in the affected hand 3. Brachial and radial arteries, releases them, and then observes the circulation to the hand 4. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

Answer: 4 Rationale: Before drawing a sample for arterial blood gas analysis, the nurse assesses the collateral circulation to the hand with Allen s test. This involves compressing the radial and ulnar arteries and asking the client to close and open the fist, which should cause the hand to become pale. The nurse then releases pressure on one artery and observes whether circulation is restored quickly. The nurse repeats the process, releasing the other artery. The blood sample may be taken safely if collateral circulation is adequate. 32. A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? Options: 1. Slow deep respirations 2. Rapid deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration Answer: 4 Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. 33. A client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? Options: 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation Answer: 3 Rationale: Flail chest results from fracture of two or more ribs in at least two places each. This results in a floating section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a telltale sign of flail chest.

34. A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of: Options: 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome Answer: 1 Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. 35. A client with no history of respiratory disease is admitted with respiratory failure. A nurse assesses the arterial blood gas report for which of the following results that are consistent with this disorder? Options: 1. PaO2 58 mm Hg, PaCO2 32 mm Hg 2. PaO2 60 mm Hg, PaCO2 45 mm Hg 3. PaO2 49 mm Hg, PaCO2 52 mm Hg 4. PaO2 73 mm Hg, PaCO2 62 mm Hg Answer: 3 Rationale: Respiratory failure is described as a PaO2 of 60 mm Hg or lower and a PaCO2 of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (PaCO2) from the client s baseline are considered diagnostic. 36. A nurse is teaching a client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: Options: 1. Inhale quickly. 2. Inhale through the nose. 3. Hold the breath after inhalation. 4. Take two inhalations during one breath.

Answer: 3 Rationale: Instructions for using a metered-dose inhaler include shaking the canister, holding it right side up, inhaling slowly and evenly through the mouth, delivering one spray per breath, and holding the breath after inhalation. 36. A nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? Options: 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate Answer: 4 Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. 37. A nurse is taking pulmonary artery catheter measurements of a client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12 mm Hg. The nurse interprets that this reading is: Options: 1. High and expected 2. Low and unexpected 3. Normal and expected 4. Uncertain and unexpected Answer: 3 Rationale: The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is noncardiac. 38. A nurse is assessing a client with chronic airflow limitation and notes that the client has a barrel chest. The nurse interprets that this client has which of the following forms of chronic airflow limitation? Options: 1. Emphysema

2. Bronchial asthma 3. Chronic obstructive bronchitis 4. Bronchial asthma and bronchitis Answer: 1

Rationale: The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as barrel chest. The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. 39. A nurse is caring for a client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? Options: 1. Cough 2. High-grade fever 3. Chills and night sweats 4. Anorexia and weight loss Answer: 2 Rationale: The client with tuberculosis usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever. 40. A nurse is teaching a client with tuberculosis about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of: Options: 1. Potatoes and fish 2. Eggs and spinach 3. Grains and broccoli 4. Meats and citrus fruits Answer: 4 Rationale: The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables.

41. A nurse has conducted discharge teaching with a client diagnosed with tuberculosis. The client has been taking medication for 1 weeks. The nurse evaluates that the client has understood the information if the client makes which of the following statements? Options: 1. I need to continue drug therapy for 2 months. 2. I can t shop at the mall for the next 6 months. 3. I can return to work if a sputum culture comes back negative. 4. I should not be contagious after 2 to 3 weeks of medication therapy. Answer: 4 Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered not to be contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative. 42. A nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which of the following items when performing this care? Options: 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear Answer: 2 Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath. 43. A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported? Options: 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken Answer: 3

Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include tachycardia, fever, diaphoresis, cough, anxiety, and possibly syncope. 44. A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported? Options: 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken Answer: 3 Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include tachycardia, fever, diaphoresis, cough, anxiety, and possibly syncope. 45. A client experiencing confusion and tremors is admitted to a nursing unit. An initial arterial blood gas report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing: Options: 1. Metabolic acidosis 2. Respiratory alkalosis 3. Carbon dioxide narcosis 4. Carbon monoxide poisoning Answer: 3 Rationale: Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possibly coma. 46. A client who is human immunodeficiency viruspositive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: Options: 1. Positive 2. Negative 3. Inconclusive

4. Indicating the need for repeat testing Answer: 1 Rationale: The client with human immunodeficiency virus (HIV) infection is considered to have positive results on Mantoux skin testing with an area larger than 5 mm of induration. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have falsenegative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations. 47. A client with uncomplicated or simple silicosis is being monitored yearly at the health care clinic. In this type of silicosis, the nurse expects that the client would: Options: 1. Be asymptomatic 2. Complain of severe dyspnea 3. Experience malaise and fatigue 4. Experience anorexia and weight loss Answer: 1 Rationale: In uncomplicated or simple silicosis, the client would be asymptomatic, although evidence of fibrosis on an x-ray would be present. Malaise, anorexia, weight loss, and severe dyspnea on exertion would occur in a client with chronic complicated silicosis. 48. A client with uncomplicated or simple silicosis is being monitored yearly at the health care clinic. In this type of silicosis, the nurse expects that the client would: Options: 1. Be asymptomatic 2. Complain of severe dyspnea 3. Experience malaise and fatigue 4. Experience anorexia and weight loss Answer: 1 Rationale: In uncomplicated or simple silicosis, the client would be asymptomatic, although evidence of fibrosis on an x-ray would be present. Malaise, anorexia, weight loss, and severe dyspnea on exertion would occur in a client with chronic complicated silicosis. 49. A nurse is evaluating the respiratory status of a client with carbon dioxide narcosis who is being ventilated mechanically. On evaluation of a set of arterial blood gases, the nurse notes that the client s carbon dioxide level has dropped significantly. The nurse then evaluates the client for which adverse

effect of this rapid change? Options: 1. Tachypnea 2. Confusion 3. Hyponatremia 4. Seizure activity Answer: 4 Rationale: With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same rate. The client can experience rebound metabolic alkalosis, with resulting seizure activity. The nurse evaluates the client s status carefully during this period. Options 1, 2, and 3 are not adverse effects. 50. A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse assesses the client for which of the following signs and symptoms? Options: 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia Answer: 1 Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with acquired immunodeficiency syndrome (AIDS). The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client s lymph nodes, liver, and spleen may occur as well. 51. A client has been admitted to a nursing unit with pulmonary sarcoidosis. A nurse assesses the client for which of the following signs that indicates a complication of the disorder? Options: 1. Weak pulse 2. Weight loss 3. Distended neck veins 4. Bilateral lung crackles Answer: 3 Rationale: Pulmonary sarcoidosis can lead to cor pulmonale (or failure of the right side of the heart), characterized by distended neck veins, elevated central venous pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema. Bilateral lung crackles would indicate failure of the left side of the heart. :

53. A nurse is caring for a client with exacerbation of sarcoidosis who is receiving corticosteroids. A nurse teaches the client about adverse effects of medication therapy, which would include: Options: 1. Pruritus 2. Weight loss 3. Hyperkalemia 4. Hyperglycemia Answer: 4 Rationale: The usual treatment for exacerbations of sarcoidosis includes systemic corticosteroids. Side effects of this therapy include weight gain, changes in mood, and hyperglycemia. Hyperkalemia and pruritus are unrelated findings. 54. A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client reports which of the following early signs of exacerbation? Options: 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath Answer: 4 Rationale: Dry cough and dyspnea are typical signs and symptoms of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms include weakness and fatigue, malaise, fever, and weight loss. 55. A nurse is taking the history of a client with silicosis. The nurse assesses whether the client wears which of the following items during periods of exposure to silica particles? Options: 1. Mask 2. Gown 3. Gloves 4. Eye protection Answer: 1 Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary.

