1.
ANSWER: B
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.
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.
2.
ANSWER: D
The original ABG analysis reveals respiratory acidosis commonly seen with a pneumothorax. After chest tube insertion, the client's respiratory status has improved, pH is increasing toward normal, and the PaCO2 is decreasing. ABG analysis in respiratory alkalosis shows an elevated pH and a low PaCO2. Assessment findings are more important than ABG analysis in determining whether the client requires intubation or if respiratory arrest is imminent.
The original ABG analysis reveals respiratory acidosis commonly seen with a pneumothorax. After chest tube insertion, the client's respiratory status has improved, pH is increasing toward normal, and the PaCO2 is decreasing. ABG analysis in respiratory alkalosis shows an elevated pH and a low PaCO2. Assessment findings are more important than ABG analysis in determining whether the client requires intubation or if respiratory arrest is imminent.
3.
ANSWER: D
Crackles are the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli.
Crackles are the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli.
A: The blood pressure is usually increased with
hypervolemia.
B: This would occur with angina or a myocardial infarction.
C: The pulse would be bounding with hypervolemia.
4.
ANSWER: A
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don't cause metabolic acidosis.
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don't cause metabolic acidosis.
5.
ANSWER: C
A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions. 1
A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions. 1
A: A low-salt diet does not help
reduce the viscosity of mucus.
B: Continuous oxygen therapy does not help reduce the
viscosity of mucus.
D: Maintaining a semi-sitting position does not help reduce
the viscosity of mucus.
6.
ANSWER: D
The client's chronic illness and increased age increase vulnerability; the daughter's condition should be explored in more detail.
The client's chronic illness and increased age increase vulnerability; the daughter's condition should be explored in more detail.
A: Children before puberty and adolescence have the least
incidence of tuberculosis.
B: The morbidity and mortality resulting from tuberculosis
are increasing, not decreasing.
C: Although the incidence of tuberculosis has increased in
the general population, it is increasing at an alarming rate in those who are
HIV positive.
7.
ANSWER: C
These positions permit ventilation of the remaining lung and prevent fluid from draining into the sutured bronchial stump.
These positions permit ventilation of the remaining lung and prevent fluid from draining into the sutured bronchial stump.
A: Lying on the unoperative side
restricts left lung excursion and may allow fluid to drain into the right
bronchial stump.
B: Although the high-Fowler's position promotes ventilation,
it is extremely tiring.
D: Lying on the unoperative side restricts left lung
excursion and may allow fluid to drain into the right bronchial stump.
8.
ANSWER: B
The nurse should immediately apply a dressing over the stab wound. Then the nurse should tape this dressing on three sides to allow air to escape and to prevent tension pneumothorax, which is more life-threatening than an open chest wound. Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist the physician in inserting a chest tube, and start an I.V. line.
The nurse should immediately apply a dressing over the stab wound. Then the nurse should tape this dressing on three sides to allow air to escape and to prevent tension pneumothorax, which is more life-threatening than an open chest wound. Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist the physician in inserting a chest tube, and start an I.V. line.
9.
ANSWER: C
A productive cough indicates mucus is being raised from the lungs.
A productive cough indicates mucus is being raised from the lungs.
A: Crackles (rales) are unaffected by postural drainage or
coughing.
B: The depth of respirations may not be altered by postural
drainage.
D: Saliva comes from the mouth and does not indicate
clearance of lungs.
10.
ANSWER: D
Percussion is the process of striking a client's body surface with short, sharp blows of the fingers to determine the size, position, and density of underlying tissue. Auscultation, inspection, or palpation wouldn't help to attain this result.
Percussion is the process of striking a client's body surface with short, sharp blows of the fingers to determine the size, position, and density of underlying tissue. Auscultation, inspection, or palpation wouldn't help to attain this result.
11.
ANSWER: A
Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client's blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.
Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client's blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.
12.
ANSWER: C
Clients with chronic obstructive pulmonary disease (COPD) must be given only low concentrations of oxygen; a decreased oxygen blood level is the only stimulus for breathing for these clients.
Clients with chronic obstructive pulmonary disease (COPD) must be given only low concentrations of oxygen; a decreased oxygen blood level is the only stimulus for breathing for these clients.
A: Prolonged hypoxia will stimulate erythrocyte production;
the goal of therapy is to relieve hypoxia.
B: The pressure, rather than the concentration, at which
oxygen is administered increases this risk.
D: To prevent its drying effects on secretions and the
mucosa, oxygen should be humidified.
13.
ANSWER: B
Physical examination techniques, such as auscultation, provide objective data, which reflect findings without interpretation. Subjective data are reported to the nurse by the client and family. The family and members of the health care team provide secondary source information. Medical data are obtained from the physician and medical record.
Physical examination techniques, such as auscultation, provide objective data, which reflect findings without interpretation. Subjective data are reported to the nurse by the client and family. The family and members of the health care team provide secondary source information. Medical data are obtained from the physician and medical record.
14.
ANSWER: B
Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances.
Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should only wear gloves for contact with mucous membranes, broken skin, blood, and body fluids and substances.
15.
ANSWER: B
Breathing humidified air." -- Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. 1
Breathing humidified air." -- Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. 1
A: Postural drainage may be helpful
for respiratory hygiene but will not affect the nature of secretions.
C: Vibration and percussion of the chest wall may be helpful
for respiratory hygiene but will not affect the nature of secretions.
D: Coughing and deep-breathing exercises may be helpful for
respiratory hygiene but will not affect the nature of secretions.
16.
ANSWER: B
Pleuritic chest pain is typically described as intermittent, sharp, and very painful and is aggravated with deep inspiration or movement. Crushing, substernal chest pain that is relieved by nitroglycerin is usually of cardiac origin. Leaning forward typically relieves pain associated with endocarditis.
