Download Respiratory 1. An ICU nurse has been assigned to four (4) clients

Respiratory
1. An ICU nurse has been assigned to four (4) clients. What situation should suggest the nurse that
the machine has malfunctioned?
a. A patient on a chest tube is having a serosangineous drainage
b. A patient on an IV pump having a high pressure alarm
c. A patient on a mechanical ventilation is having a high-pressure alarm
d. A patient on a partial rebreather mask inhales while the bag inflates
Answer: C – High-pressure alarm are cause by increased secretions are in the airway, wheezing or
brochospasm causes decreased airway size, the endotracheal tube is displaced, the ventilator tube is
obstructed because of water or a kink in the tubing, clients cough, gags, or bites on the oral
endotracheal tube, and client is anxious of flights the ventilator --- Saunders Comprehensive Review
for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.804
2. A client with tracheostomy is having difficulty of breathing cause by excessive mucus secretion
and needs to be suction immediately. In suctioning, what should the nurse prioritize in doing
first?
a. Use aseptic technique
b. Do not apply suction while inserting the catheter
c.
Insert the catheter 4 inches
d. Hyperoxygenate the client by a resuscitation bag, or increase the oxygen flow rate
before and after suctioning
e. Lubricate the catheter with sterile water
f.
Apply suction intermittently for 10 seconds; rotate the catheter and withdraw
3. Order the above by step-by-step procedure:
Answer: ADECBF– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda
Ann Silvestri, MSN, RN; Pg.794
4. A 35 year old client is diagnosed of having hemothorax and attached in a chest tube drainage
system. Which of the following are incorrect understandings on managing a chest drainage
system? SATA
a. When the wall vacuum is turned off, the drainage system must be open to the
atmosphere so that intrapleural air can escape from the system
b. If the chest tube and drainage system become disconnected, a temporary water seal
can be established by immersing the chest tube’s open end in a bottle of tap water --sterile water
c. Gently “milk” the tubing away from the drainage chamber ---in the direction of…;
milking prevents the tubing from becoming obstructed b y clots and fibrin. Constant
attention to maintaining the patency of the tube facilitates prompt expansion of the
lung and minimizes complications
d. If the patient is lying on a stretcher and must be transported to another area, place the
drainage system below the chest level. Do not clamp the chest tube during transport --the drainage apparatus must be kept at a level lower than the patient’s chest to
prevent fluid from flowing backward into the pleural space. Clamping can result in a
tension pneumothorax
Answer: BC – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne
Smeltzer, RN, EdD, FAAN; Pg.631-632
5.
A ward nurse has been assigned to a client, diagnosed of having pneumothorax, with a chest
tube drainage system. What will suggest the nurse that the system is malfunctioning?
a. Intermittent bubbling in the suction control chamber
b. Drainage in the collection chamber is 150mL every 2 hours
c. Fluctuation of the fluid level in the water seal chamber
d. Gentle bubbling in the suction control chamber
Answer: A– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann
Silvestri, MSN, RN; Pg.260-261
6.
A 50 year old client went to the ED with complaints of weight loss and labored breathing on
exertion. The client is diagnosed of having Ephysema. Which the following statements are
incorrect about the disease?
a. Recurrent inflammation is associated with the release of proteolytic enzymes from lung
cells
b. Can develop pneumomediastinum cause by alveolar blebs and bullae rupture
c. Air trapping results in hypoinflated lungs, causing a “barrel chest” appearance ---
hyperinflated lungs
d. There is loss of elastic recoil as a result of destruction of elastin and collagen fibers
found in lungs; without this recoil, air trapped in lungs and airways collapse
Answer: C– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2 nd Edition; Mary Ann Hogan,
MSN, RN; Pg.5 and Expert LPN Guides Pathophysiology; ©2007 by Lippincott Williams & Wilkins;
Pg.207
7. A client has been prescribed with Guaifenesin 300mg four times a day as an expectorant. The
dosage strength of the liquid is 200mg/5mL. How many mL should the nurse administer for each
dose?
a. 10.0mL
b. 9.5mL
c. 7.5mL
d. 5.0mL
Answer: C – 300mg/x = 200mg/5mL; x= 7.5mL --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane
Billings, EdD, RN, FAAN; Pg.309 [#9]
8. A respiratory unit nurse has been assigned to four clients. Prioritize in order how the nurse
would assess the clients from highest to lowest priority:
a. A 35 year old client with suspected tuberculosis who is complaining of a cough
b. An 85 year old client with bacterial pneumonia, temperature of 102.2 °F (42°C), and
shortness of breath
c.