56. A client tells a nurse that a physician has stated a diagnosis of uncomplicated or simple silicosis and asks the nurse exactly what this means. In formulating a response, the nurse incorporates the knowledge that: Options: 1. There is evidence of silica in the bloodstream but no clinical symptoms. 2. The client has normal pulmonary function studies but has shortness of breath. 3. The client has mild ventilation restriction and has fibrosis on chest x-ray. 4. Massive pulmonary fibrosis is visible on chest x-ray, but no extrapulmonary symptoms are apparent. Answer: 3 Rationale: The client with simple silicosis may be asymptomatic or have mild ventilatory restriction and has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. Massive fibrosis is not evident at this stage. This disease is restricted to the respiratory system only. 57. A nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which of the following clients on the nursing unit is at the lowest risk for infection with tuberculosis? Options: 1. An uninsured man who is homeless 2. A newly immigrated woman from Korea 3. A man who is an inspector for the U.S. Postal Service 4. An older woman admitted from a long-term care facility Answer: 3

Rationale: Persons at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania, medically underserved populations (ethnic minorities, homeless), those with human immunodeficiency virus infection or other immunosuppressive disorders, residents in group settings (long-term care, correctional facilities), and health care workers. 58. A client has an order to receive purified protein derivative, 0.1 mL, intradermally. A nurse administers the medication by using a tuberculin syringe with a: Options: 1. 20-gauge, 1-inch needle inserted at a 30-degree angle, with the bevel side down 2. 26-gauge, -inch needle inserted at a 45-degree angle, with the bevel side down 3. 20-gauge, 1-inch needle inserted almost parallel to the skin, with the bevel side up 4. 26-gauge, -inch needle inserted almost parallel to the skin, with the bevel side up Answer: 4

Rationale: A Mantoux skin test is administered by giving 0.1 mL of purified protein derivative (PPD) intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, -inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when the PPD is administered correctly. 59. A nurse is reading a Mantoux skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is: Options: 1. Positive 2. Negative 3. Uncertain 4. Borderline Answer: 2 Rationale: A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. Options 1, 3, and 4 are incorrect interpretations. 60. The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Of the following instructions, which will the nurse include on the list? Select all that apply. Options: 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and usually can return to former employment. Answer: 1,3.4.5 Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. Advise the client of the side effects of the medication and ways of minimizing them to ensure compliance. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-

balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment. 61. The nurse is teaching the client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which of the following positions that will aggravate breathing? Options: 1. Sitting up with the elbows resting on knees 2. Standing and leaning against a wall 3. Lying on the back in a low-Fowler s position 4. Sitting up and leaning on a table Answer: 3 Rationale: The client should use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client s chest wall. Sitting is better than standing, whenever possible. If no chair is available, then leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control. 62. The client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note that it is: Options: 1. Serous 2. Serosanguineous 3. Bloody 4. Bloody, with frequent small clots Answer: 3 Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

63. The client has had radical neck dissection, and begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?

Options: 1. Lowering the head of the bed to a flat position 2. Applying manual pressure over the site 3. Monitoring the client s airway 4. Calling the physician immediately Answer: 1 Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site, and calls the physician immediately. 64. The client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client s question based on the understanding that: Options: 1. The client should maintain enteric precautions only. 2. The disease is transmitted by droplet nuclei. 3. Clothing and sheets should be bleached after each use. 4. Deep pile carpet should be removed from the home. Answer: 2 Rationale: Tuberculosis (TB) is spread by droplet nuclei or the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand washing technique. It is unnecessary to remove carpeting from the home. 65. The nurse is caring for the client after pulmonary angiography with catheter insertion via the left groin. The nurse assesses for allergic reaction to the contrast medium by noting the presence of: Options: 1. Hematoma in the left groin. 2. Discomfort in the left groin. 3. Stridor. 4. Hypothermia. Answer: 3 Rationale: Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are then followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure.

66. The nurse is preparing to care for a client who will be weaned from a tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which of the following nursing interventions are required prior to plugging the tube? Options: 1. Place the inner cannula into the tube. 2. Deflate the cuff on the tube. 3. Ensure that the client is able to swallow. 4. Ensure that the client is able to speak. Answer: 2 Rationale: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur and respiratory arrest could result. The ability to swallow or speak is unrelated to weaning and plugging the tube. 67. The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis (DVT) and pulmonary emboli. Which of the following nursing actions would be most helpful to prevent these disorders from developing? Options: 1. Applying a heating pad to the lower extremities 2. Encouraging active range-of-motion (ROM) exercises 3. Placing a pillow under the knees 4. Restricting fluids Answer: 2 Rationale: Persons at greatest risk for pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a physician s prescription. 68. The client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when: Options: 1. Three sputum cultures are negative. 2. Five sputum cultures are negative. 3. A sputum culture and a chest x-ray are negative. 4. A sputum culture and a Mantoux test are negative.

Answer: 1 Rationale: The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis drug therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. 69. The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to a room that has: Options: 1. Ultraviolet light and three air exchanges per hour. 2. Ten air exchanges per hour and venting to the outside. 3. Venting to the outside and ultraviolet light. 4. Venting to the outside, six air exchanges per hour, and ultraviolet light. Answer: 4 Rationale: The client is admitted to a private room that has at least six air exchanges per hour, and that has negative pressure in relation to surrounding areas. The room should be vented to the outside, and should have ultraviolet lights installed. 70. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which of the following is the appropriate action? Options: 1. Change the chest tube drainage system. 2. Document the findings. 3. Check for an air leak. 4. Notify the physician. Answer: 2 Rationale: Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. 71. The client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client s central venous pressure (CVP) is rising, and the arterial blood pressure is falling. The nurse interprets that the client is experiencing: Options: 1. Mediastinal flutter. 2. Mediastinal shift.

3. Hypovolemic shock. 4. Fat embolism. Answer: 1 Rationale: The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client s central venous pressure (CVP) rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter.

72. The nurse is caring for the client who is suspected of having lung cancer. The nurse assesses the client for which most frequent early symptom of lung cancer? Options: 1. Hemoptysis 2. Cough 3. Hoarseness 4. Pleuritic pain Answer: 2 Rationale: Cough is the most frequent symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of cough usually occurs. Wheezing and blood-streaked sputum (hemoptysis) are later signs. Pain is a very late sign, and is usually pleuritic in nature. Hoarseness indicates that the affected tissue is in the upper airway. 73. A nurse has assisted the physician and the anesthesiologist with placement of an endotracheal (ET) tube in a client in respiratory distress. Which of the following is the initial nursing action to evaluate proper ET tube placement? Options: 1. Ask the radiology department to obtain a stat portable radiograph at the client s bedside. 2. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 3. Tape the ET tube in place and note the centimeter marking at the lip line. 4. Attach the ET tube to the ventilator and determine if the client is able to tolerate the tidal volume prescribed. Answer: 2 Rationale: The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is then checked radiographically. The nurse marks the ET tube at the point

where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client s toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement. 74. A nurse is preparing to suction a client with a tracheostomy tube and gathers the supplies needed for the procedure. Which of the following is the initial nursing action? Options: 1. Set the suction pressure range at 150 mm Hg. 2. Hyperoxygenate the client. 3. Place the catheter into the tracheostomy tube. 4. Apply suction on the catheter and insert it into the tracheostomy tube. Answer: 2 Rationale: The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 100 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client s oxygen. 75. A home care nurse visits a client who is started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement if made by the client indicates a need for further instruction? Options: 1. I need to be sure that no one smokes in my home. 2. I need to be sure that I stay at least 10 feet away from any burning candles. 3. It is all right to use an electric razor for shaving only if I leave it plugged in for a short period of time. 4. I need to be sure that there is space between the oxygen concentrator and the wall in the room. Answer: 3 Rationale: The use of small electric items, tools, or other equipment could emit sparks and should be avoided while oxygen is in use. The use of this equipment could result in fire and injury to the client. The oxygen concentrator is kept away from walls and corners to permit adequate airflow. The client also should be instructed not to allow smoking in the home and to stay at least 10 feet away from any type of flame. 76. A clinic nurse is performing an assessment on a client who is complaining of shortness of breath. The client tells the nurse that he is a cigarette smoker and admits to smoking one pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many packyears? Options: 1. 7.5 2. 10