Pleuritic chest pain is typically described as intermittent, sharp, and very painful and is aggravated with deep inspiration or movement. Crushing, substernal chest pain that is relieved by nitroglycerin is usually of cardiac origin. Leaning forward typically relieves pain associated with endocarditis.
17.
ANSWER: C
Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the notation makes it inaccurate.
Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the notation makes it inaccurate.
A: Crackles and rhonchi are client adaptations, not a
nursing diagnosis.
B: It would be incorrect to use the term rhonchi to refer to
crackling sounds in the lower lung.
D: Crepitus, which indicates subcutaneous emphysema, is a
condition unrelated to the breath sounds heard on auscultation.
18.
ANSWER: D
The nurse is inserting the nasopharyngeal airway correctly when she places the client in a supine position, pushes the tip of the client's nose upward, and inserts the airway along the floor of the nostril into the posterior pharynx. The airway should be inserted to a predetermined length (measuring from the tip of the nose to the ear lobe and marking the distance on the tube) or until the flange is flush with the nostril. An oropharyngeal (not nasopharyngeal) airway should be inserted by pointing the tip upward toward the roof of the mouth. Only water-based lubricant, not petroleum jelly, should be used. Because the airway is inserted nasally, the client's tongue is bypassed and doesn't need to be depressed.
The nurse is inserting the nasopharyngeal airway correctly when she places the client in a supine position, pushes the tip of the client's nose upward, and inserts the airway along the floor of the nostril into the posterior pharynx. The airway should be inserted to a predetermined length (measuring from the tip of the nose to the ear lobe and marking the distance on the tube) or until the flange is flush with the nostril. An oropharyngeal (not nasopharyngeal) airway should be inserted by pointing the tip upward toward the roof of the mouth. Only water-based lubricant, not petroleum jelly, should be used. Because the airway is inserted nasally, the client's tongue is bypassed and doesn't need to be depressed.
19.
ANSWER: D
Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They're classified as fine, medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, high-pitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways.
Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They're classified as fine, medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, high-pitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways.
20.
ANSWER: C
Prednisone causes severe gastric upset. Therefore, it should be given with food.
Prednisone causes severe gastric upset. Therefore, it should be given with food.
A: It is recommended that the daily
dose be given in the morning before 9:00 AM. Given at this time, the medication
will suppress adrenal cortex activity less, which may reduce the risk of
HPA-axis suppression.
B: The drug must be given as ordered and not titrated to
response. If the drug has been given over a long period, abrupt cessation can
cause serious side effects.
D: Because the pills are not enteric-coated, they may be
crushed and mixed with food if the child has difficulty swallowing them.
21.
ANSWER: B
A 10-year-old should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress at this age suggesting Anxiety.
A 10-year-old should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress at this age suggesting Anxiety.
A: The inability to get comfortable
is commonly characteristic of child with a diagnosis of Pain.
C: Inability to answer questions correctly may reflect a
state of anoxia or a lack of knowledge.
D: Tightness in the chest occurs as a result of bronchial
spasms and indicates a diagnosis of Ineffective Airway Clearance.
22.
ANSWER: C
Nothing is achieved if the equipment is working and the client is not responding.
Nothing is achieved if the equipment is working and the client is not responding.
A: This is presumptive; the data base is incomplete for the
assessment that surgery is necessary.
B: Endotracheal intubation does not permit verbal
communication.
D: This is important but not the priority.
23.
ANSWER: B
Cromolyn sodium (Intal) is used as a prophylactic agent to help prevent bronchial asthmatic attacks. The drug inhibits histamine release and acts locally to prevent the release of mediator substances from mast (connective tissue) cells after exposure to allergens. The drug is not an anti-inflammatory, bronchodilator, or antihistamine agent. Therefore, it is of no use during an asthma attack.
Cromolyn sodium (Intal) is used as a prophylactic agent to help prevent bronchial asthmatic attacks. The drug inhibits histamine release and acts locally to prevent the release of mediator substances from mast (connective tissue) cells after exposure to allergens. The drug is not an anti-inflammatory, bronchodilator, or antihistamine agent. Therefore, it is of no use during an asthma attack.
A: To be effective, cromolyn should
be administered consistently over a long period of time. Short-term dosing
provides no benefits.
C: Cromolyn is used prophylactically and administered
routinely several times a day. Although preparation for bed would not affect
the effectiveness of cromolyn, it may be one of the scheduled dosing times.
D: Although cromolyn is indicated for the prevention of
exercise-induced bronchospasm, riding a bicycle one block is usually not
considered to be strenuous exercise. Thus, cromolyn would not be helpful in
preventing airway narrowing.
24.
ANSWER: C
This pause allows added time for gaseous exchange at the alveolar capillary beds.
This pause allows added time for gaseous exchange at the alveolar capillary beds.
A: Inhalation should be through the nose to moisten, filter,
and warm the air.
B: This decreases the effectiveness of respirations.
D: The expiratory phase should be lengthened, and exhalation
should be through pursed lips.
25.
ANSWER: A
Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the endotracheal tube, and the client being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.
Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the endotracheal tube, and the client being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.
26.
ANSWER: A
As a compensatory measure in the early stage of shock, the client hyperventilates in response to hypoxemia. Hyperventilation is an attempt to provide more oxygen to the tissues to compensate for decreased circulating volume. It increases minute volume and results in decreased PaCO2), while PaO2 remains normal. This is the classic picture of respiratory alkalosis.
As a compensatory measure in the early stage of shock, the client hyperventilates in response to hypoxemia. Hyperventilation is an attempt to provide more oxygen to the tissues to compensate for decreased circulating volume. It increases minute volume and results in decreased PaCO2), while PaO2 remains normal. This is the classic picture of respiratory alkalosis.
B: Respiratory acidosis occurs in the advanced stage of
shock.