A 56 year old client with emphysema who has a schedule dose of a bronchodilator due
to be administered, with no report of acute respiratory distress
d. A 60 year old client with chest tubes who is 2 days postoperative following a
thoracotomy for lung cancer and is requesting something for pain
Answer: BDCA – The elderly client with pneumonia, shortness of breath and an elevated temperature
is the most acutely ill client described and should be the client with the highest priority. The shortness
of breath and elevated temperature can lead to a decrease in the client’s oxygen levels, and can
predispose the client to dehydration and confusion. The nurse should assess the client with
thoracotomy who is requesting pain medication and administer any needed medication. The client
with emphysema should be the next priority so that the bronchodilator can be administered on
schedule as possible. The nurse would then assess the client with suspected tuberculosis and a cough -
-- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.311-312 [#31]
9. The client was brought in the ED with complaints of sudden onset of shaking chill and a
temperature of 102-104 °F (38.9-40°C). The client was diagnosed of having bacterial Pneumonia.
Which nursing management is incorrect?
a. Sympathomimetic drugs such as albuterol sulfate (Proventil) or metaproterenol
(Alupent)
b. Antibiotic therapy as indicated by culture and sensitivity within 4hours of diagnosis or
admission
c. Increased fluid intake to 2.5-3L/day to help liquefy the secretion
d. Encourage the elderly and at-risk clients to have a pneumonia vaccine every 2 years ---5
years
Answer: D– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan,
MSN, RN; Pg.17
10. A 55 year old client has been diagnosed of having Pulmonary Embolism. Which of the following
are the signs and symptoms of this disease? SATA
a. Tachypnea
b. Tachycardia
c. Left-sided heart failure ---right-sided heart failure
d. Respiratory acidosis ---respiratory alkalosis
e. Friction rub
f.
Increased breath sounds ---decreased breath sounds
g. Chest pain
h. Pleuritic pain
Answer: ABEGH– Other signs and symptoms include sudden acute dyspnea with extreme anxiety,
abnormal lung sounds (wheezing, or crackles), hypoxia, diaphoresis, and coughing; petechiae may
develop with fat emboli; large clots or more complicated situations include pulmonary hypertension,
shock, or sudden respiratory arrest --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2 nd
Edition; Mary Ann Hogan, MSN, RN; Pg.25 and Expert LPN Guides Pathophysiology; ©2007 by
Lippincott Williams & Wilkins; Pg.222-223
11. A 56 year old client has an arterial blood gas of pH: 7.31; PaO2: 80 mm Hg; PaCO2: 63mm Hg;
HCO3: 36mEq/L. The nurse would expect this sign/symptom will occur:
a. Anxiety
b. Cyanosis
c. Irritability
d. Flushed skin
Answer: D – The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy
and lethargy because carbon dioxide has a depressant effect on the central nervous system. Cyanosis
is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are
associated with hypoxia --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN,
FAAN; Pg.315 [#71]
12. The nurse is assigned to care for the following clients. Which client should the nurse prioritize to
assess first?
a. A 51 year old client with asthma complaining of shortness of breath (SOB) after using a
bronchodilator inhaler
b. A 57 year old client with COPD and pulse oximetry reading from previous shift of 90%
saturation
c. A 68 year old client on ventilator who needs a sterile sputum specimen sent to the
laboratory
d. A 72 year old client with pneumonia who needs to be started on intravenous antibiotics
Answer: A – The client with asthma did not achieve relief from SOB after using the bronchodilator and
is at risk for respiratory complications. The client’s needs are urgent --- Prioritization, Delegation, &
Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.178
[#15]
13. The charge nurse is making assignments for the following shift. Which client should be assigned
to a nurse who has been working in the hospital for two months and was pulled from the
surgical unit to the medical unit?
a. A 72 year old client who needs teaching about incentive spirometry
b. A 69 year old client with COPD who is ventilator dependent
c. A 65 year old client just returned from bronchoscopy and biopsy
d. A 58 year old client on airborne precautions for tuberculosis (TB)
Answer: A – Many surgical clients are taught about coughing, deep breathing, and use of incentive
spirometry preoperatively. To care for the client with TB on isolation, the nurse must be fitted with a
high-efficiency particulate (HEPA) respirator mask. The bronchoscopy client needs specialized and
careful assessment and monitoring after the procedure, and ventilator-dependent client needs a
nurse who is familiar with ventilator care. Both of these clients need experienced nurses --Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition;
Linda LaCharity, PhD, RN; Pg.178 [#15]
14. A 45 year old client went to the ED with complaints of low-grade fever in the afternoon, dry
cough, and blood-tinged sputum. After some laboratory test it was found out that the client has
Pulmonary Tuberculosis (PTB). In caring for the client, which nursing management is incorrect?