3. 15 4. 20 Answer: 2 Rationale: The standard method for quantifying the smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The number is then recorded as the number of pack-years. The calculation for the number of pack-years for the client in this question who smokes 1 pack per day for 10 years is 1 pack 10 years = 10 pack-years. 77. A nurse is performing a respiratory assessment and is auscultating the client s breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets that this client has: Options: 1. Rhonchi 2. Crackles 3. Pleural friction rub 4. Wheezes Answer: 3 Rationale: A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. 78. A nurse is preparing to assist a physician with the removal of a client s chest tube. The nurse gathers items that will be needed for this procedure. Which of the following items are unnecessary for removal of the chest tube? Options: 1. Petrolatum gauze dressing 2. Telfa dressing 3. A sterile 4 4 gauze 4. Adhesive tape Answer: 2 Rationale: On removal of a chest tube, a sterile petrolatum gauze dressing is applied to the chest tube insertion site, followed by a sterile gauze pad and adhesive tape. The entire dressing is securely taped to ensure

that it remains occlusive. The petrolatum dressing is the key element for an airtight seal at the chest tube insertion site. A Telfa dressing is not used and is not indicated for this procedure. Although this is the usual procedure, somewhat different procedures may be used in accordance with physician preferences and agency protocols. 79. A nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted following thoracic surgery. Which of the following statements if made by the client indicates a need for further instruction? Options: 1. If I note any signs of infection, I should contact the physician. 2. If I have any difficulty in breathing, I should call the physician. 3. I should remove the chest tube site dressing when I get home. 4. I should avoid heavy lifting for at least 4 to 6 weeks. Answer: 3 Rationale: When a chest tube is removed, an occlusive dressing consisting of petrolatum gauze covered by a dry sterile dressing usually is placed over the chest tube site. This dressing is maintained in place until the physician says that it may be removed. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. 80. A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. The nurse observing the student intervenes if the student performs which incorrect technique? Options: 1. Palpating over the lung apices in the supraclavicular area 2. Asking the client to repeat the word ninety-nine during palpation 3. Palpating over the breast tissue to assess and compare vibrations from one side to the other 4. Comparing vibrations from one side to the other as the client repeats the word ninety-nine Answer: 3 Rationale: When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from one side to the other as the client repeats the word ninety-nine. The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound. 81. A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor would indicate an inappropriate action? Options:

1. Hyperventilating the client with 100% oxygen before suctioning 2. Applying suction intermittently during withdrawal of the catheter 3. Suctioning the client every hour 4. Applying suction only during withdrawal of the catheter Answer: 3 Rationale: The client should be suctioned as needed. Unnecessary suctioning needs to be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter, and intermittent suction and a twirling motion of the catheter are used during withdrawal. 82. A nurse is changing the tracheotomy ties on a client with a tracheotomy and is assessing the security of the ties. What method is used to ensure that the ties are not too tightly placed? Options: 1. The nurse places two fingers between the tie and the neck. 2. The tracheotomy can be pulled slightly away from the neck. 3. The ties leave no marks on the neck. 4. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures. Answer: 1 Rationale: The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for two fingers to slide comfortably under the ties. Options 2, 3, and 4 are incorrect.

83. A nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the physician in this procedure, which initial nursing action is appropriate? Options: 1. Suction the ET tube. 2. Deflate the cuff. 3. Turn off the ventilator. 4. Obtain a code cart and place it at the bedside. Answer: 1 Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. Additionally, resuscitative equipment should already be available at the client s bedside. Option 3 is not the initial action.

84. A client is intubated with an endotracheal (ET) tube by the anesthesiologist. What is the responsibility of the nurse with regard to checking for tube placement immediately after tube insertion? Options: 1. It is not the responsibility of the nurse to check for tube placement. 2. Arrange for a chest radiograph. 3. Auscultate the lungs for the presence of bilateral breath sounds. 4. Instill air into the ET tube and listen for its being forced into the lungs. Answer: 3 Rationale: Immediately after an ET tube is inserted, tube placement is verified by both auscultation and chest radiography. Auscultating the lungs would be the immediate action, and the nurse would auscultate for bilateral breath sounds. Option 4 is an inappropriate action. 85. A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations is made? Options: 1. Secretions are becoming bloody. 2. Heart rate decreases from 78 to 54 beats/min. 3. Coughing occurs with suctioning. 4. Skin color becomes cyanotic. Answer: 3 Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the physician. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure.

86. A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations is made? Options: 1. Secretions are becoming bloody. 2. Heart rate decreases from 78 to 54 beats/min. 3. Coughing occurs with suctioning. 4. Skin color becomes cyanotic. Answer: 3 Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow

heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the physician. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure. 87. A client with a tracheostomy tube on a ventilator is at risk for impaired gas exchange. The nurse should assess for which of the following items as the best indicator of adequate ongoing respiratory status? Options: 1. Moderate amounts of tracheobronchial secretions 2. Small to moderate amounts of frank blood suctioned from the tube 3. Respiratory rate of 16 breaths/min 4. Oxygen saturation of 91% Answer: 3 Rationale: Impaired gas exchange could occur after tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion due to immobility, or concurrent respiratory conditions. An oxygen saturation of 91% is less than optimal. A respiratory rate of 16 breaths/min is in the normal range.

88. A nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems? Options: 1. Hypotension 2. Fever 3. Respiratory failure 4. Epilepsy Answer: 1 Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low. 89. A nurse is monitoring the function of a client s chest tube that is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse interprets that: Options: 1. The client has residual pneumothorax. 2. The system is patent.

3. Suction should be added to the system. 4. There is a leak in the system. Answer: 2 Rationale: When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system. Options 1, 3, and 4 are inaccurate interpretations. 90. An older client is diagnosed with a rib fracture and asks the nurse why strapping the ribs is not being done. Which response by the nurse is appropriate? Options: 1. That isn t done anymore because people often would develop pneumonia from the constricting effect on the lungs. 2. That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store. 3. Strapping is useful only if the ribs are fractured in several places at once. 4. That s a good idea. I ll ask the physician for an order for the needed supplies. Answer: 1 Rationale: Strapping the ribs has a constricting effect on the ribs and deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 2, 3, and 4 are incorrect. 91. A nurse is caring for a postoperative pneumonectomy client. Which of the following findings on nursing assessment of the client would be an adverse sign/symptom indicating pulmonary edema? Options: 1. Respiratory rate of 20 breaths/min 2. Pain with deep breathing 3. Lung crackles 4. Increased chest tube drainage Answer: 3 Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths/min is within normal limits. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube. 92. A nurse reads a client s Mantoux skin test as positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse s response is based on the understanding that the client has:

Options: 1. No evidence of tuberculosis 2. Systemic tuberculosis 3. Pulmonary tuberculosis 4. Exposure to tuberculosis Answer: 4 Rationale: A client who tests positive on a Mantoux skin test either has been exposed to tuberculosis or has inactive (dormant) tuberculosis. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. 93. A nurse is caring for a client with tuberculosis who is fearful of the disease and anxious about prognosis. In planning nursing care, the nurse should incorporate which of the following as the best strategy to assist the client in coping with the illness? Options: 1. Encourage the client to visit with the pastoral care department chaplain. 2. Ask family members if they wish a psychiatric consult. 3. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. 4. Allow the client to deal with the disease in an individual fashion. Answer: 3 Rationale: A primary role of the nurse in working with the client with tuberculosis is to teach the client about medication therapy. The anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids) and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy, which will eradicate it. This gives the client a measure of power over the situation and outcome.

94. A nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse evaluates that the client needs further reinforcement of information if the client makes which of the following statements? Options: 1. It s very important to wash my hands after I touch my mask, tissues, or body fluids. 2. I should cough into tissues and throw them away carefully. 3. It s important to cover my mouth if I laugh, sneeze, or cough. 4. I should use disposable plates, forks, and knives. Answer: 4

Rationale: Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. It is important to perform proper hand washing after contact with body substances, tissues, or face masks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and dispose of tissues carefully. The client also may need to wear a mask as advised by the physician. 95. A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family and others. The nurse provides the reassurance by telling the client that: Options: 1. The family does not need therapy, and the client will not be contagious after 1 month of drug therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of drug therapy. 3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of drug therapy. 4. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of drug therapy. Answer: 4 Rationale: Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client usually is not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis.

96. A client diagnosed with tuberculosis is distressed over the loss of physical stamina and fatigue. The nurse plans to teach the client that: Options: 1. This is a short-lived problem, which should be gone within 1 week of drug therapy. 2. This is an unexpected finding with tuberculosis, but it should resolve within 1 month or so. 3. This is expected, and the client should gradually increase activity as tolerated. 4. This is expected and will last for at least 1 year. Answer: 3 Rationale: The client with tuberculosis has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. Options 1, 2, and 4 are incorrect.

97. A nurse is assessing a client with the typical clinical manifestations of tuberculosis. The nurse would expect the client to report having fatigue and cough that have been present for: Options: 1. 1 or 2 days 2. Almost 1 week 3. 1 to 2 weeks 4. Several weeks to months Answer: 4 Rationale: The client with tuberculosis may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, lowgrade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care. 98. A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need: Options: 1. More medication instructions 2. Involvement of the family in teaching 3. Reinforcement by the physician 4. Directly observed therapy Answer: 4 Rationale: Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. The client may be required to have directly observed therapy to reduce the risk to the general public. This involves having a responsible person actually observe the client taking the medication each day.