C: Metabolic alkalosis does not develop in shock unless
overcorrection of acidosis is a result of administering sodium bicarbonate.
D: Metabolic acidosis occurs in the advanced stage of shock.
27.
ANSWER: B
Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage.
Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won't cause a tension pneumothorax. Excessive water won't affect the chest tube drainage.
28.
ANSWER: B
Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling to occur during inspiration, but continuous bubbling signifies a leak in the closed system. Absence of bubbling in the second chamber signifies a block in the system. It can also mean that the affected lung has reexpanded.
Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling to occur during inspiration, but continuous bubbling signifies a leak in the closed system. Absence of bubbling in the second chamber signifies a block in the system. It can also mean that the affected lung has reexpanded.
29.
ANSWER: C
To prevent further possibility of pneumothorax, the nurse should immediately reconnect the tube.
To prevent further possibility of pneumothorax, the nurse should immediately reconnect the tube.
A: This is unnecessary.
B: Clamping is appropriate for changing a broken drainage
system or to check for an air leak; it should not be done needlessly.
D: The high-Fowler's position is appropriate for a client in
respiratory distress, but this does not remedy this problem.
30.
ANSWER: B
Commonly, family members are reluctant to talk to a client who has had a total laryngectomy and no longer can speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client and family to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
Commonly, family members are reluctant to talk to a client who has had a total laryngectomy and no longer can speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client and family to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
31.
ANSWER: A
Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle may ease respirations and make them more effective but wouldn't help mobilize secretions.
Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle may ease respirations and make them more effective but wouldn't help mobilize secretions.
32.
ANSWER: D
Increased negative pressure on inspiration causes the fluid to rise; a decrease in the negative intrapleural pressure on expiration causes the fluid to fall.
Increased negative pressure on inspiration causes the fluid to rise; a decrease in the negative intrapleural pressure on expiration causes the fluid to fall.
A: This would indicate an air leak.
B: This would indicate that there is an obstruction in the
drainage tubing or the suction is too low; there should be a slight increase in
fluid in this chamber postoperatively.
C: The suction is too high; bubbling should be gentle.
33.
ANSWER: B
Before weaning a 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.
Before weaning a 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.
34.
ANSWER: A
A client who smokes is at increased risk for atelectasis postoperatively; thus, smoking is the most significant risk factor listed in this item.
A client who smokes is at increased risk for atelectasis postoperatively; thus, smoking is the most significant risk factor listed in this item.
B: If the client has completely recovered from the cold he
had 6 weeks ago, it would be irrelevant to his postoperative recovery.
C: This amount of alcohol intake is minimal and will have no
bearing on his postoperative recovery.
D: Although an obese client faces increased surgical risks,
an excess of 10 pounds is not significant to pose a greater risk than the
smoking.
35.
ANSWER: C
A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client’s need for oxygen therapy.
A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client’s need for oxygen therapy.
A: Although the client may feel the
need for oxygen during periods of dyspnea, this is not a reliable way of
determining the client’s need.
B: Fatigue may be due to other factors besides oxygenation
levels.
D: Evaluating the client’s hemoglobin level can provide an
indication that the client may have less oxygen-carrying capacity but is not a
reliable indicator of oxygen need.
36.
ANSWER: C
Endotracheal suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not endotracheal suctioning.
Endotracheal suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not endotracheal suctioning.
37.
ANSWER: B
When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified.
When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified.
A: First priority must be given to clamping the chest tube.
C: To prevent backward flow of drainage, the drainage system
should never be raised above chest level.
D: To prevent backward flow of drainage, the drainage system
should never be raised above chest level.
38.
ANSWER: A
Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
39.
ANSWER: B
Fatigue is a major problem for the client with pneumonia, making it difficult to perform self-care activities. Fatigue is due to reduced oxygenation and inability to sleep and rest because of coughing. The hospital environment further contributes to interrupted sleep patterns.
Fatigue is a major problem for the client with pneumonia, making it difficult to perform self-care activities. Fatigue is due to reduced oxygenation and inability to sleep and rest because of coughing. The hospital environment further contributes to interrupted sleep patterns.
A: Myocardial damage is not typically
associated with pneumonia.
C: Deficient Fluid Volume might occur with the client with
pneumonia; however, it would most likely be related to fever and increased
insensible fluid loss from respiratory secretions, not nausea and vomiting. 4
D: Disturbed Thought Processes, which is characterized by
cognitive dissonance, memory problems, and inappropriate or non-reality-based
thinking
40.
ANSWER: A
While all these nursing diagnoses are appropriate for the client with AIDS, Impaired gas exchange is the priority nursing diagnosis for the client with P. carinii pneumonia. Airway, breathing, and circulation take top priority with any client.
While all these nursing diagnoses are appropriate for the client with AIDS, Impaired gas exchange is the priority nursing diagnosis for the client with P. carinii pneumonia. Airway, breathing, and circulation take top priority with any client.
41.
ANSWER: B
A nonrebreather mask can deliver levels of oxygen concentration as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of oxygen concentration.
A nonrebreather mask can deliver levels of oxygen concentration as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of oxygen concentration.
42.
ANSWER: B
Answer 1 and 4 do not cause weight gain, so they're incorrect. And answer 3 would be reflected in pulmonary edema, so it's incorrect.
Answer 1 and 4 do not cause weight gain, so they're incorrect. And answer 3 would be reflected in pulmonary edema, so it's incorrect.
43.
ANSWER: D
One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.
One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Salt supplements are almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual.
A: In the child with cystic fibrosis,
the functioning of the sweat glands is the problem, causing abnormal amounts of
salt to be lost with perspiration. The ability to concentrate urine is not the
problem.
B: Little skin pigment is not a condition associated with
cystic fibrosis.
