Respiratory System | Pneumonia & Tuberculosis NCLEX Quiz 41

1. A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority?

Acute pain related to lung expansion secondary to lung infection

Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever.

Anxiety related to dyspnea and chest pain.

Ineffective airway clearance related to retained secretions.

Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces. leading to an ineffective airway clearance related to retained secretions.

Explanation

Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces. leading to an ineffective airway clearance related to retained secretions.

2. A client's ABG analysis reveals a pH of 7.18. PaCO2 of 72 mm Hg. PaO2 of 77 mm Hg. and HCO3- of 24 mEq/L. What do these values indicate?

Metabolic acidosis

Respiratory alkalosis

Metabolic alkalosis

Respiratory acidosis

The ABG analysis results indicate respiratory acidosis. A pH below 7.35 is considered acidic, and a pH of 7.18 falls within this range. PaCO2 above 45 mm Hg suggests retention of carbon dioxide, which is a characteristic of respiratory acidosis. PaO2 of 77 mm Hg is within the normal range, and HCO3- of 24 mEq/L indicates normal bicarbonate levels, which rules out metabolic acidosis or alkalosis. Therefore, the combination of low pH and high PaCO2 points to respiratory acidosis.

Explanation

The ABG analysis results indicate respiratory acidosis. A pH below 7.35 is considered acidic, and a pH of 7.18 falls within this range. PaCO2 above 45 mm Hg suggests retention of carbon dioxide, which is a characteristic of respiratory acidosis. PaO2 of 77 mm Hg is within the normal range, and HCO3- of 24 mEq/L indicates normal bicarbonate levels, which rules out metabolic acidosis or alkalosis. Therefore, the combination of low pH and high PaCO2 points to respiratory acidosis.

3. A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if which of the following were noted in the laboratory report?

5 mcg/mL

15 mcg/mL

25 mcg/mL

30 mcg/mL

The therapeutic theophylline blood level range from 10-20 mcg/mL.

Explanation

The therapeutic theophylline blood level range from 10-20 mcg/mL.

4. An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct?

Using intermittent suction while advancing the catheter.

Using continuous suction while withdrawing the catheter.

Using intermittent suction while withdrawing the catheter.

Using continuous suction while advancing the catheter.

Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia. suctioning shouldn’t last more than 10-seconds at a time. Suction shouldn’t be applied while the catheter is being advanced.

Explanation

Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia. suctioning shouldn’t last more than 10-seconds at a time. Suction shouldn’t be applied while the catheter is being advanced.

5. A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is:

A bloody. productive cough

A cough with the expectoration of mucoid sputum

Chest pain

Dyspnea

One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.

Explanation

One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.

6. A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. Which of the following is a normal physiologic change related to aging?

Increased elastic recoil of the lungs

Increased number of functional capillaries in the alveoli

Decreased residual volume

Decreased vital capacity.

Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs. fewer functional capillaries in the alveoli. and an increase is residual volume.

Explanation

Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs. fewer functional capillaries in the alveoli. and an increase is residual volume.

7. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following. if noted in the client's history. would require physician notification?

Heart disease

Allergy to penicillin

Hepatitis B

Rheumatic fever

Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.

Explanation

Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.

8. A police officer brings in a homeless client to the ER. A chest x-ray suggests he has TB. The physician orders an intradermal injection of 5 tuberculin units/0.1 ml of tuberculin purified derivative. Which needle is appropriate for this injection?

5/8” to ½” 25G to 27G needle.

1” to 3” 20G to 25G needle.

½” to 3/8” 26 or 27G needle.

1” 20G needle.

Intradermal injections like those used in TN skin tests are administered in small volumes (usually 0.5 ml or less) into the outer skin layers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or 27G needle should be inserted about 1/8” below the epidermis.

Explanation

Intradermal injections like those used in TN skin tests are administered in small volumes (usually 0.5 ml or less) into the outer skin layers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or 27G needle should be inserted about 1/8” below the epidermis.

9. A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted. he gags and coughs. Which action should the nurse take?

Remove the airway and insert a shorter one.

Reposition the airway.

Leave the airway in place until the client gets used to it.

Remove the airway and attempt suctioning without it.

If a client gags or coughs after nasopharyngeal airway placement. the tube may be too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway won’t solve the problem. The client won’t get used to the tube because it’s the wrong size. Suctioning without a nasopharyngeal airway causes trauma to the natural airway.

Explanation

If a client gags or coughs after nasopharyngeal airway placement. the tube may be too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway won’t solve the problem. The client won’t get used to the tube because it’s the wrong size. Suctioning without a nasopharyngeal airway causes trauma to the natural airway.

10. A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm Hg. whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing:

Carbon monoxide poisoning

Carbon dioxide narcosis

Respiratory alkalosis

Metabolic acidosis

Carbon dioxide narcosis is a condition that results from extreme hypercapnia. with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors. which may progress to convulsions and possible coma.

Explanation

Carbon dioxide narcosis is a condition that results from extreme hypercapnia. with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors. which may progress to convulsions and possible coma.