Respiratory Disorders (Part 2)

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A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the:
- Frontal sinuses only.
- Sphenoidal sinuses only.
- Frontal and maxillary sinuses.
- Sphenoidal and ethmoidal sinuses.

About This Quiz

As a medical practitioner, proper diagnosis of a respiratory disorder will lead to giving the correct care and medication to a patient. Are you studying to be or practicing as a medical practitioner? Take the quiz below and see how conversant you are with issues regarding the respiratory disorders. Good luck!

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2.

For a client with impaired gas exchange, which position is best?
- Lateral decubitus
- High Fowler's
- Supine
- Semi-Fowler's
Correct Answer

A. High Fowler's

Explanation

RATIONALE: For a client with impaired gas exchange, high Fowler's positionis the best position because it allows maximal chest expansion. If the client can't tolerate high Fowler's position, semi-Fowler's is the next best choice because it increases comfort and allows chest expansion. The lateral decubitus and supine positions don't promote chest expansion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1620.

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3.

A 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. When percussing the client's chest wall, the nurse expects to elicit:
- Resonant sounds.
- Hyperresonant sounds.
- Dull sounds.
- Flat sounds.
Correct Answer

A. Resonant sounds.

Explanation

RATIONALE: When percussing the chest wall of a client with allergy-induced asthma, the nurse should expect 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 fromconsolidationor 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 76.

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4.

A 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

RATIONALE: 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 edemausually results from left-sidedheart 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 707.

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5.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3–) 25 mEq/L. What should the nurse do first?
- Instruct the client to breathe into a paper bag.
- Administer oxygen by nasal cannula as ordered.
- Auscultate breath sounds bilaterally every 4 hours.
- Encourage the client to deep-breathe and cough every 2 hours.
Correct Answer

A. Administer oxygen by nasal cannula as ordered.

Explanation

RATIONALE: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2value of 60 mm Hg, which indicateshypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 664.

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6.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2of 96% or better. The client most likely has:
- Poor peripheral perfusion.
- A possible hematologic problem.
- A psychosomatic disorder.
- Left-sided heart failure.
Correct Answer

A. A possible hematologic problem.

Explanation

RATIONALE: SaO2is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2and still be short of breath, indicating a possible hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sidedheart failure, the client would exhibit pulmonarycrackles.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 579.

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7.

The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse manager should take which step to meet the needs of her staff?
- Contact the institutional ethics committee.
- Arrange a meeting with the client's family.
- Ask the physician to meet with the staff.
- Reinforce to the staff that the decision is the client's to make.
Correct Answer

A. Contact the institutional ethics committee.

Explanation

RATIONALE: The institutional ethics committee can help the staff develop strategies to resolve their ethical dilemma. The Patient's Bill of Rights states that the client (not the family) has the right to make decisions about the care plan and to refuse recommended treatment. Arranging a meeting with the client's family is inappropriate, whether or not they're in agreement with the client's wishes. The physician must comply with the client's wishes, so scheduling a meeting with the physician isn't beneficial to the staff. Reinforcing to the staff that the decision is the client's to make dismisses the staff's concerns.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 113.

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8.

A client undergoes a tracheostomyafter many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?
- Call the physician.
- Remove the malfunctioning cuff.
- Add more air to the cuff.
- Suction the client, withdraw residual air from the cuff, and reinflate it.
Correct Answer

A. Suction the client, withdraw residual air from the cuff, and reinflate it.

Explanation

RATIONALE: After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 739.

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9.

A client with asthmais receiving a theophylline (Uniphyl) preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?
- 2 to 5 mcg/ml
- 5 to 10 mcg/ml
- 10 to 20 mcg/ml
- 21 to 25 mcg/ml
Correct Answer

A. 10 to 20 mcg/ml

Explanation

RATIONALE: The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic. Concentrations above 20 mcg/ml are considered toxic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1225.

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10.

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary diseasewho wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care?
- Decreasing administration of pain medications
- Reducing oxygen requirements
- Increasing the need for antianxiety agents
- Decreasing the use of bronchodilators
Correct Answer

A. Increasing the need for antianxiety agents

Explanation

RATIONALE: The nurse should anticipate that the physician will increase antianxiety agents during treatment to maintain comfort throughout the dying process. Bronchodilators, pain medications, and home oxygen therapy help promote client comfort. Therefore, they should be continued as part of palliative care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 989.