99. A client experienced an open pneumothorax and a chest wound, which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first: Options: 1. Remove the dressing. 2. Reinforce the dressing. 3. Call the physician. 4. Measure oxygen saturation by oximetry. Answer: 1

Rationale: Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occurs, the nurse removes the dressing immediately, allowing air to escape. 100. A clinic nurse administers a Mantoux skin test to a client. The nurse tells the client to return to the clinic for reading the results in: Options: 1. 24 to 36 hours 2. 24 to 48 hours 3. 36 to 48 hours 4. 48 to 72 hours Answer: 4 Rationale: The Mantoux skin test is the most accurate and reliable tuberculin skin test currently available. Interpretation of the Mantoux test result should be done 48 to 72 hours after the injection. 101. A client who has undergone radical neck dissection for a tumor has a nursing diagnosis of ineffective airway clearance related to obstruction secondary to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse needs to avoid which of the following activities? Options: 1. Placing the bed in low Fowler s position 2. Supporting the neck incision when the client coughs 3. Suctioning the client as needed 4. Encouraging coughing every 2 hours Answer: 1 Rationale: The client s respiratory status is promoted by the use of high Fowler s position after this surgery. Low Fowler s position is avoided because it could result in increased venous pressure on the graft and increased risk of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2 hours, to support the neck incision when the client coughs, and to suction periodically as needed by the client. 102. A client is seen in the health care clinic and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction? Options: 1. I should apply heat, such as a wet pack, over the sinuses.

2. I should use a warm mist vaporizer to liquify secretions. 3. I should drink large amounts of fluids. 4. I should try to sleep with the head of the bed elevated. Answer: 2 Rationale: The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The nurse instructs the client to apply heat in the form of wet packs over the affected sinuses to promote comfort and help resolve the infection. The client should be instructed to use a cool mist vaporizer to help liquify secretions and promote drainage. Consumption of large amounts of fluids is important to help liquify secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. 103. A clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse instructs the client to: Options: 1. Drink warm tea throughout the day. 2. Drink warm hot chocolate in place of coffee. 3. Avoid foods that are highly seasoned. 4. Restrict fluid intake to 1000 mL daily. Answer: 3 Rationale: The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. Foods that are highly seasoned are irritating to the throat and should be avoided, and the client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated. 104. An ambulatory care nurse is preparing a list of instructions for the adult client who is being discharged after tonsillectomy. The nurse avoids placing which of the following on the list? Options: 1. Avoid hot fluids. 2. Consume carbonated beverages and milk products. 3. Avoid raw vegetables. 4. Rest in bed or on a couch for 24 hours. Answer: 2 Rationale: After tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. Milk and milk products are avoided because they may cause the client to cough, which could cause pain at

the surgical site. Foods and snacks that are rough in texture, such as raw fruits or vegetables, should be avoided for 10 days to protect the operative site and to prevent bleeding. The client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity. 105. A client arrives in the hospital emergency department with a bloody nose. The initial nursing action is to: Options: 1. Place the client in supine position. 2. Apply an ice collar around client s neck. 3. Assist the client to a sitting position with the head tilted forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled. Answer: 3 Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pitching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The physician also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood, to reduce the risk of nausea and vomiting. 106. A nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? Options: 1. Soaps should be avoided near the stoma. 2. I should use diluted alcohol on the stoma to clean it. 3. I should apply a thin layer of petroleum to the skin surrounding the stoma. 4. I need to protect the stoma from water. Answer: 2 Rationale: The client with a stoma should be instructed to wash the stoma daily with a wash cloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum applied to the skin around the stoma helps to prevent cracking. The client is instructed to protect the stoma from water.

107. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when: Options: 1. Suctioning is required frequently. 2. Excessive secretions are suctioned from the tube and stoma. 3. The client s skin and mucous membranes are light pink in color. 4. Aspiration of gastric contents occurs during suctioning. Answer: 4 Rationale: Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication. 108. A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which of the following initial nursing actions would be appropriate if the nurse is unable to determine the cause of ventilator alarm? Options: 1. Call the physician. 2. Call the respiratory therapy department. 3. Shut the alarm off. 4. Manually ventilate the client with a resuscitation device. Answer: 4 Rationale: If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should manually ventilate the client with a resuscitation device. The nurse should never shut off the alarms. It is not necessary to contact the physician, although the respiratory therapist may be notified to assist in troubleshooting the cause of the problem. However, the initial nursing action would be to manually ventilate the client. 109. The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which of the following? Options: 1. Excessive secretions 2. The presence of a mucous plug 3. Kinks in the ventilator tubing 4. Displacement of the endotracheal tube Answer: 4

Rationale: The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound. 110. A nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high- pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which of the following? Options: 1. A leak in the endotracheal tube cuff 2. Displacement of the endotracheal tube 3. A disconnection of the ventilator tubing 4. A kink in the ventilator circuit Answer: 4 Rationale: A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions, mucous plugs, the client s biting on the endotracheal tube, kinks in the ventilator tubing, and the client s coughing, gagging, or attempting to talk. 111. A physician writes an order to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by: Options: 1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance 2. Providing pressure support to decrease the workload of breathing and increase the client s ability to initiate spontaneous breathing efforts 3. Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting 4. Removing the ventilator from the client and closely monitoring the client s ability to breathe spontaneously for a predetermined amount of time Answer: 1 Rationale: IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased until clients assumes all of the work of breathing on their own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an

hourly basis until the client is weaned and is ready for extubation. 112. A nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which of the following would not be a component of the plan of care with this type of weaning process? Options: 1. The client is removed from the mechanical ventilator for a short period of time. 2. The T-piece is connected to the client s artificial airway. 3. Supplemental oxygen is provided through the T-piece at an FIO2 (fraction of inspired oxygen) that is 10% higher than a ventilator setting. 4. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. Answer: 4 Rationale: The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected and the T- piece is connected to the client s artificial airway. Supplemental oxygen is provided through the device, often at an FIO2 that is 10% higher than the ventilator setting. 113. A nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL and determines that the tidal volume indicates: Options: 1. The number of breaths that the client will receive per minute by the ventilator 2. The amount of air delivered with each set breath 3. The fraction of inspired oxygen (FIO2) that is delivered to the client through the ventilator 4. A breath that has a greater volume than the preset tidal volume Answer: 2 Rationale: Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. The respiratory rate is the number of breaths to be delivered by the ventilator. The fraction of inspired oxygen delivered to the client is indicated by the FIO2 indicator on the ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. 114. A nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, Pa O2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which of the following? Options: 1. Normal results 2. Metabolic alkalosis 3. Metabolic acidosis

4. Respiratory acidosis Answer: 1 Rationale: The client s results fall in the normal range for pH (7.35 to 7.45), PaCO2 (35 to 45), and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis was present. 115. A nurse in the respiratory care unit is reviewing the laboratory results of a serum drug level assay for a client receiving theophylline. The nurse determines that a therapeutic medication level is achieved if which of the following values is noted? Options: 1. 5 mcg/mL 2. 9 mcg/mL 3. 15 mcg/mL 4. 25 mcg/mL Answer: 3 Rationale: The therapeutic range for serum theophylline (or aminophylline) is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the respiratory disorder. If the level is too high, the medication may need to be stopped or the dose may need to be lowered. Options 1 and 2 indicate low values. Option 4 indicates an elevated value. 116. A client who is intubated and receiving mechanical ventilation has a nursing diagnosis of risk for infection. The nurse should avoid doing which of the following in the care of this client? Options: 1. Monitor the client s temperature. 2. Monitor sputum characteristics and amounts. 3. Use the closed-system method of suctioning. 4. Drain water from the ventilator tubing into the humidifier bottle. Answer: 4 Rationale: Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas . Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning does not harm the client and decreases the risk of infection associated with suctioning. 117. A physician tells the nurse that a client s chest tube is to be removed. The nurse brings which of the following dressing materials to the bedside for the physician s use?

