Respiratory System | Respiratory System Disorders NCLEX Quiz 23

1. For a female patient with chronic obstructive pulmonary disease. which nursing intervention would help maintain a patent airway?

Restricting fluid intake to 1.000 ml per day

Enforcing absolute bed rest

Teaching the patient how to perform controlled coughing

Administering prescribe sedatives regularly and in large amounts

Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient’s ability to maintain a patent airway. causing a high risk for infection from pooled secretions.

Explanation

Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient’s ability to maintain a patent airway. causing a high risk for infection from pooled secretions.

2. A male patient has a sucking stab wound to the chest. Which action should the nurse take first?

Drawing blood for a hematocrit and hemoglobin level

Applying a dressing over the wound and taping it on three sides

Preparing a chest tube insertion tray

Preparing to start an I.V. line

The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests. assist with chest tube insertion. and start an I.V. line.

Explanation

The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests. assist with chest tube insertion. and start an I.V. line.

3. When caring for a male patient who has just had a total laryngectomy. the nurse should plan to:

Encourage oral feeding as soon as possible

Develop an alternative communication method

Keep the tracheostomy cuff fully inflated

Keep the patient flat in bed

A patient with a laryngectomy cannot speak. yet still needs to communicate. Therefore. the nurse should plan to develop an alternative communication method. After a laryngectomy. edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa. the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema. the nurse should place the patient in semi-Fowler’s position.

Explanation

A patient with a laryngectomy cannot speak. yet still needs to communicate. Therefore. the nurse should plan to develop an alternative communication method. After a laryngectomy. edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa. the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema. the nurse should place the patient in semi-Fowler’s position.

4. Nurse Maureen 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?

Inform the physician

Continue to monitor the client

Reinforce the occlusive dressing

Encourage the client to deep breathe

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 A. C. and D are incorrect.

Explanation

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 A. C. and D are incorrect.

5. A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:

Exhale slowly

Stay very still

Inhale and exhale quickly

Perform the Valsalva maneuver

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 A. B. and C are incorrect client instructions.

Explanation

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 A. B. and C are incorrect client instructions.

6. Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate?

Do nothing. because this is an expected finding

Immediately clamp the chest tube and notify the physician

Check for an air leak because the bubbling should be intermittent

Increase the suction pressure so that the bubbling becomes vigorous

Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

Explanation

Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

7. After undergoing a left pneumonectomy. a female patient has a chest tube in place for drainage. When caring for this patient. the nurse must:

Monitor fluctuations in the water-seal chamber

Clamp the chest tube once every shift

Encourage coughing and deep breathing

Milk the chest tube every 2 hours

When caring for a patient who is recovering from a pneumonectomy. the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed. the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

Explanation

When caring for a patient who is recovering from a pneumonectomy. the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed. the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

8. Nurse Reynolds 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:

Call the physician

Place the tube in bottle of sterile water

Immediately replace the chest tube system

Place a sterile dressing over the disconnection site

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.

Explanation

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.

9. For a patient with advanced chronic obstructive pulmonary disease (COPD). which nursing action best promotes adequate gas exchange?

Encouraging the patient to drink three glasses of fluid daily

Keeping the patient in semi-Fowler’s position

Using a high-flow venture mask to deliver oxygen as prescribe

Administering a sedative. as prescribe

The patient with COPD retains carbon dioxide. which inhibits stimulation of breathing by the medullary center in the brain. As a result. low oxygen levels in the blood stimulate respiration. and administering unspecified. unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange. the nurse should use a Venturi mask to deliver a specified. controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions. which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler’s position and should not receive sedatives or other drugs that may further depress the respiratory center.

Explanation

The patient with COPD retains carbon dioxide. which inhibits stimulation of breathing by the medullary center in the brain. As a result. low oxygen levels in the blood stimulate respiration. and administering unspecified. unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange. the nurse should use a Venturi mask to deliver a specified. controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions. which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler’s position and should not receive sedatives or other drugs that may further depress the respiratory center.

10. A male patient's X-ray result reveals bilateral white-outs. indicating adult respiratory distress syndrome (ARDS). This syndrome results from:

Cardiogenic pulmonary edema

Respiratory alkalosis

Increased pulmonary capillary permeability

Renal failure

ARDS results from increased pulmonary capillary permeability. which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema. pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS. respiratory alkalosis may arise secondary to hyperventilation; however. it does not cause ARDS. Renal failure does not cause ARDS. either.

Explanation

ARDS results from increased pulmonary capillary permeability. which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema. pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS. respiratory alkalosis may arise secondary to hyperventilation; however. it does not cause ARDS. Renal failure does not cause ARDS. either.