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11.

A physician orders prednisone (Deltasone) to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:
- Hyperglycemia and glycosuria.
- Acute adrenocortical insufficiency.
- GI bleeding.
- Restlessness and seizures.
Correct Answer

A. Acute adrenocortical insufficiency.

Explanation

RATIONALE: Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology,4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 564.

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12.

A client with severe acute respiratory syndromeprivately informs a nurse that he doesn't want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate action by the nurse would be to:
- Inform the family of the client's wishes.
- Assure the family that all possible measures will be taken.
- Support the client's decision.
- Assure the client that all possible measures will be taken.
Correct Answer

A. Support the client's decision.

Explanation

RATIONALE: The nurse is obligated to act as the client's advocate. The nurse shouldn't discuss the issue with the client's family unless the client gives permission. Assuring the family and client that all possible measures will be taken opposes the client's wishes and doesn't demonstrate client advocacy.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 114.

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13.

A client admitted to the facility for treatment for tuberculosisreceives instructions about the disease. Which statement made by the client indicates the need for further instruction?
- "I'll have to take the medication for up to a year."
- "This disease may come back later if I am under stress."
- "I'll stay in isolation for 6 weeks."
- "I'll always have a positive test for tuberculosis."
Correct Answer

A. "I'll stay in isolation for 6 weeks."

Explanation

RATIONALE: The client requires additional teaching if he states that he'll be in isolation for 6 weeks. The client needs to be in isolation for 2 weeks, not 6, while taking the tuberculosis drugs. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He'll be positive when tested and if he's sick or under some stress he could have a relapse of the disease.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 648.

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14.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
- "I need to keep my inhaler at the bedside."
- "I should eat a high-protein diet."
- "I should become involved in a weight loss program."
- "I should sleep on my side all night long."
Correct Answer

A. "I should become involved in a weight loss program."

Explanation

RATIONALE: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 604.

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15.

A client is experiencing dryness in the nares while receiving oxygen via nasal cannulaat 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?
- Petroleum jelly
- Sterile water
- Lubricant jelly
- Antibiotic ointment
Correct Answer

A. Lubricant jelly

Explanation

RATIONALE: Lubricant jelly is a water-soluble agent that the nurse can apply safely during oxygen therapy to alleviate dryness of the nares. Petroleum jelly is combustible; it isn't safe to use with oxygen. The nurse shouldn't use sterile water or antibiotic ointment to alleviate dryness in the nares.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 851.

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16.

A client with chronic obstructive pulmonary disease(COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
- "Limit yourself to smoking only 2 cigarettes per day."
- "Eat a high-sodium diet."
- "Weigh yourself daily and report a gain of 2 lb in 1 day."
- "Maintain bed rest."
Correct Answer

A. "Weigh yourself daily and report a gain of 2 lb in 1 day."

Explanation

RATIONALE: The nurse should instruct the client to weigh himself daily and report a gain of 2 lb in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failureor cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy.The client shouldn't smoke at all.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 704.

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17.

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?
- "My cough has changed from a dry cough to one with lots of sputum production."
- "I've had a low-grade fever for 2 weeks."
- "My voice is hoarser than it used to be."
- "I've lost 10 pounds in the last month."
Correct Answer

A. "My cough has changed from a dry cough to one with lots of sputum production."

Explanation

RATIONALE: A cough that changes in character is one of the hallmark signs of lung cancer. Low-grade fever, hoarseness, and weight loss may be attributed to other disease processes and don't necessarily indicate lung cancer.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 671.

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18.

A 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

RATIONALE: 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 the word "ninety-nine" 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.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1612.

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19.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
- Fluid intake for the past 24 hours
- Baseline arterial blood gas (ABG) levels
- Prior outcomes of weaning
- Electrocardiogram (ECG) results
Correct Answer

A. Baseline arterial blood gas (ABG) levels

Explanation

RATIONALE: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 752.

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20.

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventinginfection. Which finding indicates that this outcome has been met?
- Decreased oxygen requirements
- Increased sputum production
- Decreased activity tolerance
- Normothermia
Correct Answer

A. Decreased oxygen requirements

Explanation

RATIONALE: A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 700.

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1
21.