Options: 1. Telfa dressing and neosporin ointment 2. Petrolatum gauze and sterile 4 4 gauze 3. Sterile 4 4 gauze, Neosporin ointment, and tape 4. Benzoin spray and a hydrocolloid dressing Answer: 2 Rationale: On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the physician as the tape of choice to make the dressing occlusive

118. A nurse enters the client s room with a pulse oximetry machine and tells the client that the physician has ordered continuous oxygen saturation readings. The client s facial expression changes to one of apprehension. The nurse can quickly and most effectively alleviate the client s anxiety by stating that pulse oximetry: Options: 1. Is painless and safe 2. Causes only mild discomfort at the site 3. Requires insertion of only a very small catheter 4. Has an alarm to signal dangerous drops in oxygen saturation levels Answer: 1 Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level. 119. A young adult client has never had a chest x-ray examination before and expresses to the nurse a fear of experiencing some form of harm from the test. Which of the following statements by the nurse would provide valid reassurance to the client? Options: 1. You ll wear a lead shield to partially protect your organs from harm. 2. The amount of x-ray exposure is not sufficient to cause DNA damage. 3. The test isn t harmful at all. The most frustrating part is the long wait in radiology. 4. The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation.

Answer: 4 Rationale: Clients should be taught that the amount of exposure to radiation is minimal, and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client. 120. A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least: Options: 1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes Answer: 3 Rationale: After blood is drawn for arterial blood gas analysis, continuous pressure must be applied to the site. A radial artery site requires at least 5 minutes of pressure, whereas a femoral artery site requires 10 minutes. A small pressure dressing often is placed on the site after this time period. When the client is receiving anticoagulant therapy, application of pressure for a longer period of time may be needed.

121. A nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). The nurse includes in the plan of care to assess for early signs of this disorder by monitoring the client for: Options: 1. Dyspnea 2. Frothy sputum 3. Diminished breath sounds 4. Edema Answer: 1 Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would present as a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS. 122. The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client s respiratory status had worsened if which of the following is noted on assessment? Options:

1. Diminished breath sounds 2. Wheezing during inhalation 3. Wheezing during exhalation 4. Wheezing throughout the lung fields Answer: 1 Rationale: Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. Diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure. 123. A nurse is performing an assessment on a client who was admitted to the hospital with a diagnosis of carbon monoxide poisoning. Which of the following assessments performed by the nurse would primarily elicit data related to a deterioration of the client s condition? Options: 1. Skin color 2. Apical rate 3. Respiratory rate 4. Level of consciousness Answer: 4

Rationale: The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although options 1, 2, and 3 would be a component of the assessment of the client with carbon monoxide poisoning, assessment of the neurological status of the client would elicit data specific to a deterioration in the client s condition.

124. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving aminophylline (Theophylline). The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which of the following values is noted? Options: 1. 5 mg/mL 2. 10 mg/mL 3. 15 mg/mL 4. 20 mg/mL Answer: 1

Rationale: Aminophylline is a bronchodilator. The nurse monitors the theophylline blood serum level daily when a client is on this medication to ensure that a therapeutic range is present and to monitor for the potential for toxicity. The therapeutic serum level range is 10 to 20 mg/mL. If the laboratory result indicated a level of 5 mg/mL, the dosage of the medication would need to be increased. 125. A nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect that: Options: 1. The chest tubes are obstructed. 2. Suction needs to be increased. 3. The system needs changing. 4. Suction needs to be decreased. Answer: 1 Rationale: Fluid in the water seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Options 2, 3, and 4 are incorrect interpretations. 126. A nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. Which of the following is the priority intervention before the client is permitted to drink or eat? Options: 1. Place the tray in a comfortable position in front of the client. 2. Inflate the cuff on the tracheostomy tube. 3. Deflate the cuff on the tracheostomy tube. 4. Maintain the head of the bed in low Fowler s position. Answer: 2 Rationale: If a client with a tracheostomy is allowed to eat, and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The head of the bed should always be elevated; low Fowler s position could lead to aspiration. The cuff would not be deflated, because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. 127. A nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement if made by the client indicates an understanding of appropriate home care measures? Options: 1. I should restrict my fluid intake for 2 weeks.

2. If I experience any soreness in my chest or shoulder, I should notify the physician. 3. I should perform arm exercises two or three times a day. 4. If I experience any numbness or altered sensation around the incision, I should contact the physician. Answer: 3 Rationale: The client should be instructed to perform arm and shoulder exercises two or three times a day. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the physician if these symptoms occur. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate.

128. A nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which of the following would the nurse include in the list? Options: 1. Avoid lifting any objects greater than 30 pounds for at least 3 weeks. 2. Avoid breathing exercises to allow the diaphragm to strengthen. 3. Contact the physician if any feelings of weakness and fatigue occur. 4. Report any signs of respiratory infection to the physician. Answer: 4 Rationale: After a pneumonectomy, the client should be instructed to avoid heavy lifting of any objects more that 20 pounds until the muscles of the chest wall have healed completely, which takes about 3 to 6 months. The client also is instructed to perform breathing exercises for the first 3 weeks at home and to space activities to allow for frequent rest periods. The client should be told to expect feelings of weakness and fatigue for the first 3 weeks after surgery. If any signs of respiratory infection occur, the physician should be notified. 129. A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the client has: Options: 1. Decreased severity of cough 2. Absence of dyspnea 3. Decreased tactile fremitus 4. Dull percussion notes Answer: 2 Rationale: The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry,

nonproductive cough, dyspnea (usually on exertion), decreased or absent tactile fremitus, and dull or flat percussion notes on respiratory assessment. 130. A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse assesses the client for which of the following signs and symptoms associated with this problem? Options: 1. Pleural pain and fever 2. Hyperresonant breath sounds over the left thorax 3. Decreased respiratory rate 4. Diaphoresis during the day Answer: 1 Rationale: The client with empyema usually experiences dyspnea, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus. 131. A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively, the nurse places the client in which position? Options: 1. Supine 2. Sims 3. Side-lying 4. Semi-Fowler s Answer: 4 Rationale: After any procedure involving thoracotomy, the nurse positions the client in semi-Fowler s position. This position allows for maximal lung expansion and promotes drainage through chest tubes that may be placed during surgery. 132. A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, which of the following nursing actions would be appropriate? Options: 1. Document the findings. 2. Reassess the pH in 4 hours. 3. Instill 30 mL of sterile water. 4. Administer a dose as needed of a prescribed antacid. Answer: 4

Rationale: The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of the shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH of less than 5 should be treated with prescribed antacids. If there is no order for the antacid, the physician should be notified. 133. A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which of the following? Options: 1. A disconnection of the ventilator tubing 2. An exaggerated client inspiratory effort 3. Generation of extreme negative pressure by the client 4. Accumulation of respiratory secretions Answer: 4 Rationale: The high pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing out of phase or bucking the ventilator, accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. Options 1, 2, and 3 identify causes for triggering the low-pressure alarm. 134. A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which of the following? Options: 1. A disconnection of the ventilator tubing 2. An exaggerated client inspiratory effort 3. Generation of extreme negative pressure by the client 4. Accumulation of respiratory secretions Answer: 4 Rationale: The high pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing out of phase or bucking the ventilator, accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. Options 1, 2, and 3 identify causes for triggering the low-pressure alarm. 135. A nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that which of the following is the underlying cause for triggering this alarm? Options:

1. A tubing obstruction or kink 2. The accumulation of secretions 3. Condensation of water in the ventilator tubing 4. Disconnection of the ventilator tubing Answer: 4 Rationale: The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. Options 1, 2, and 3 identify causes for triggering the high-pressure alarm. 136. A nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest drainage system accidentally disconnects. The initial nursing action is which of the following? Options: 1. Place the end of the chest tube in a container of sterile water. 2. Contact the physician. 3. Call a respiratory therapist. 4. Encourage the client to perform the Valsalva maneuver. Answer: 1 Rationale: If a chest tube becomes disconnected, the nurse should as quickly as possible place the end of the tube in a container of sterile water or saline until the drainage system can be replaced. It may be necessary to contact the physician, but this would not be the initial nursing action. It is not necessary to contact a respiratory therapist at this time. Asking the client to perform a Valsalva maneuver is not appropriate.

