Medical Surgical Nursing- Respiratory care Test

1. A postop patient who had a bronchoscopy two hours ago is NPO and states that he is hungry. What should the nurse do?

Notify the physician

Calmly tell the patient that he must remain NPO until another four hours

Order food since the patient is A&O

Check for a gag reflex return

The anesthesia from bronchoscopy inhibits swallowing. Therefore, it is important for the nurse to check for the gag reflex as an aspiration precaution

Explanation

The anesthesia from bronchoscopy inhibits swallowing. Therefore, it is important for the nurse to check for the gag reflex as an aspiration precaution

2. As the nurse auscultates the patient, she hears a popping, discontinuous sound over the lung fields. This type of adventitious sound is known as:

Wheezes

Crackles

Resonance

Pleural friction rub

Crackles are popping, discontinuous sounds caused by fluid in the airways

Explanation

Crackles are popping, discontinuous sounds caused by fluid in the airways

3. A nurse is caring for a patient who had a thoracentesis eight hours ago. While assessing the patient, the nurse observes that the patient has a rapid heart rate, rapid, shallow respirations, and has absent breath sounds to the left upper lobe of the lung. The nurse interprets this complication as:

Pulmonary embolism

Pneumothorax

Respiratory distress

Flail chest

A pneumothrorax, or partial or complete lung collapse, can occur within the first 24 hours following a thoracentesis.

Explanation

A pneumothrorax, or partial or complete lung collapse, can occur within the first 24 hours following a thoracentesis.

4. The nurse is suctioning a patient with an endotracheal tube. Which of the following is a correct technique for this procedure?

Suction for 5 seconds

Apply suction during insertion

Suction the mouth before suctioning the airway

Hyperoxygenate before and after suctioning

Hyperoxygenating before and after prevents hypoxia

Explanation

Hyperoxygenating before and after prevents hypoxia

5. A 53-year-old patient reports smoking two packs of cigarettes per day for the past 35 years. Calculate the pack-years for this patient.

17.5

35

70

106

2 packs/day x 35 years = 70 pack years

Explanation

2 packs/day x 35 years = 70 pack years

6. While auscultating a 65-year-old patient, the nurse hears bronchovesicular breath sounds over the lung fields. How does this nurse interpret this finding?

Pulmonary consolidation

This is a normal finding

Bronchitis

Pleural effusion

Bronchovesicular breath sounds are normally heard over the major bronchi. When heard elsewhere, this would indicate normal aging or an abnormality

Explanation

Bronchovesicular breath sounds are normally heard over the major bronchi. When heard elsewhere, this would indicate normal aging or an abnormality

7. A patient with a chronic lung disease arrives on the med-surg unit. Which delivery system would offer the most precise oxygen concentration for this patient?

Nonrebreather

Venturi facemask

Nasal cannula

Face tent

The Venturi mask offers the most accurate flow rate than the nasal cannula and is therefore preferred for a patient with chronic lung disease

Explanation

The Venturi mask offers the most accurate flow rate than the nasal cannula and is therefore preferred for a patient with chronic lung disease

8. A 37-year-old patient is admitted to the ED with dyspnea, tachypnea and pink, frothy sputum. The nurse determines that the patient is experiencing:

Lung abscess

Neck trauma

Cor pulmonale

Pulmonary embolism

Pulmonary embolism is life threatening and requires emergent medical intervention

Explanation

Pulmonary embolism is life threatening and requires emergent medical intervention

9. The nurse comes into the patient's room and discovers that the patient's pulse oximetry reading is 91%. The nurse should first:

Notify the Rapid Response Team

Assess the patient's respiratory status

Apply supplemental oxygen

Place patient in high-Fowler's position

A reading between 95%-100% is WNL, while a reading less than 85% is life-threatening. Since this question asks what the nurse will do FIRST, the nurse should assess before implementing an appropriate intervention. Remember ADPIE.

Explanation

A reading between 95%-100% is WNL, while a reading less than 85% is life-threatening. Since this question asks what the nurse will do FIRST, the nurse should assess before implementing an appropriate intervention. Remember ADPIE.