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?
- It's a centrally acting antitussive and doesn't cause dependence.
- It's a peripherally acting antitussive and doesn't cause dependence.
- It's a centrally acting antitussive and can cause dependence.
- It's a peripherally acting antitussive and can cause dependence.
Correct Answer

A. It's a centrally acting antitussive and can cause dependence.

Explanation

RATIONALE: As a centrally acting antitussive, codeine suppresses the cough reflex by directly affecting the sensitivity of the cough center in the medulla to incoming stimuli. Because codeine is an opioid, it can cause dependence.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p.357.

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22.

Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?
- The client who requires continuous pulse oximetry monitoring
- The client who requires assistance with eating
- The client who requires intermittent nasotracheal suctioning
- The client receiving patient-controlled analgesia
Correct Answer

A. The client who requires assistance with eating

Explanation

RATIONALE: The RN may safely delegate assistance with eating to the nursing assistant. An RN should provide direct care to the client who requires continuous pulse oximetry monitoring because pulse oximetry interpretation requires assessment skills. Care of the clients requiring nasotracheal suctioning and patient-controlled analgesia can be safely delegated to a licensed practical nurse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 323.

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23.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
- Nausea or vomiting
- Abdominal pain or diarrhea
- Hallucinations or tinnitus
- Light-headedness or paresthesia
Correct Answer

A. Light-headedness or paresthesia

Explanation

RATIONALE: The client with respiratory alkalosis may complain of light-headedness or paresthesia(numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompanyrespiratory acidosis.Hallucinationsand tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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24.

A client with Guillain-Barré syndromedevelopsrespiratory acidosisas a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
- PH, 7.5; PaCO230 mm Hg
- PH, 7.40; PaCO235 mm Hg
- PH, 7.35; PaCO240 mm Hg
- PH, 7.25; PaCO250 mm Hg
Correct Answer

A. pH, 7.25; PaCO250 mm Hg

Explanation

RATIONALE: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2value of 30 mm Hg indicatesrespiratory alkalosis. A ph value of 7.40 with a PaCO2value of 35 mm Hg and a pH value of 7.35 with a PaCO2value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE:Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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25.

A physician orders metaproterenol (Alupent) by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?
- "I can stop using this drug when I begin to feel better."
- "I should use this inhaler whenever I get short of breath."
- "I need to hold my breath as long as possible after I take a deep inhalation."
- "I need to call the physician right away if I feel my heart beating fast after using the drug."
Correct Answer

A. "I need to hold my breath as long as possible after I take a deep inhalation."

Explanation

RATIONALE: The client demonstrates effective teaching if he states that he'll hold his breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli. Metaproterenol needs to be used over an extended period for maximum effect. The client shouldn't use the inhaler whenever he feels out of breath because dependency can develop if the drug is used excessively. The client should adhere to the prescribed dosage. Tachycardiais an expected adverse reaction to metaproterenol. The client should be taught how to monitor his heart rate and contact the physician only if the heart rate exceeds 130 beats/minute.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 698.

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26.

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?
- Impaired color discrimination
- Increased urinary frequency
- Decreased hearing acuity
- Increased appetite
Correct Answer

A. Decreased hearing acuity

Explanation

RATIONALE: Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be ordered. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompanydiabetes mellitus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007.Philadelphia: Lippincott Williams & Wilkins, 2007, p.1177.

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27.

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?
- Bronchophony
- Tactile fremitus
- Crepitation
- Egophony
Correct Answer

A. Bronchophony

Explanation

RATIONALE: Bronchophony is an increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. Over normal lung tissue, the words are unintelligible; however, over areas of tissue consolidation, such as with pneumonia, the words are clear because the tissue enhances the sounds. Tactile fremitusis the vibration felt when the client speaks while the nurse holds her hand against his chest. Crepitation is a crackling sound heard in certain diseases such as pneumonia. Egophony is an abnormal change in tone heard when the client speaks normally as the nurse auscultates his chest.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 576.

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28.

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3–), 15 mEq/L. These ABG values suggest which disorder?
- Respiratory alkalosis
- Respiratory acidosis
- Metabolic alkalosis
- Metabolic acidosis
Correct Answer

A. Metabolic acidosis

Explanation

RATIONALE: This client's pH value is below normal, indicating acidosis. The HCO3–value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggestsmetabolic acidosis. The PaCO2value is normal, indicating absence of respiratory compensation. These ABG values eliminaterespiratory alkalosis,respiratory acidosis, andmetabolic alkalosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 338.