137. A nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. The initial nursing action is which of the following? Options: 1. Contact the physician. 2. Contact the respiratory therapist. 3. Apply an occlusive dressing. 4. Reinsert the chest tube quickly. Answer: 3 Rationale: If a chest tube is accidentally pulled out, the nurse would immediately apply an occlusive dressing and then contact the physician. The physician needs to be notified, but this is not the initial nursing action. It is not necessary to contact the respiratory therapist. It is not appropriate and not a nursing role to

reinsert a chest tube. 138. A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food doesn t seem to have any taste during illness. In formulating a response, the nurse understands that this is due to which of the following? Options: 1. Anorexia, triggered by the infectious organism 2. Blocked nasal passages that impair the sense of smell 3. Lack of client energy to cook wholesome meals 4. Infection, which blocks sensation in the taste buds of the tongue Answer: 2 Rationale: When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect. 139. A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the physician. The nursing graduate determines that this instruction is based on the understanding that the endotracheal tube could enter the: Options: 1. Right main bronchus if inserted too far 2. Left main bronchus if inserted too far 3. Right main bronchus if not inserted far enough 4. Left main bronchus if not inserted far enough Answer: 1 Rationale: If the endotracheal tube is inserted too far into the client s trachea, the tube will travel down and enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect. 140. A nurse is reinforcing instructions to a client for use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to: Options: 1. Dilate the major bronchi 2. Increase surfactant production 3. Enhance ciliary action in the tracheobronchial tree 4. Maintain inflation of the alveoli

Answer: 4 Rationale: Sustained inhalation helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. Options 1, 2, and 3 are incorrect. 141. 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 to 3 L/min. The nurse responds that this would be harmful because a higher oxygen flow rate could: Options: 1. Increase the risk of pneumonia from drier air passages 2. Lead to drying of nasal passages 3. Decrease the client s oxygen-based respiratory drive 4. Decrease the client s carbon dioxidebased respiratory drive Answer: 3 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 flow rate levels independently because a higher oxygen level could obliterate the respiratory drive, leading to respiratory failure. Options 1, 2, and 4 are incorrect. 142. A client who is experiencing respiratory difficulty asks the nurse, Why it is so much easier to breathe out than in? In providing a response, the nurse explains that breathing is easier on exhalation because: Options: 1. The respiratory muscles contract. 2. The respiratory muscles relax. 3. Air flows by gravity. 4. Air is flowing against a pressure gradient. Answer: 2 Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow against a pressure gradient. 143. A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because: Options:

1. The inflamed pleura cannot glide against each other as they normally do. 2. This condition causes nerve endings to be especially sensitive. 3. The stretch receptors in the lungs are irritated. 4. The diaphragm is weak and is difficult to move. Answer: 1 Rationale: Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration. Options 2, 3, and 4 are incorrect. 144. A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse tells the client that this an expected symptom because: Options: 1. Blood flows more slowly when the hemoglobin or hematocrit is low. 2. Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism. 3. The work of breathing is increased when the client is anemic. 4. The body has to work harder to fight infection with anemia. Answer: 2

Rationale: Oxygen is needed to meet the metabolic needs of the body. With decreased hemoglobin, such as in iron deficiency anemia, oxygen-carrying capacity of the blood is less than normal. The client feels the effect of this change as fatigue. Options 1, 3, and 4 are incorrect. 145. A nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The physician states that as a result of fluid in the alveoli, surfactant production is falling. The nurse interprets that the natural consequence of insufficient surfactant is: Options: 1. Collapse of alveoli and decreased compliance 2. Bronchoconstriction and stridor 3. Decreased ciliary action and retained secretions 4. Atelectasis and viral infection Answer: 1 Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become stiff because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. Options 2, 3, and 4 are incorrect.

146. A nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) due to respiratory disease. The nurse anticipates that as the client s CO2 level rises, the pH should: Options: 1. Rise 2. Fall 3. Remain unchanged 4. Double Answer: 2 Rationale: CO2 acts as an acid in the body. Therefore, with a rise in CO2, a corresponding fall in pH occurs. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect

147. A nurse reads in the progress notes for a client with pneumonia that areas of the client s lungs are being perfused but are not being ventilated. The nurse interprets this occurrence as the presence of: Options: 1. Anatomical dead space 2. Physiological dead space 3. Shunting 4. Ventilation-perfusion matching Answer: 3 Rationale: Shunting occurs when a portion of the lung area has adequate capillary perfusion but is not being ventilated. As a result, no gas exchange occurs. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs. 148. A nurse is monitoring the status of the client who is being treated for dyspnea. The nurse is aware that which of the following factors will decrease the work of breathing for this client? Options: 1. Increased mucus production 2. Interstitial pulmonary edema 3. Increased airway resistance 4. Bronchodilation Answer: 4

Rationale: Bronchodilation decreases the airway resistance and decreases the work of breathing for the client. Clients with dyspnea who have increased mucus production, edema, or bronchospasm exhibit increased airway resistance, which increase the work of breathing. 149. A nurse is reinforcing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because, in normal respiration, as the diaphragm contracts, it: Options: 1. Moves downward and out 2. Moves up and inward 3. Makes the thoracic cage smaller 4. Aids in exhalation Answer: 1 Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm. 150. A nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above: Options: 1. The point at which the larynx connects to the trachea 2. The area connecting the oropharynx to the laryngopharynx 3. The bifurcation of the right and left main bronchi 4. The first tracheal cartilaginous ring Answer: 3 Rationale: The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected, because only the right lung will have breath sounds and rise and fall with ventilation. Options 1, 2, and 4 are incorrect interpretations. 151. A nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? Options: 1. 16% 2. 21%

3. 30% 4. 40% Answer: 2 Rationale: Room air contains 21% oxygen. It is not possible to give a client 16% oxygen because it is less than room air. Options 3 and 4 specify oxygen amounts that commonly are used to supplement clients experiencing respiratory difficulty. 152. A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for this client monitors the status of breath sounds in that area by placing the stethoscope: Options: 1. Posteriorly under the left scapula 2. Just under the left clavicle 3. In the fifth intercostal space 4. Near the lateral twelfth rib Answer: 2 Rationale: The nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded, uppermost part of the lung. The other options are incorrect. 153. A nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When requested for further details by the client, the nurse explains that gas exchange occurs through a process called: Options: 1. Diffusion 2. Osmosis 3. Active transport 4. Ionization Answer: 1 Rationale: Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Active transport is movement of molecules by carrying them across a cell membrane. Ionization refers to the process whereby a molecule gains or loses electrons.

154. A nurse is caring for a client who has just returned from the post-anesthesia care unit after radical neck dissection. The nurse assesses the type of drainage from the wound for which of the following characteristics as expected in the immediate postoperative period?

Options: 1. Serosanguineous 2. Grossly bloody 3. Serous 4. Serous with sputum Answer: 1 Rationale: Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction, which drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. Options 2, 3, and 4 are not expected findings. 155. A nurse has provided instructions for the client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions by stating: Options: 1. I need to wash my hands at least four times a day. 2. I will turn my head to the side if I need to cough or sneeze. 3. I will discard used tissues in a plastic bag. 4. I will brush my teeth and rinse my mouth once a day. Answer: 3 Rationale: The client with TB should wash hands carefully after each contact with respiratory secretions. The client should cover the mouth and nose when laughing, sneezing, or coughing. Used tissues are discarded in a plastic bag. Oral care is done as for any other client. 156. A nurse is caring for a client who had a Mantoux skin test 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? Options: 1. Contact the physician. 2. Call the radiology department for a chest x-ray study to be done. 3. Document the finding in the client s record. 4. Call the employee health service department. Answer: 1 Rationale: The nurse who obtains a positive Mantoux test reading calls the physician immediately. The physician would order a chest x-ray study to rule out whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on TB precautions prophylactically until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these

are not the actions of highest priority from the options provided. 157. A client has a chest tube attached to a Pleur-Evac drainage system. As part of routine nursing care, the nurse would ensure that: Options: 1. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client s record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. Answer: 1 Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Drainage is noted and recorded every hour in the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. 158. A nurse is planning care for a client scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery? Options: 1. Oral airway 2. Epinephrine (Adrenalin) 3. Obturator 4. Tracheostomy set with the next larger size Answer: 3

Rationale: A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube is dislodged. Additionally, a curved hemostat that could be used to hold the trachea open if dislodgment occurs should also be kept at the bedside. An oral airway and epinephrine would not be needed. 159. A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse plans to: Options:

1. Assess for a disconnection. 2. Evaluate the cuff for a leak. 3. Notify the respiratory therapist. 4. Suction the client. Answer: 4 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, kinking of the tubing, or mucus plugging requiring suctioning. Options 1 and 2 would cause the low-pressure alarm to sound. Option 3 delays necessary treatment. 160. A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. Which nursing action is appropriate? Options: 1. Document the findings. 2. Encourage coughing and deep breathing. 3. Suction the client. 4. Increase the suction. Answer: 1

Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite the level falls with inspiration and rises with expirationoccurs when the client is on positive-pressure mechanical ventilation. This is an expected normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings. 161. A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. Which nursing action is appropriate? Options: 1. Document the findings. 2. Encourage coughing and deep breathing. 3. Suction the client. 4. Increase the suction. Answer: 1 Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite the level falls with inspiration and rises with expirationoccurs when the client is on positive-pressure

mechanical ventilation. This is an expected normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings. 162. A nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which of the following nursing actions is appropriate? Options: 1. Reposition the client. 2. Change the chest tube drainage system. 3. Notify the physician. 4. No action is necessary because this is a normal expected finding. Answer: 3 Rationale: Constant bubbling occurring in the water seal chamber may indicate a leak in the system. Among the options provided, the appropriate action is to notify the physician. Options 1, 2, and 4 are incorrect.