a. Prevention of TB requires taking BCG vaccine once for TB or medication for 6-12 months
for exposure and at least 1year for clients with HIV ---9 months
b. Hepatotoxicity is a common side effect for many agents, and clients should be
monitored closely
c. Once positive, the purified protein derivative (PPD) will remain positive and should not
be repeated
d. Place clients with active cases on airborne precautions (in negative-pressure room)
Answer: A– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2 nd Edition; Mary Ann Hogan,
MSN, RN; Pg.18-20
15. A 48year old miner went to the ED with complaints of chest pain and recurrent respiratory tract
infection. He has been diagnosed of having Asbestosis. A nurse know that Asbestosis: SATA
a. May progress to pulmonary fibrosis
b. Has no cure
c. Is caused by prolonged inhalation of asbestos fibers
d. Has signs and symptoms of decreased lung inflation, and finger clubbing
Answer: ALL– Expert LPN Guides Pathophysiology; ©2007 by Lippincott Williams & Wilkins; Pg.192194
16. A client with lung injuries undergoes surgery. Postoperative orders include blood transfusion of
one unit of PRBC at a rate of 60mL/hr. How long will the transfusion take to infuse the entire
unit?
a. 8 hours
b. 6 hours
c. 4 hours
d. 2 hours
Answer: C – One unit of PRBC is about 250mL. If the blood is delivered at a rate of 60mL/hr, it will take
4 hours to infuse the entire unit. The transfusion of a single unit of PRBC should not exceed 4 hours to
prevent growth and minimize the risk of septicemia --- Lippincott’s Review for NCLEX-RN 8th Edition;
Diane Billings, EdD, RN, FAAN; Pg.319 [#113]
17. Assessment findings of a client with Pleural effusion are as follows:
a. Tactile Fremitus: Increased; Percussion: Dull; Auscultation: Bronchial breath sounds,
crackles, bronchophony, egophony, whispered pectoriloquy ---Consolidation like
pneumonia
b. Tactile Fremitus: Normal; Percussion: Resonant; Auscultation: Normal to decreased
breath sounds, wheezes ---Bronchitis
c. Tactile Fremitus: Decreased; Percussion: Hyperresonant; Auscultation: Decreased
intensity of breath sounds, usually with prolonged expiration ---Emphysema
d. Tactile Fremitus: Absent; Percussion: Dull to flat; Auscultation: Decreased to absent
bronchial breath sounds and bronchophony, egophony, and whispered pectoriloquy
above the effusion over the area of compressed lung
Answer: D – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne
Smeltzer, RN, EdD, FAAN; Pg.483
18. Which of the following criteria would indicate that a nurse can start weaning the client from his
mechanical ventilator? SATA
a. Vital Capacity – 10-25mL/kg
b. Maximum inspiratory pressure (MIP) at least – 20 cm H2O
c. Tidal volume – 7-9 mL/kg
d. Minute ventilation – 6L/min
e. Rapid/shallow breathing index – below 100 breaths/minute/L
f.
PaO2 greater than 60 mm Hg with FiO2 less than 40%
Answer: ALL – Careful assessment of multiple weaning indices helps to determine readiness for
weaning. When the criteria have been met, the patient’s likelihood of successful weaning increases --Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD,
FAAN; Pg.624
19. The nursing assistant is taking the vital signs of a client who is intubated after being suctioned by
the respiratory therapist. Which vital sign should she immediately report to the RN?
a. Blood pressure: 168/90
b. Heart rate: 98 beats/min
c. Tympanic temperature: 101.4°F
d. Respiratory rate: 24 breaths/min
Answer: C – Infections are always a threat for the client using a ventilator. The ET tube bypasses the
body’s normal process of filtering air and provides a direct access for bacteria to the lower parts of the
respiratory system --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical
Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.179 [#25]
20. A PTB client asks the nurse the importance of multiple drug treatment. The nurse knows that
the rationale for using multiple drug treatment for PTB clients is?
a. Multiple drugs reduce development of resistant strains of the bacteria
b. Multiple drugs reduce undesirable drug side effects
c. Multiple drugs allow reduced drug dosages to be given
d. Multiple drugs potentiate the drug’s actions
Answer: A – Use of combination of anti-tuberculosis drugs slows the rate at which organisms develop
drug resistance. Combination therapy also appears to be more effective than single-drug therapy.
Many drugs potentiate or inhibit the actions of other drugs; however, this is not the rationale for
using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce side effects.
Combination therapy may allow some medications to be given in reduced dosages; however, reduced
dosages are not prescribed for antibiotics and anti-tuberculosis drugs --- Lippincott’s Review for
NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.313 [#51]