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29.

A 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's the drug of choice for treating legionnaires' disease?
- Azithromycin (Zithromax)
- Rifampin (Rifadin)
- Amantadine (Symmetrel)
- Amphotericin B (Fungizone)
Correct Answer

A. Azithromycin (Zithromax)

Explanation

RATIONALE: Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterialinfection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2511.

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30.

A client who has been hospitalized for treatment of a pneumothoraxis ready for discharge. Which outcome indicates that the client has adequate respiratory function?
- The client exhibits orthopneic breathing.
- The client breathes at a rate of 12 to 20 breaths/minute.
- The client uses accessory muscles to breathe.
- The client exhibits bilateral crackles on auscultation.
Correct Answer

A. The client breathes at a rate of 12 to 20 breaths/minute.

Explanation

RATIONALE: A respiratory rate of 12 to 20 breaths/minute is a normal finding, indicating adequate respiratory function. Orthopneic breathing, accessory muscle use, and bilateral cracklesindicate an interference with respiratory function.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. p. 571. Philadelphia: Lippincott Williams & Wilkins, 2008.

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31.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:
- Chronic obstructive pulmonary disease (COPD).
- Bronchial asthma.
- Acute respiratory distress syndrome (ARDS).
- Renal failure.
Correct Answer

A. Acute respiratory distress syndrome (ARDS).

Explanation

RATIONALE: A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation.COPDrefers to a group of chronic diseases, including bronchialasthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 657.

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32.

A nurse is planning postoperative care for a client who has received general anesthesia. During the immediate postoperative period, which nursing activity takes the highest priority?
- Checking the dressing for bleeding
- Maintaining a patent airway
- Monitoring the vital signs
- Promoting urine output
Correct Answer

A. Maintaining a patent airway

Explanation

RATIONALE: The nurse's first priority for the postoperative client is to maintain a patent airway because lack of a patent airway is rapidly fatal. The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 291.

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33.

During inspiration, which action occurs?
- Lungs recoil.
- Diaphragm descends.
- Alveolar pressure is positive.
- Inspiratory muscles relax.
Correct Answer

A. Diaphragm descends.

Explanation

RATIONALE: During inspiration, inspiratory muscles contract, the diaphragm descends, alveolar pressure is negative, and air moves into the lungs. The lungs recoil during expiration.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1606.

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34.

A client presents to a physician's office complaining of dyspneawith exertion, weakness, and coughing up blood. Further examination reveals peripheral edema,crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?
- Pulmonary hypertension
- Chronic obstructive pulmonary disease (COPD)
- Empyema
- Pulmonary tuberculosis
Correct Answer

A. Pulmonary hypertension

Explanation

RATIONALE: Dyspnea, weakness, hemoptysis, and right-sidedheart failureare all signs of pulmonary hypertension. Clients withCOPDpresent with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratoryinfectionorpneumonia. Clients with pulmonarytuberculosisusually present with low-grade fever, night sweats, fatigue, cough, and weight loss.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 659.

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35.

A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?
- Bronchial
- Tracheal
- Vesicular
- Bronchovesicular
Correct Answer

A. Vesicular

Explanation

RATIONALE: Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 628.

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36.

A client has hypoxemiaof pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?
- Partial pressure of arterial oxygen (PaO2)
- Partial pressure of arterial carbon dioxide (PaCO2)
- PH
- Bicarbonate (HCO3–)
Correct Answer

A. Partial pressure of arterial oxygen (PaO2)

Explanation

RATIONALE: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2requires positive end-expiratory pressure. In both situations, the PaCO2is elevated and the pH and HCO3–are depressed.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 655.

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37.

A client with chronic obstructive pulmonary disease(COPD) is admitted to an acute care facility because of an acute respiratoryinfection. When assessing the client's respiratory status, which finding should the nurse anticipate?
- An inspiratory-expiratory (I:E) ratio of 2:1
- A transverse chest diameter twice that of the anteroposterior diameter
- An oxygen saturation of 99%
- A respiratory rate of 12 breaths/minute
Correct Answer

A. An inspiratory-expiratory (I:E) ratio of 2:1

Explanation

RATIONALE: The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. A ratio of 2:1 is seen in clients with COPD because inspiration is shorter than expiration. A client with COPD typically has a barrel chest in which the anteroposterior diameter is larger than the transverse chest diameter. A client with COPD usually has a respiratory rate greater than 12 breaths/minute and an oxygen saturation rate below 93%.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 689.