163. A nurse in an ambulatory clinic is preparing to administer a Mantoux test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacille CalmetteGurin (bCG) vaccine before moving to the United States from a foreign country. The nurse interprets that: Options: 1. The client s test result will be negative, and a sputum culture will be required for diagnosis. 2. The client s test result will be positive, and a chest x-ray study will be required for evaluation. 3. The client has no risk of acquiring TB and needs no further workup. 4. The client is at increased risk of acquiring TB and needs immediate medication therapy. Answer: 2 Rationale: BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest x-ray study. Options 1, 3, and 4 are incorrect interpretations. 164. A nurse is caring for a client who is receiving feedings by nasogastric tube. The client suddenly begins to vomit, and the nurse quickly repositions the client. The client is coughing and having difficulty breathing, and the nurse suspects that the client has aspirated the feeding. What is the nurse s next action? Options: 1. Call the physician. 2. Call a code. 3. Suction the client.

4. Check the client s vital signs. Answer: 3 Rationale: If the client aspirates the feeding, the nurse would suction the client s airway. The client s respiratory status would be monitored closely until a normal respiratory pattern resumed. Although the physician may need to be notified, ensuring a patent airway is the priority. The question presents no data indicating the need to call a code. The client s vital signs may need to be monitored, but this is not the priority action. 165. A nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse would place the stethoscope over: Options: 1. The peripheral lung fields 2. The major bronchi 3. The trachea and larynx 4. The lower posterior thorax Answer: 2 Rationale: Bronchovesicular breath sounds are heard over major bronchi. Vesicular breath sounds are heard over the peripheral lung fields. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. The upper sternum area is where major bronchi are located. 166. A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food doesn t seem to have any taste during illness. In formulating a response, the nurse understands that this is due to which of the following? Options: 1. Anorexia is triggered by the infectious organism. 2. Blocked nasal passages impair the senses of smell and taste. 3. The client does not have enough energy to cook wholesome meals. 4. The infection blocks sensation from the taste buds of the tongue. Answer: 2 Rationale: When nasal passages become blocked as a result of a URI, the client s senses of taste and smell are impaired. This occurs because one of the normal functions of the nose is to stimulate appetite through the senses of smell and its adjunct role in the sense of taste. The other options are incorrect

167. A nurse who is orienting another nurse to the hospital emergency department instructs the orientee to assess for one-sided chest movement on the right while a client is being intubated by the physician. The nurse s instruction is based on the possibility that the endotracheal tube could inadvertently enter the: Options: 1. Right main bronchus if inserted too far 2. Left main bronchus if inserted too far 3. Right main bronchus if not inserted far enough 4. Left main bronchus if not inserted far enough Answer: 1 Rationale: If the endotracheal tube is inserted too far into the client s trachea, the tube will travel down and enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. The other options are incorrect. 168. A nurse has instructed a client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains in simple terms that the primary benefit is to: Options: 1. Dilate the major bronchi 2. Increase surfactant production 3. Enhance ciliary action in the tracheobronchial tree 4. Maintain inflation of the alveoli Answer: 4 Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk for these conditions. Therefore options 1, 2, and 3 are incorrect. 169. A nurse is assisting a respiratory therapist to position a client for postural drainage. A nursing student asks the nurse how the respiratory therapist selects the position used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain which of the following areas? Options: 1. Trachea 2. Main bronchi 3. Lobes 4. Alveoli Answer: 3 Rationale: Postural drainage utilizes specific client positions that vary depending on the affected lobe(s). The

positions usually involve having the head lower than the affected lung segment(s) to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect. 170. A client s baseline vital signs are: temperature 98.8 F oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure (BP) 124/76 mm Hg. The client s temperature suddenly spikes to 103 F. Which of the following respiratory rates should the nurse anticipate in this client as part of the body s response to the change in status? Options: 1. 12 breaths/min 2. 16 breaths/min 3. 18 breaths/min 4. 22 breaths/min Answer: 4 Rationale: Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. The client who has a decrease in body temperature will experience a decrease in respiratory rate. 171. A client with postoperative incisional pain complains to the nurse about discomfort with prescribed 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: Options: 1. Expel mucus from the airways 2. Dilate the terminal bronchioles 3. Provide for increased oxygen tension in the alveoli 4. Exercise the muscles of respiration Answer: 1 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 describe this purpose. 172. A nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which critical action(s) should the nurse take before entering the client s room? Options: 1. Wash the hands. 2. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth. 3. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and

nose when coughing or sneezing. 4. Wash the hands and wear a gown and gloves. Answer: 2

Rationale: The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 3 is an incorrect statement. Option 4 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. 173. A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of respiratory disease. The nurse anticipates that as the client s CO2 level rises, the pH should: Options: 1. Rise 2. Fall 3. Remain unchanged 4. Double Answer: 2 Rationale: CO2 acts as an acid in the body. Therefore, in a respiratory disorder with a rise in CO2, a corresponding fall in pH occurs. The other options are incorrect. 174. A nurse is evaluating the status of a client experiencing dyspnea. The nurse is aware that which of the following factors will decrease the work of breathing for this client? Options: 1. Increased mucus production 2. Interstitial pulmonary edema 3. Increased airway resistance 4. Bronchodilation Answer: 4 Rationale: Bronchodilation decreases the airway resistance and decreases the work of breathing for the client. Clients with increased mucus production, edema, or bronchospasm have increased airway resistance, which increases the work of breathing. 175. A nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, the diaphragm: Options: 1. Moves downward and out as it contracts

2. Moves up and inward as it contracts 3. Makes the thoracic cage smaller as it contracts 4. Aids in exhalation as it contracts Answer: 1 Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage. This process occurs during the inspiratory phase of the respiratory cycle. Therefore, options 2, 3, and 4 are incorrect. 176. A nurse is reading the chest x-ray report for a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above: Options: 1. The point at which the larynx connects to the trachea 2. The area connecting the oropharynx to the laryngopharynx 3. The bifurcation of the right and left main bronchi 4. The first tracheal cartilaginous ring Answer: 3 Rationale: The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus due to the natural curvature of the airway. This is hazardous because only the right lung will be ventilated. It is easily detected, however, because breath sounds will be heard only over the right lung, and only the right side of the chest will rise and fall with ventilation. Options 1, 2, and 4 are incorrect. 177. A nurse is told to draw an arterial blood gas sample with the client on ambient (room) air. The nurse documents in the record that the client was receiving how much oxygen for this procedure? Options: 1. 16% 2. 21% 3. 30% 4. 40% Answer: 2 Rationale: Ambient air is the same as room air, which contains 21% oxygen. It is not possible to give a client 16% oxygen because it is less than room air. Options 3 and 4 contain oxygen amounts that are commonly used to supplement clients having respiratory difficulty.

178. A chest x-ray report for a client documents the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope: Options: 1. Posteriorly under the left scapula 2. Just under the left clavicle 3. Over the ffith intercostal space 4. Near the lateral twelfth rib Answer: 2 Rationale: The nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded, uppermost part of the lung. All of the other options are incorrect. 179. A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. The nurse plans to have which of the following items readily available at the client s bedside? Options: 1. Chest tube and drainage system 2. Intubation tray 3. Thoracentesis tray 4. Code cart Answer: 2 Rationale: The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client s bedside. 180. A nurse is planning to obtain blood for arterial blood gas (ABG) analysis from a client with chronic obstructive pulmonary disease (COPD). The nurse plans time for which activity after the arterial blood specimen is drawn? Options: 1. Holding a warm compress over the puncture site for 5 minutes 2. Applying pressure to the puncture site by applying a 2 2 gauze for 5 minutes 3. Encouraging the client to open and close the hand rapidly for 2 minutes 4. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes Answer: 2

Rationale: Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the

artery. A cold compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site. 181. A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. The best nursing action for this client would be to: Options: 1. Notify the surgeon. 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage. Answer: 1 Rationale: Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential threat to life, and the surgeon is notified to further evaluate the client and suture or repair the source of the bleeding. The other options do not address the urgency of the problem. Failure to notify the surgeon places the client at risk. 182. A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, the nurse plans to have which of the following items available at the bedside? Options: 1. Chest tube and drainage system 2. Intubation tray 3. Portable chest x-ray machine 4. Morphine sulfate injection Answer: 1 Rationale: Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client may be premedicated before the procedure, or a local anesthetic is used. A portable chest x-ray machine would be called for to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure. 183. A client is admitted to the hospital with a diagnosis of legionnaires disease. The nurse is providing information regarding the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments? Options: 1. I should avoid all contact with my family. 2. I should avoid large crowds for at least 3 weeks.