C: A poorly functioning temperature control center is not a
condition related to cystic fibrosis.
44.
ANSWER: D
This is not true; most men with cystic fibrosis are sterile.
This is not true; most men with cystic fibrosis are sterile.
A: Cystic fibrosis is inherited as an autosomal recessive
trait; it is not sex-linked.
B: This is not true; most men with cystic fibrosis are
sterile.
C: Because of a failure of normal development of the vas
deferens, epididymis, and seminal vesicles and a blockage of the vas deferens
with abnormal secretions, there is decreased or absent sperm production.
45.
ANSWER: B
Conditions that increase oxygen demands include being overweight, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals per day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six per day).
Conditions that increase oxygen demands include being overweight, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals per day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six per day).
46.
ANSWER: D
Casual contacts such as people at work need not be tested for tuberculosis. However, a person in close contact with a person who is infectious is at risk and should be checked. Taking the medication for 9 to 12 months, coworkers not needing medications, and having scheduled laboratory tests are all appropriate statements.
Casual contacts such as people at work need not be tested for tuberculosis. However, a person in close contact with a person who is infectious is at risk and should be checked. Taking the medication for 9 to 12 months, coworkers not needing medications, and having scheduled laboratory tests are all appropriate statements.
47.
ANSWER: D
These are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil.
These are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil.
A: Coughing is done after deep breathing.
B: The breaths should not be in succession; they should be
spaced by several normal breaths to avoid fatigue.
C: These are incorrect techniques; inhalation should be
through the mouthpiece.
48.
ANSWER: D
A: The test result was positive, not negative; further
testing is necessary.
B: The tine test is less accurate than the Mantoux and would
not be used as a follow-up test.
C: More than 10 mm induration is a positive test result, not
a doubtful test result.
D: The Mantoux is the most accurate skin test because of the
testing material used and the intradermal method; no other skin test would be
appropriate as a follow-up; further tests are now warranted, including a chest
x-ray film.
49.
ANSWER: B
During an acute 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. Crackles don't replace wheezes during an acute asthma attack.
During an acute 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. Crackles don't replace wheezes during an acute asthma attack.
50.
ANSWER: C
Smoking cessation should receive highest priority when trying to reduce risk factors for respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension.
Smoking cessation should receive highest priority when trying to reduce risk factors for respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension.
51.
ANSWER: B
Glue, nail polish remover, aerosols, paint thinners, and cleaning solutions are inhalants used for a "high." Insecticides inhalation would likely cause illness, and inhaling a spray paint would color the person's face, an obvious detriment.
Glue, nail polish remover, aerosols, paint thinners, and cleaning solutions are inhalants used for a "high." Insecticides inhalation would likely cause illness, and inhaling a spray paint would color the person's face, an obvious detriment.
52.
ANSWER: A
In the child with asthma and allergic rhinitis, the allergic reaction to inhaled particles generally causes frequent nose rubbing, subsequently leading to a nasal crease. The child also may exhibit allergic shiners, dark circles under the eyes caused by nasal congestion.
In the child with asthma and allergic rhinitis, the allergic reaction to inhaled particles generally causes frequent nose rubbing, subsequently leading to a nasal crease. The child also may exhibit allergic shiners, dark circles under the eyes caused by nasal congestion.
B: Typically abdominal pain, although
associated with numerous disorders, is not related to allergic rhinitis.
C: Fever, although a common assessment finding with numerous
disorders, is unrelated to allergic rhinitis. Fever would be present if the
child developed a subsequent infection secondary to the allergic rhinitis.
D: Mouth breathing usually occurs when the child has
enlarged tonsils or adenoids.
53.
S ANSWER: C
The infectious stage of tuberculosis declines immediately after effective chemotherapy. The risk of infectious tuberculosis is much higher for persons who are immunosuppressed. Patients need to be taught to cover their mouth when coughing, because tuberculosis is spread by droplets.
The infectious stage of tuberculosis declines immediately after effective chemotherapy. The risk of infectious tuberculosis is much higher for persons who are immunosuppressed. Patients need to be taught to cover their mouth when coughing, because tuberculosis is spread by droplets.
A: Antimycobacterial therapy is usually prescribed for six
to nine months. Short-term use of antibiotics is not effective chemotherapy.
The Centers for Disease Control (COG) recommends a minimum of six months of
therapy.
B: For a definite diagnosis of tuberculosis, a positive
sputum culture is necessary. A Mantoux test identifies individuals exposed to
mycobacterium tuberculosis. This test does not differentiate between active and
dormant infection.
D: BCG (Bacille Calmette-Guerin) strengthens the body's immune
system.
54.
ANSWER: A
The client should be monitored closely and given low-flow oxygen to decrease chances of depressing the respiratory drive. Increasing fluids to liquefy secretions, humidifying the air, and performing postural drainage are also important for a client with acute bronchitis.
The client should be monitored closely and given low-flow oxygen to decrease chances of depressing the respiratory drive. Increasing fluids to liquefy secretions, humidifying the air, and performing postural drainage are also important for a client with acute bronchitis.
55.
ANSWER: C
These cuffs do not compress the capillary beds and thus do not cause tracheal damage.
These cuffs do not compress the capillary beds and thus do not cause tracheal damage.
A: Surgical asepsis, not the use of these cuffs, prevents
infection.
B: A minimal air leak is desirable to ensure the lowest
possible pressure in the cuff while still maintaining placement of the tube.
D: Secretions will be increased because the cuff is a
foreign body in the trachea.
56.
ANSWER: A
Although the meter does assist in evaluating the effectiveness of a treatment, repeating the dose of bronchodilator therapy is not recommended unless prescribed by a physician. Bronchodilators have serious side effects, and the child would need to be monitored closely if several treatments were given in a row.