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38.

A nurse is caring for a client experiencing an acute asthmaattack. The client stops wheezing and breath sounds aren't audible. This change occurred because:
- The attack is over.
- The airways are so swollen that no air can get through.
- The swelling has decreased.
- Crackles have replaced wheezes.
Correct Answer

A. The airways are so swollen that no air can get through.

Explanation

RATIONALE: During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Cracklesdon't replace wheezes during an acute asthma attack.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 711.

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39.

To prevent oral complications when using a metered-dose inhaler, a nurse should instruct the client to:
- Keep the head of the bed at a 30-degree angle.
- Use the inhaler before meals.
- Rinse out his mouth after using the inhaler
- Use the inhaler as needed.
Correct Answer

A. Rinse out his mouth after using the inhaler

Explanation

RATIONALE: To prevent mouth sores, the nurse should teach the client to rinse his mouth after using a metered-dose inhaler. Keeping the head of the bed at a 30-degree angle, using the inhaler before meals, and using the inhaler as needed aren't appropriate considerations.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 809.

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40.

A physician orders home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use?
- Home health nurse
- Physician
- Hospital staff nurse
- Social worker
Correct Answer

A. Home health nurse

Explanation

RATIONALE: The home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker is responsible only for coordinating the services. The hospital staff nurse and physician don't observe the client in the home, so they can't adequately evaluate the client's knowledge of home oxygen use.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 161.

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41.

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease(COPD). The nurse bases her next action on the principle that:
- Inserting a Foley catheter can decrease fluid retention.
- Administering I.V. antibiotics can prevent pneumonia.
- This client may need intubation.
- It may be necessary to raise the head of this client's bed.
Correct Answer

A. It may be necessary to raise the head of this client's bed.

Explanation

RATIONALE: The nurse should consider positioning when caring for a client who has COPD and difficulty breathing. Elevating the head of the bed assists these clients in breathing. There's no indication that it's necessary to intubate the client. A Foley catheter isn't indicated. Prophylactic I.V. antibiotics aren't administered with moderate sedation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 515.

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42.

Which assessment finding puts a client at increased risk for epistaxis?
- Use of a humidifier at night
- Hypotension
- Cocaine use
- History of nasal surgery
Correct Answer

A. Cocaine use

Explanation

RATIONALE: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 605.

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43.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
- Hypotension, hyperoxemia, and hypercapnia
- Hyperventilation, hypertension, and hypocapnia
- Hyperoxemia, hypocapnia, and hyperventilation
- Hypercapnia, hypoventilation, and hypoxemia
Correct Answer

A. Hypercapnia, hypoventilation, and hypoxemia

Explanation

RATIONALE: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, andhypoxemia. The nurse should focus on resolving these problems.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 656.

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44.

A client with chronic obstructive pulmonary disease(COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? Select all that apply.
- Decreased respiratory rate
- Dyspnea on exertion
- Barrel chest
- Shortened expiratory phase
- Clubbed fingers and toes
- Fever
Correct Answer(s)

A. Dyspnea on exertion
A. Barrel chest
A. Clubbed fingers and toes

Explanation

RATIONALE: Typical findings in clients with COPD include dyspneaon exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usuallytachypneicwith a prolonged expiratory phase. Fever isn't associated with COPD unless aninfectionis also present.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 689.

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45.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
- 3 to 5 days
- 1 to 3 weeks
- 2 to 4 months
- 6 to 12 months
Correct Answer

A. 6 to 12 months

Explanation

RATIONALE: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 648.

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46.

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?
- Heightened alertness
- Increased heart rate
- Numbness and tingling of the extremities
- Respiratory depression
Correct Answer

A. Respiratory depression

Explanation

RATIONALE: Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1398.

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47.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
- Medication allergies
- Swallow reflex
- Presence of carotid pulse
- Ability to deep breathe
Correct Answer

A. Swallow reflex

Explanation

RATIONALE: The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 582.

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48.