10. While the nurse interviews a patient, he verbalizes that he has difficulty breathing during sleep and uses three pillows for relief. The nurse notes that he may be experiencing :

Paroxysmal nocturnal dyspnea

Orthopnea

Hyperventilation

Claudication

Orthopnea is shortness of breath during sleep and is relieved by sitting up or stacking pillows behind the head

Explanation

Orthopnea is shortness of breath during sleep and is relieved by sitting up or stacking pillows behind the head

11. The patient is scheduled to have a pulmonary function test. Further instruction is needed when she states:

" I should use my atenolol right away before the test."

"I shouldn't smoke 6 hours beforehand."

"I should only breathe through my mouth."

"This test will help identify the cause of my shortness of breath."

Atenolol is a bronchodilator that must be withheld 4-6 hours before the procedure as to not skew the results

Explanation

Atenolol is a bronchodilator that must be withheld 4-6 hours before the procedure as to not skew the results

12. A nurse is caring for a patient who had a surgical placement of a tracheostomy 48 hours ago. What should the nurse's initial action be if tube dislodgement occurs?

Re-insert the tube and notify the physician

Place a 4x4 sterile gauze over the stoma to prevent infection

Obtain the patient's vital signs

Ventilate the patient using a manual resuscitation bag as another nurse notifies for help from the resuscitation team

Tube dislodgement that occurs 72 hours after surgery is an emergency. As such, ventilating the patient first is priority. Remember your ABCs.

Explanation

Tube dislodgement that occurs 72 hours after surgery is an emergency. As such, ventilating the patient first is priority. Remember your ABCs.

13. While assessing a trachostomy patient, the nurse notices that there is a crackling sensation around the neck. The nurse suspects this complication as:

Pneumothorax

Tracheomalacia

Subcutaneous emphysema

Trachea-innominate artery fistula

Subcutaenous emphysema occurs when there is an opening in the trachea and air has leaked into the subcutaneous area of the neck

Explanation

Subcutaenous emphysema occurs when there is an opening in the trachea and air has leaked into the subcutaneous area of the neck

14. A nurse is administering oxygen to a patient who has hypoxemia and hypercarbia. Which oxygen delivery system is appropriate for this patient?

Nonrebreather mask

Nasal cannula at 2L/min

Nasal cannula at 4L/min

Simple facemask at 5L/min

A nasal cannula at 2L/min is given since increased oxygen levels will disrupt the hypoxic drive to breathe causing the patient to have a respiratory depression

Explanation

A nasal cannula at 2L/min is given since increased oxygen levels will disrupt the hypoxic drive to breathe causing the patient to have a respiratory depression

15. A nurse is monitoring a patient who has a chest tube drainage system and notices that there is gentle bubbling in the suction control chamber. What is the appropriate nursing action for this scenario?

Document this finding.

Check to see if the chest tube is blocked or kinked

Check for an air leak

Notify the physician immediately

Gentle bubbling indicates there is suctioning and is normal. Vigorous bubbling indicates an air leak in the chest tube system, while a blocked or kinked tube can cause bubbling to stop.

Explanation

Gentle bubbling indicates there is suctioning and is normal. Vigorous bubbling indicates an air leak in the chest tube system, while a blocked or kinked tube can cause bubbling to stop.

16. Which of the following is a normal finding in the aging adult?

Anteroposterior diameter increases

Residual volume decreases

Airways close late

Ability to cough increases

A barreled-chest is a normal finding in the aging adult due to the decreased elastic recoil of the lungs

Explanation

A barreled-chest is a normal finding in the aging adult due to the decreased elastic recoil of the lungs

17. A nurse is reviewing the ABG values and notes a pH of 7.42, a PCO2 of 55 mm Hg, and a HCO3 of 24 mEq/L. What does the nurse interpret these values as?

Uncompensated respiratory alkalosis

Compensated respiratory alkalosis

Compensated respiratory acidosis

Uncompensated respiratory acidosis

The pH is WNL (7.35-7.45) which suggests that compensation has occurred. The PCO2 is higher than normal limits (35-45 mm Hg) which indicates respiratory acidosis. Since HCO3 is WNL (22-26 mEq/L) alkalosis has not taken place. Remember ROME (Respiratory Opposite Metabolic Equal)

Explanation

The pH is WNL (7.35-7.45) which suggests that compensation has occurred. The PCO2 is higher than normal limits (35-45 mm Hg) which indicates respiratory acidosis. Since HCO3 is WNL (22-26 mEq/L) alkalosis has not taken place. Remember ROME (Respiratory Opposite Metabolic Equal)