Although the meter does assist in evaluating the effectiveness of a treatment, repeating the dose of bronchodilator therapy is not recommended unless prescribed by a physician. Bronchodilators have serious side effects, and the child would need to be monitored closely if several treatments were given in a row.
B: The peak expiratory flow meter is
used to follow trends for diurnal variations that predict instability of asthma
and need for increased therapy. It also assists in early detection of
exacerbation of the asthma because decreases in the peek expiratory flow rate
may indicate a worsening condition.
C: The peak expiratory flow meter is used to monitor the
asthma and assist in making decisions about increasing or decreasing therapy.
D: By monitoring trends in readings and the child’s
condition, a peak expiratory flow meter can also be used to identify triggers
of asthma.
57.
ANSWER: C
Fresh airflow into the house changes the air and lowers the concentration of microorganisms.
Fresh airflow into the house changes the air and lowers the concentration of microorganisms.
A: This is not necessary.
B: This is not necessary; only articles contaminated with
infected sputum, such as used tissues, should be contained.
D: It is permissible to do this because the extreme heat
used to process the dishes kills the mycobacteria.
58.
ANSWER: D
A: This would not maximally promote aeration of the
unaffected lung.
B: This would not maximally promote aeration of the
unaffected lung.
C: This would not maximally promote aeration of the
unaffected lung; the prone position increases the effort of breathing because
respiratory excursion is impeded by the weight of the body.
D: Placing the infant on the operative side promotes gas
exchange in the unimpaired lung.
59.
ANSWER: B
Emphysema is characterized by destruction of the alveolar walls, hyperinflation of the alveoli, and loss of lung elasticity.
Emphysema is characterized by destruction of the alveolar walls, hyperinflation of the alveoli, and loss of lung elasticity.
A: Airspace is not constricted as air
can flow easily into the lungs.
C: The diaphragm becomes flattened due to the hyperinflated
lungs.
D: The air becomes trapped due to the loss of elasticity and
airflow going out of the lungs is decreased.
60.
ANSWER: C
It is essential that a client with tuberculosis take medications exactly as prescribed.
It is essential that a client with tuberculosis take medications exactly as prescribed.
A: Sufficient rest is important for
the healing process but not as important as taking medications as prescribed.
B: Eating a nourishing diet is important for the healing
process but not as important as taking medications as prescribed.
D: Smoking cessation is a priority for all clients,
especially those with respiratory problems. However, taking antitubercular
medication as prescribed has the highest priority.
61.
ANSWER: D
Annual influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia.
Annual influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia.
A:
Dietary changes are not indicated in the prevention of pneumonia.
B: Antibiotics are ineffective against viral infections.
C: Prophylactic antibiotic therapy is not typically
prescribed because of the increasing prevalence of resistant bacterial strains.
62.
ANSWER: D
During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.
During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.
63.
ANSWER: C
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.
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.
64.
ANSWER: B
This is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid and others have to be temporarily disconnected while emptying the fluid.
This is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid and others have to be temporarily disconnected while emptying the fluid.
A: This circumstance does not require assistance from a
respiratory therapist.
C: This is unsafe; humidity is necessary to preserve
moistness of the respiratory tract and liquefy secretions.
D: The amount of condensation is irrelevant in terms of
recording the intake and output.
65.
ANSWER: D
Pneumothorax will cause a client to feel extremely short of
breath. Semi- or high- Fowler's position will facilitate ventilation by the
unaffected lung.
A: A flat Trendelenburg's position places additional
pressure on the chest and inhibits ventilation.
B: Reverse Trendelenburg places additional pressure on the
chest and inhibits ventilation.
C: Likewise, positioning the client on the unaffected side
compromises the remaining functional lung.
66.
ANSWER: B
The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis.
The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis.
A:
Eupnea is normal, quiet breathing; the client has shallow, rapid breathing.
C: Kussmaul's respirations are deep, gasping respirations
associated with diabetic acidosis and coma, not hyperventilation associated
with anxiety.
D: These symptoms are related to a decreased carbon dioxide
level in the body.
67.
ANSWER: D
A nonrebreathing mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A partial rebreathing mask delivers oxygen concentrations up to 90%.
A nonrebreathing mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A partial rebreathing mask delivers oxygen concentrations up to 90%.
68.
ANSWER: C
COPD causes pulmonary hypertension, leading to right ventricular failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy.
COPD causes pulmonary hypertension, leading to right ventricular failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy.
69.
ANSWER: B
A nosocomial infection, by definition, is acquired during hospitalization.
A nosocomial infection, by definition, is acquired during hospitalization.
A: This is unrelated to a nosocomial infection.
C: The need for precautions relates to the type of
infection, not to the situation in which it was acquired.
D: The infection may or may not be associated with medical
treatment.
70.
ANSWER: C
To prevent aspiration during the procedure, clients are required to be NPO for at least 8 to 12 hours prior to the procedure.
To prevent aspiration during the procedure, clients are required to be NPO for at least 8 to 12 hours prior to the procedure.
A: Chest tubes are not required unless the lungs are
accidentally punctured; the client will have a small incision near the
clavicle.
B: A mediastinoscopy permits visualization of the anterior
mediastinum or hilum extrapleurally; a bronchoscopy permits visualization of
the main stem bronchus.
D: Fluid is removed from the pleural space during a
thoracentesis.
71.
ANSWER: C
Hoarseness is a sign of potential respiratory insufficiency as a result of inhalation burns, which cause edema in the surrounding tissues, including the vocal cords.
Hoarseness is a sign of potential respiratory insufficiency as a result of inhalation burns, which cause edema in the surrounding tissues, including the vocal cords.
A: This would indicate metabolic acidosis, not respiratory
insufficiency.
B: Sputum would be sooty, not frothy; pink-tinged, frothy
sputum is associated with pulmonary edema.
D: This would indicate metabolic acidosis, not respiratory
insufficiency.
72.
ANSWER: D
With COPD the diaphragm is flattened and weakened; strengthening the diaphragm is desirable.
With COPD the diaphragm is flattened and weakened; strengthening the diaphragm is desirable.
A: The opposite is more desirable; clients with COPD retain
too much carbon dioxide, which eventually causes a barrel chest.
B: The abdominal muscles are accessory muscles of
respiration, and their contraction and relaxation are involved in diaphragmatic
breathing.
C: Sit-ups are too strenuous for clients with emphysema.
73.
ANSWER: C
Blood-tinged sputum in the absence of pronounced coughing may be the presenting symptom; diaphoresis at night is a later symptom.
Blood-tinged sputum in the absence of pronounced coughing may be the presenting symptom; diaphoresis at night is a later symptom.
A: Recurrent fever is present; however, frothy sputum is
present with pulmonary edema, not tuberculosis.
B: The cough would be productive, not dry.
D: A productive cough may occur, but engorged neck veins are
symptomatic of congestive heart failure.
74.
ANSWER: C
This is secondary to cerebral hypoxia, which accompanies ARDS; cognition and level of consciousness are reduced.
This is secondary to cerebral hypoxia, which accompanies ARDS; cognition and level of consciousness are reduced.
A: Hypotension occurs because of the hypoxia of the heart.
B: The sputum is not tenacious, but it may be frothy if
pulmonary edema is present.
D: Breathing will be fast and shallow.
75.
ANSWER: D
With few exceptions males are sterile; failure of normal development of the wolffian duct structures (vas deferens, epididymis, and seminal vesicles) and blockage of the vas deferens by abnormal secretions result in decreased or absent sperm production.
With few exceptions males are sterile; failure of normal development of the wolffian duct structures (vas deferens, epididymis, and seminal vesicles) and blockage of the vas deferens by abnormal secretions result in decreased or absent sperm production.
A: This does not answer the client's
question.
B: Females with CF generally have normal ovaries and
fallopian tubes and are fertile; however, fertility can be inhibited by highly
viscous cervical secretions.
C: Theoretically, all offspring of couples who are
homozygous for a recessive gene will have the disease; however with cystic
fibrosis, affected men are usually sterile.
76.
ANSWER: B
After bronchoscopy, airway obstruction secondary to laryngeal edema may occur. Therefore, assessment of the child’s respiratory quality is the priority. The child should be observed for signs and symptoms of respiratory distress including tachypnea, increased stridor and retractions, and tachycardia.
After bronchoscopy, airway obstruction secondary to laryngeal edema may occur. Therefore, assessment of the child’s respiratory quality is the priority. The child should be observed for signs and symptoms of respiratory distress including tachypnea, increased stridor and retractions, and tachycardia.
A: Assessing cardiac rate and rhythm is important and would
be done once the client’s respiratory status is assessed.
C: Although observing the color of the sputum is an
important assessment, it is not the priority. The sputum may be bloody after
bronchoscopy.
D: A change in pulse pressure is not associated with
bronchoscopy but rather with intracranial pressure and shock. A pulse deficit
is associated with some dysrhythmias.
77.
ANSWER: B
The arterial blood gas results indicate respiratory alkalosis. As the alkalinity of body fluids increases, ionization of calcium decreases. A low level of circulating ionized calcium increases the excitability of nerve and muscle tissue, manifested by paresthesia (numbness and tingling) of the digits, upper lip, and earlobes.
The arterial blood gas results indicate respiratory alkalosis. As the alkalinity of body fluids increases, ionization of calcium decreases. A low level of circulating ionized calcium increases the excitability of nerve and muscle tissue, manifested by paresthesia (numbness and tingling) of the digits, upper lip, and earlobes.
A: In mild asthma with respiratory alkalosis, breath sounds
are typically loud with expiratory wheezing.
C: In mild asthma with respiratory alkalosis, the heart rate
is usually elevated because of hyperventilation.
D: In mild asthma with respiratory alkalosis, urine
production is increased because of the increased renal circulation. As a
result, bicarbonate, sodium, and potassium excretion increases in an attempt to
conserve hydrogen to correct the alkalosis.
78.
ANSWER: C
Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
A: There is no fluid in the alveoli, so no crackles are
produced.
B: If there is tracheal deviation, it is away from the
involved side.
D: Dullness is produced on percussion of the involved area.
79.
ANSWER: A
This is a critical time; the client's response to reduction of ventilator support must be closely observed and evaluated for signs of respiratory distress such as shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, tachypnea, etc.
This is a critical time; the client's response to reduction of ventilator support must be closely observed and evaluated for signs of respiratory distress such as shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, tachypnea, etc.
B: This delegates the professional responsibility
inappropriately.
C: This does not ensure client's safety.
D: This does not provide client with support and
professional assistance.
80.
ANSWER: B
When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artifical airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. With standard procedures the other choices wouldn't be at high risk.
When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artifical airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. With standard procedures the other choices wouldn't be at high risk.
81.
ANSWER: B
Theophylline ethylenediamide is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Strengthen myocardial contractions. Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used. 1
Theophylline ethylenediamide is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Strengthen myocardial contractions. Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used. 1
A:
Theophylline ethylenediamide does not reduce bronchial secretions.
C: Theophylline ethylenediamide does increase strength of
myocardial contractility, but this is not the action for which it is used.
D: Theophylline ethylenediamide does not decrease alveolar
elasticity.
82.
ANSWER: A
Pneumocystis carinii pneumonia (PCP) is an opportunistic infection that develops in patients with AIDS because the regulators of the immune system are destroyed by the HIV virus. The pathogens responsible for opportunistic infection are ubiquitous. Pneumocystis carinii pneumonia is in the air we breathe. People with intact immune systems do not become sick from this organism. Morbidity and mortality from this complication has been reduced by prophylactic drug treatment.