A nurse preparing to administer medications on the respiratory floor is using the computerized medication-dispensing system. Her password isn't working. The nurse should:
- Ask computer support to reset her password.
- Use another nurse's password to finish dispensing the medications.
- Have a nursing assistant administer the medications while she resets her password.
- Override the machine and deliver the medications.
Correct Answer

A. Ask computer support to reset her password.

Explanation

RATIONALE: The nurse should have computer support reset her password. A nurse should never give her password to anyone. It's inappropriate for the nurse to delegate medication administration to a nursing assistant. The nurse shouldn't override the machine to dispense the medications; doing so is unsafe and could cause medication errors.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 564.

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49.

A trauma victim in the intensive care unit has a tension pneumothorax. Which signs or symptoms are associated with a tension pneumothorax? Select all that apply.
- Decreased cardiac output
- Flattened jugular veins
- Tracheal deviation to the affected side
- Hypotension
- Tracheal deviation to the opposite side
- Bradypnea
Correct Answer(s)

A. Decreased cardiac output
A. Hypotension
A. Tracheal deviation to the opposite side

Explanation

RATIONALE: Tension pneumothorax results when air in the pleural space is under higher pressure than air in the adjacent lung. The site of the rupture of the pleural space acts as a one-way valve, allowing the air to enter on inspiration but not allowing it to escape on expiration. The air presses against the mediastinum, causing a shift to the opposite side and decreased venous return (reflected by decreased cardiac outputand hypotension). As the air presses against the mediastinum, compensatorytachycardiaandtachypneaalso occur. Decreased cardiac output may cause distended, not flattened, jugular veins.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 679.

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Current Version
Mar 22, 2023

Quiz Edited by
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Feb 10, 2016

Quiz Created by
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Respiratory Disorders (Part 2)

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the:

Quiz Preview

For a client with impaired gas exchange, which position is best?

A 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:

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3–) 25 mEq/L. What should the nurse do first?

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2of 96% or better. The client most likely has:

The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse manager should take which step to meet the needs of her staff?

A client undergoes a tracheostomyafter many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

A client with asthmais receiving a theophylline (Uniphyl) preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary diseasewho wishes no further medical intervention. Which step should the nurse anticipate based on her knowledge of palliative care?

A client admitted to the facility for treatment for tuberculosisreceives instructions about the disease. Which statement made by the client indicates the need for further instruction?

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

A client is experiencing dryness in the nares while receiving oxygen via nasal cannulaat 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

A client with chronic obstructive pulmonary disease(COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?

A 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:

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventinginfection. Which finding indicates that this outcome has been met?

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?

Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

A client with Guillain-Barré syndromedevelopsrespiratory acidosisas a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

A physician orders metaproterenol (Alupent) by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?

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

A nurse is performing a respiratory assessment on a client with pneumonia. She asks the client to say "ninety-nine" several times. Through her stethoscope, she hears the words clearly over his left lower lobe. What term should the nurse use to document this finding?

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3–), 15 mEq/L. These ABG values suggest which disorder?

A client who has been hospitalized for treatment of a pneumothoraxis ready for discharge. Which outcome indicates that the client has adequate respiratory function?

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

A nurse is planning postoperative care for a client who has received general anesthesia. During the immediate postoperative period, which nursing activity takes the highest priority?

During inspiration, which action occurs?

A client presents to a physician's office complaining of dyspneawith exertion, weakness, and coughing up blood. Further examination reveals peripheral edema,crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis?

A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?

A client has hypoxemiaof pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

A client with chronic obstructive pulmonary disease(COPD) is admitted to an acute care facility because of an acute respiratoryinfection. When assessing the client's respiratory status, which finding should the nurse anticipate?

A nurse is caring for a client experiencing an acute asthmaattack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

To prevent oral complications when using a metered-dose inhaler, a nurse should instruct the client to:

A physician orders home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use?

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease(COPD). The nurse bases her next action on the principle that:

Which assessment finding puts a client at increased risk for epistaxis?

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

A client with chronic obstructive pulmonary disease(COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? Select all that apply.

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

A nurse preparing to administer medications on the respiratory floor is using the computerized medication-dispensing system. Her password isn't working. The nurse should:

A trauma victim in the intensive care unit has a tension pneumothorax. Which signs or symptoms are associated with a tension pneumothorax? Select all that apply.