3. I cannot give legionnaires disease to other people. 4. I will have to take antibiotics until my symptoms disappear. Answer: 3 Rationale: Legionnaires disease is spread through infected aeresolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription. Therefore, options 1, 2, and 4 are incorrect. 184. The nurse is planning care for a 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified a nursing diagnosis of ineffective airway clearance related to retained secretions. Which of the following is an appropriate intervention? Options: 1. Initiate and maintain supplemental oxygen as prescribed. 2. Monitor oxygenation (the oxygen saturation [SaO2]) during activity. 3. Plan activities with rest periods to conserve oxygen needs. 4. Provide nasotracheal suctioning as needed to remove secretions. Answer: 4 Rationale: Ineffective airway clearance reflects the client s inability to expectorate excretions. The intervention specifically addressing retained secretions is option 4. Options 1 and 3 are interventions addressing an impaired gas exchange. Option 3 addresses an activity intolerance diagnosis. 185. A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths/min, bilateral crackles, and cyanosis and is coughing but is unable to expectorate sputum. Which nursing diagnosis is the priority for this client? Options: 1. Risk for decreased cardiac output secondary to cor pulmonale 2. Impaired gas exchange related to ventilation-perfusion mismatch 3. Ineffective breathing pattern related to increased work of breathing 4. Ineffective airway clearance related to inability to expectorate sputum Answer: 4 Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the diagnoses listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client s problems, it is important to first maintain airway, breathing, and circulation. At present, the client demonstrates problems with ventilation because of ineffective coughing, so option 4 would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client s respiratory rate is only slightly elevated, so ineffective breathing pattern is not as important as

airway. The client is cyanotic, but this probably is due to the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support decreased cardiac output as being most important at this time 186. A nurse is performing a respiratory assessment on a client with a left lower lobe lung mass. Chest auscultation over the posterior left lower lobe reveals these breath sounds. (Click on sound icon.) The nurse would interpret these sounds to be which of the following? Options: 1. Pleural friction rub 2. Vesicular breath sounds 3. Bronchial breath sounds 4. Bronchovesicular breath sounds Answer: 3 Rationale: The sounds that the nurse hears are bronchial breath sounds. Bronchial breath sounds are loud, highpitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia. A pleural friction rub is a superficial, lowpitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity. 187. A nurse is performing a respiratory assessment on a client with a left lower lobe lung mass. Chest auscultation over the posterior left lower lobe reveals these breath sounds. (Click on sound icon.) The nurse would interpret these sounds to be which of the following? Options: 1. Pleural friction rub 2. Vesicular breath sounds 3. Bronchial breath sounds 4. Bronchovesicular breath sounds Answer: 3 Rationale: The sounds that the nurse hears are bronchial breath sounds. Bronchial breath sounds are loud, high-

pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia. A pleural friction rub is a superficial, lowpitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity. 188. An emergency department nurse is performing a respiratory assessment on a client complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. (Click on sound icon.) The nurse interprets that these findings are characteristic of which of the following? Options: 1. Asthma 2. Pleurisy 3. Emphysema 4. Pulmonary edema Answer: 2 Rationale: The sound that the nurse hears is a pleural friction rub. Pleural friction rubs are the result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural infarction. It is a superficial, lowpitched, coarse rubbing or grating sound that sounds like two rough surfaces are rubbing together. A pleural friction rub is heard throughout inspiration and expiration and is loudest over the lower anterolateral surface. It is not cleared by a cough. Disorders that cause airflow obstruction such as emphysema or asthma would produce high-pitched or low-pitched wheezes (musical sounds similar to a squeak). Crackles occur with sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. Some material 189. A nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. (Click on sound icon.) The nurse documents this finding as which of the following? Options: 1. Crackles 2. High-pitched wheezes

3. Bronchial breath sounds 4. Bronchovesicular breath sounds Answer: 2 Rationale: The sounds that the nurse hears are high-pitched wheezes. These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed airway diseases such as asthma or emphysema. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger. Crackles occur with sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles are heard in conditions such as congestive heart failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity. 190. An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse interprets that which of the following client manifestations is unrelated to this problem? Options: 1. Purulent nasal discharge 2. Chronic cough 3. Headache more pronounced in the evening 4. Anosmia Answer: 3 Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. 191. A clinic nurse notes that large numbers of clients whose chief complaint is the presence of flu-like symptoms are being seen in the clinic. Which of the following recommendations by the nurse would be least helpful for these clients? Options: 1. Increase intake of liquids. 2. Take antipyretics for fever. 3. Get a flu shot immediately. 4. Get plenty of rest. Answer: 3

Rationale: Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. 192. A client seeks treatment in an ambulatory clinic for a complaint of hoarseness that has lasted for 6 weeks. On the basis of this symptom, the nurse interprets that the client is at risk for a diagnosis of: Options: 1. Laryngeal cancer 2. Acute laryngitis 3. Bronchogenic cancer 4. Thyroid cancer Answer: 1 Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of bronchogenic or thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute problem, such as laryngitis. 193. A nurse is auscultating the chest of a client with new-onset pleurisy. The client does not have a pleural friction rub, which was auscultated the previous day. The nurse interprets that this change is most likely to be due to: Options: 1. Decreased inflammatory reaction at the site 2. The deep breaths that the client is taking 3. Accumulation of pleural fluid in the inflamed area 4. Effectiveness of medication therapy Answer: 3 Rationale: Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears. Options 1, 2, and 4 are incorrect interpretations. 194. A nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least three ribs. The nurse does which of the following to assist the victim s respiratory status until help arrives? Options: 1. Assists the victim to sit up 2. Turns the victim onto the side with the flail chest 3. Removes the victim s shirt 4. Applies firm but gentle pressure with the hands to the flail segment

Answer: 4 Rationale: If significant flail chest is present, the nurse applies firm yet gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victim s respiratory status. The nurse does not move an injured person for fear of worsening an undetected spinal injury. Removing the victim s shirt is of no value in this situation and could in fact result in chilling the victim, which is counterproductive. Injured persons should be kept warm until help arrives at the scene. 195. A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse carries out which of the following prescribed measures as the most effective means to treat the problem? Options: 1. Administers prescribed antibiotics 2. Administers antipyretics as needed (on PRN basis) 3. Has the client breathe into a paper bag 4. Requests an order for a partial rebreather oxygen mask Answer: 1 Rationale: The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance. 196. A nurse is performing a cardiovascular assessment on a client. Which of the following parameters would the nurse assess to gain the best information about the client s left-sided heart function? Options: 1. Breath sounds 2. Peripheral edema 3. Jugular vein distention 4. Hepatojugular reflux Answer: 1 Rationale: The client with heart failure may present with different symptoms according to whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux all are indicators of impaired right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function. 197. A nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism?

Options: 1. A 65-year-old man out of bed 1 day after prostate resection 2. A 73-year-old woman who has just had pinning of a hip fracture 3. A 25-year-old woman with diabetic ketoacidosis 4. A 38-year-old man with pulmonary contusion sustained in an automobile crash Answer: 2 Rationale: Clients frequently at risk for pulmonary embolism include clients who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age. 198. A nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following assessment findings would indicate a deterioration in ventilation? Options: 1. Cyanosis 2. Rapid, shallow respirations 3. Hyperinflated chest 4. Coarse crackles auscultated bilaterally Answer: 2 Rationale: An increase in the rate of respirations and a decrease in the depth of respirations together indicate a deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present with some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation. 199. A nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client toward this goal. Which statement by the client indicates that further instruction is needed? Options: 1. I will let you know at once if I have trouble breathing. 2. I will lie on the affected side for an hour. 3. I can expect a chest x-ray exam to be done shortly. 4. I will notify you if I feel a crackling sensation in my chest. Answer: 2

Rationale: After the procedure, the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the physician. A chest x-ray exam may be performed to evaluate the degree of lung re-expansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure, because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.