Pneumocystis carinii pneumonia (PCP) is an opportunistic infection that develops in patients with AIDS because the regulators of the immune system are destroyed by the HIV virus. The pathogens responsible for opportunistic infection are ubiquitous. Pneumocystis carinii pneumonia is in the air we breathe. People with intact immune systems do not become sick from this organism. Morbidity and mortality from this complication has been reduced by prophylactic drug treatment.
B: Most opportunistic infections result from secondary
reactivation of previously acquired pathogens rather than from a new or primary
infection. Most people become infected with Pneumocystis carinii pneumonia in
the pre-school years and the child's intact immune system brings it under
control. The organism remains dormant in the person's body and can be
reactivated when immunodeficiency occurs.
C: The pathogen responsible for PCP is airborne and can be
found in the lungs of humans and animals. Lifetime suppressive therapy with
antibiotics is given to people with PCP to keep the infection under control.
Helping patients comply with the antibiotic regimen is an essential part of the
nursing care plan.
D: PCP is an airborne organism. It is not acquired from
unprotected sex with an infected individual
83.
ANSWER: B
SaO2 is 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 SaO2 and still be short of breath. In this case, the nurse could assume that the client has a 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-sided heart failure, the client would exhibit pulmonary crackles.
SaO2 is 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 SaO2 and still be short of breath. In this case, the nurse could assume that the client has a 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-sided heart failure, the client would exhibit pulmonary crackles.
84.
ANSWER: C
Knowing that this child is most likely experiencing an asthmatic attack, the nurse would expect to hear wheezing and note some shortness of breath with a prolonged expiratory phase. However, of greatest concern would be the absence of wheezing indicating that the child is not moving air well through the lungs and is at risk for hypoxia and possible respiratory failure.
Knowing that this child is most likely experiencing an asthmatic attack, the nurse would expect to hear wheezing and note some shortness of breath with a prolonged expiratory phase. However, of greatest concern would be the absence of wheezing indicating that the child is not moving air well through the lungs and is at risk for hypoxia and possible respiratory failure.
A: Increased respiratory effort would be suspected secondary
to bronchospasm associated with asthma.
B: During an asthma attack, the cough usually is dry and
sounds tight due to mucus accumulation and bronchoconstriction.
D: Typically during an asthmatic attack, the client would
demonstrate a prolonged expiratory phase because of air trapping and the
increased effort to move air through constricted bronchioles.
85.
ANSWER: B
Maintaining a patent airway is the most basic and most critical human need. All other interventions are important to the client's well-being, but they aren't as important as having sufficient oxygen to breathe.
Maintaining a patent airway is the most basic and most critical human need. All other interventions are important to the client's well-being, but they aren't as important as having sufficient oxygen to breathe.
86.
ANSWER: C
Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 qt [2 L] or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.
Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 qt [2 L] or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.
87.
ANSWER: A
In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade.
In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade.
88.
ANSWER: B
Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual is exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has or will develop tuberculosis.
Skin testing is based on the antigen/antibody response and will show a positive reaction after an individual is exposed to tuberculosis and has formed antibodies to the tuberculosis bacteria. Thus, a positive Mantoux test indicates the production of an immune response. Exposure doesn't confer immunity. A positive test doesn't confirm that a person has or will develop tuberculosis.
89.
ANSWER: B
Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning.
Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client prior to and after suctioning.
A: To prevent trauma to the trachea, suction should only be
applied while removing the catheter.
C: This kind of movement could cause tracheal damage.
D: Suction only as needed; excessive suctioning irritates
the mucosa, which increases secretion production.
90.
ANSWER: B
Flail chest occurs when two or more adjacent ribs are fractured at two or more sites, resulting in a free-floating segment. This loss of chest wall stability causes respiratory impairment and notable paradoxical chest wall movement. Hemothorax or pneumothorax both decrease chest wall excursion on the affected side. A tension pneumothorax causes a mediastinal shift and tracheal deviation toward the unaffected side.
Flail chest occurs when two or more adjacent ribs are fractured at two or more sites, resulting in a free-floating segment. This loss of chest wall stability causes respiratory impairment and notable paradoxical chest wall movement. Hemothorax or pneumothorax both decrease chest wall excursion on the affected side. A tension pneumothorax causes a mediastinal shift and tracheal deviation toward the unaffected side.
91.
ANSWER: D
Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax, but they typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently.
Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax, but they typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently.
92.
ANSWER: B
A respiratory rate of 16 to 20 breaths/minute is a normal finding, indicating adequate respiratory function. Orthopneic breathing, accessory muscle use, and bilateral rales indicate an interference with respiratory function.
A respiratory rate of 16 to 20 breaths/minute is a normal finding, indicating adequate respiratory function. Orthopneic breathing, accessory muscle use, and bilateral rales indicate an interference with respiratory function.
93.
ANSWER: B
As a result of the infectious process and mucus accumulation, classic signs of pneumonia include fever and cough.
As a result of the infectious process and mucus accumulation, classic signs of pneumonia include fever and cough.
A: Weight loss may occur in a child with cystic fibrosis
because of the energy expenditure needed to fight the infection. Typically
stools are large, bulky, and greasy.
C: Constipation is not a common manifestation of pneumonia.
However, vomiting may occur, especially if the child is coughing frequently and
has a lot of mucus.
D: Dysuria and rash are not associated with pneumonia.
94.
ANSWER: A
If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The physician should be notified as he or she may want to consider changing antibiotics.
If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The physician should be notified as he or she may want to consider changing antibiotics.
B: Altering prescribed medication
doses is not a nursing responsibility.
C: Reverse isolation is used for clients with a very low
white blood cell count.
D: The antibiotic dosing schedule should be strictly
maintained.
