Respiratory System | Respiratory System Disorders NCLEX Quiz 26

2.

A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

Area of redness is measured in 3 days and determines whether tuberculosis is present.
Skin test doesn’t differentiate between active and dormant tuberculosis infection.
Presence of a wheal at the injection site in 2 days indicates active tuberculosis.
Test stimulates a reddened response in some clients and requires a second test in 3 months.

Correct Answer

A. Skin test doesn’t differentiate between active and dormant tuberculosis infection.

Explanation

The Mantoux test doesn’t differentiate between active and dormant infections. If a positive reaction occurs. a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days. a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test. an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn’t indicate active tuberculosis.

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3.

A female adult client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube. the nurse initially should plug the opening in the tube for:

15 to 60 seconds.
5 to 20 minutes.
30 to 40 minutes.
45 to 60 minutes.

Correct Answer

A. 5 to 20 minutes.

Explanation

Initially. the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes. then gradually lengthen this interval according to the client’s respiratory status. A client who doesn’t require continuous mechanical ventilation already is breathing without assistance. at least for short periods; therefore. plugging the opening of the tube for only 15 to 60 seconds wouldn’t be long enough to reveal the client’s true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

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4.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system is functioning normally
The client has a pneumothorax.
The system has an air leak.
The chest tube is obstructed.

Correct Answer

A. The system has an air leak.

Explanation

Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed. the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

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5.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin. the nurse should assess for cyanosis by inspecting the:

Lips.
Mucous membranes.
Nail beds.
Earlobes.

Correct Answer

A. Mucous membranes.

Explanation

Skin color doesn’t affect the mucous membranes. The lips. nail beds. and earlobes are less reliable indicators of cyanosis because they’re affected by skin color.

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6.

For a male client with an endotracheal (ET) tube. which nursing action is most essential?

Auscultating the lungs for bilateral breath sounds
Turning the client from side to side every 2 hours
Monitoring serial blood gas values every 4 hours
Providing frequent oral hygiene

Correct Answer

A. Auscultating the lungs for bilateral breath sounds

Explanation

For a client with an ET tube. the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client. they’re secondary to ensuring adequate oxygenation.

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7.

The nurse assesses a male client’s respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

Diaphragmatic breathing
Use of accessory muscles
Pursed-lip breathing
Controlled breathing

Correct Answer

A. Use of accessory muscles

Explanation

The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

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8.

A female client is undergoing a complete physical examination as a requirement for college. When checking the client’s respiratory status. the nurse observes respiratory excursion to help assess:

Lung vibrations.
Vocal sounds.
Breath sounds.
Chest movements.

Correct Answer

A. Chest movements.

Explanation

The nurse observes respiratory excursion to help assess chest movements. Normally. thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion. atelectasis. pulmonary embolus. or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say “99.” the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse’s palms. The nurse assesses breath sounds during auscultation.

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9.

A male client comes to the emergency department complaining of sudden onset of diarrhea. anorexia. malaise. cough. headache. and recurrent chills. Based on the client’s history and physical findings. the physician suspects legionnaires’ disease. While awaiting diagnostic test results. the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating legionnaires’ disease?

Erythromycin (Erythrocin)
Rifampin (Rifadin)
Amantadine (Symmetrel)
Amphotericin B (Fungizone)

Correct Answer

A. Erythromycin (Erythrocin)

Explanation

Erythromycin is the drug of choice for treating legionnaires’ disease. Rifampin may be added to the regimen if erythromycin alone is ineffective; however. it isn’t administered first. Amantadine. an antiviral agent. and amphotericin B. an antifungal agent. are ineffective against legionnaires’ disease. which is caused by bacterial infection.

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10.

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough. the nurse should monitor closely for:

Pleural effusion.
Pulmonary edema.
Atelectasis.
Oxygen toxicity.

Correct Answer

A. Atelectasis.

Explanation

In a client with COPD. an ineffective cough impedes secretion removal. This. in turn. causes mucus plugging. which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn’t cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure. not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema. an ineffective cough isn’t one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations. not an ineffective cough.

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Respiratory System | Respiratory System Disorders NCLEX Quiz 26

A female client must take streptomycin for tuberculosis. Before therapy begins. the nurse should instruct the client to notify the physician if which health concern occurs?

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A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

A female adult client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube. the nurse initially should plug the opening in the tube for:

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin. the nurse should assess for cyanosis by inspecting the:

For a male client with an endotracheal (ET) tube. which nursing action is most essential?

The nurse assesses a male client’s respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

A female client is undergoing a complete physical examination as a requirement for college. When checking the client’s respiratory status. the nurse observes respiratory excursion to help assess:

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough. the nurse should monitor closely for: