Respiratory System | Respiratory System Disorders NCLEX Quiz 25

1. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure. the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?

Continue to suction

Notify the physician immediately

Stop the procedure and reoxygenate the client

Ensure that the suction is limited to 15 seconds

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.

Explanation

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.

2. A male adult 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?

Dyspnea

Bradypnea

Bradycardia

Decreased respirations

The common clinical manifestations of pulmonary embolism are tachypnea. tachycardia. dyspnea. and chest pain.

Explanation

The common clinical manifestations of pulmonary embolism are tachypnea. tachycardia. dyspnea. and chest pain.

3. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning. the nurse must limit the suctioning time to a maximum of:

1 minute

5 seconds

10 seconds

30 seconds

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.

Explanation

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.

4. Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs. if noticed in the client. should be reported immediately to the physician?

Dry cough

Hematuria

Bronchospasm

Blood-streaked sputum

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.

Explanation

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.

5. Which phrase is used to describe the volume of air inspired and expired with a normal breath?

Total lung capacity

Forced vital capacity

Tidal volume

Residual volume

Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

Explanation

Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

6. A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?

Limiting fluid

Having the client take deep breaths

Asking the client to spit into the collection container

Asking the client to obtain the specimen after eating

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.

Explanation

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.

7. A male client abruptly sits up in bed. reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

Simple mask

Non-rebreather mask

Face tent

Nasal cannula

A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask. face tent. and nasal cannula — deliver lower levels of FIO2.

Explanation

A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask. face tent. and nasal cannula — deliver lower levels of FIO2.

8. The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

Make inhalation longer than exhalation.

Exhale through an open mouth.

Use diaphragmatic breathing.

Use chest breathing.

In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation. keep the bronchioles from collapsing. and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

Explanation

In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation. keep the bronchioles from collapsing. and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

9. A male client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the nurse to change the dosage to 0.45 mg/kg/hour. The nurse should:

Question the order because it’s too low.

Question the order because it’s too high.

Set the pump at 45 ml/hour.

Stop the infusion and have the laboratory repeat the theophylline measurement.

A therapeutic theophylline level is 10 to 20 mcg/ml. The client is currently receiving 0.5 mg/kg/hour of aminophylline. Because the client’s theophylline level is sub-therapeutic. reducing the dose (which is what the physician’s order would do) would be inappropriate. Therefore. the nurse should question the order.

Explanation

A therapeutic theophylline level is 10 to 20 mcg/ml. The client is currently receiving 0.5 mg/kg/hour of aminophylline. Because the client’s theophylline level is sub-therapeutic. reducing the dose (which is what the physician’s order would do) would be inappropriate. Therefore. the nurse should question the order.

10. A slightly obese female client with a history of allergy-induced asthma. hypertension. and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination. paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall. the nurse expects to elicit:

Resonant sounds.

Hyperresonant sounds.

Dull sounds.

Flat sounds.

When percussing the chest wall. the nurse expects to elicit resonant sounds — low-pitched. hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they’re louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax. they may be normal in children and very thin adults. Dull sounds. normally heard only over the liver and heart. may occur over dense lung tissue. such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds. soft and high-pitched. are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.

Explanation

When percussing the chest wall. the nurse expects to elicit resonant sounds — low-pitched. hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they’re louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax. they may be normal in children and very thin adults. Dull sounds. normally heard only over the liver and heart. may occur over dense lung tissue. such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds. soft and high-pitched. are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.