95.
ANSWER: A
In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaO2 is elevated and the pH and HCO3– are depressed.
In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaO2 is elevated and the pH and HCO3– are depressed.
96.
ANSWER: C
A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
A reaction to the Mantoux test for tuberculosis means that the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction doesn't mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
97.
ANSWER: C
During inspiration negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration negative pressure in the pleural space decreases, causing fluid to drop in the chamber.
During inspiration negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration negative pressure in the pleural space decreases, causing fluid to drop in the chamber.
A: If the system is closed to the atmosphere, as it should
be, no bubbles will be present.
B: If the system is closed to the atmosphere, as it should
be, no bubbling will occur.
D: Changes in intrapleural pressure cause fluid to rise on inspiration
and fall on expiration (tidaling).
98.
ANSWER: C
Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months.
Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months.
A: The client needs with a newly positive Mantoux test
requires prophylactic drug treatment.
B: Repeat skin testing should not be performed as it will
always be positive.
D: Skin tests do not convert to negative once a positive
response has been obtained.
99.
ANSWER: C
The chest was opened during surgery for the sternal repair, and air was allowed into the thorax; the air must be removed for the lungs to expand properly.
The chest was opened during surgery for the sternal repair, and air was allowed into the thorax; the air must be removed for the lungs to expand properly.
A: The chest tube is unrelated to the baby's ability to
retain feedings.
B: Chest tubes are uncomfortable; also, this response
discounts the importance of the chest tube to the baby's respiratory status.
D: The baby did not have a punctured lung.
100.ANSWER: C
TB transmission occurs when an infected person coughs or sneezes, spreading infected droplets. Many other infectious diseases can be transmitted through contact with stool, urine, or blood but not TB.
TB transmission occurs when an infected person coughs or sneezes, spreading infected droplets. Many other infectious diseases can be transmitted through contact with stool, urine, or blood but not TB.
101.ANSWER: D
Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system.
Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system.
A: In later childhood and adolescence, morbidity and
mortality are higher in females than males.
B: A higher than average weight and height would indicate
that the child has had good nutrition. Poor nutrition is a risk factor for
tuberculosis.
C: Prenatal care is unrelated to tuberculosis.
102.ANSWER: B
The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems.
The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems.
103.ANSWER: C
The client's concerns will be reduced if he or she knows the stoma will stay open long enough so that another tube can easily be inserted.
The client's concerns will be reduced if he or she knows the stoma will stay open long enough so that another tube can easily be inserted.
A: The client is in no immediate
danger and it is not imperative to notify the physician at once.
B: A permanent opening into the trachea is formed after 2 or
3 weeks, and a tube need not be promptly reinserted.
D: A permanent opening into the trachea is formed after 2 to
3 weeks and will not close quickly.
104.On the first day following a right pneumonectomy a male
client suddenly sits straight up in bed. His respirations are labored, and he
is making a crowing sound. His skin is pale, cool, and moist. Immediately the
nurse should:
A.
Notify the physician
B.
Auscultate the left lung
C.
Inspect the incision for bleeding
D.
Check the chest tube for patency
104. 2
B","This is unsafe; the client needs immediate intervention; the airway is the priority. ","A mediastinal shift with airway obstruction may occur because pressure builds up on the operative side, causing the trachea to deviate toward the unoperative side; assessment of the airway takes priority. ","This is unsafe; the client needs immediate intervention; the airway is the priority. ","There is no need for a chest tube when a pneumonectomy is performed.
105.ANSWER: C
Tension is placed on the pleura at the height of inspiration and causes pain.
Tension is placed on the pleura at the height of inspiration and causes pain.
A: This is typical of congestive heart failure.
B: This may indicate pulmonary infection.
D: This may indicate pulmonary infection.
106.ANSWER: B
Crackles occur because of retained secretions and shallow breathing. Shallow breathing is a common problem after thoracic surgery owing to the pain associated with deep inspiration. Assisting the client to deep breathe and ambulate will help expand the lung tissue, clear secretions and improve oxygenation.
Crackles occur because of retained secretions and shallow breathing. Shallow breathing is a common problem after thoracic surgery owing to the pain associated with deep inspiration. Assisting the client to deep breathe and ambulate will help expand the lung tissue, clear secretions and improve oxygenation.
A: Scattered crackles are indicative of fluid in the
airways, not a malfunctioning drainage system.
C: The alert, nonintubated client should not be suctioned
when coughing and deep breathing can clear the airways.
D: Reducing pain medication would make effective deep
breathing and ambulating more difficult.
107.ANSWER: D
The client with a chronic illness goes through a grieving process that is related to the loss of his previous level of function. Grief is commonly manifested as loss of motivation and refusal to perform functions of which the client is fully capable. Self-actualization is the process of fulfilling one’s potential. Confabulation is a behavioral reaction in which the client creates stories or invents answers to fill in memory gaps in an unconscious attempt to maintain self-esteem. In reaction formation, the client uses behaviors that are the opposite of what he would like to do.
The client with a chronic illness goes through a grieving process that is related to the loss of his previous level of function. Grief is commonly manifested as loss of motivation and refusal to perform functions of which the client is fully capable. Self-actualization is the process of fulfilling one’s potential. Confabulation is a behavioral reaction in which the client creates stories or invents answers to fill in memory gaps in an unconscious attempt to maintain self-esteem. In reaction formation, the client uses behaviors that are the opposite of what he would like to do.
108.ANSWER: A
This medication causes hyperuricemia, leading to joint swelling and pain; fluids dilute the urine and help remove the uric acid.
This medication causes hyperuricemia, leading to joint swelling and pain; fluids dilute the urine and help remove the uric acid.
B: This medication causes GI irritation and should be taken
with food.
C: This is not a side effect of this medication.
D: This is a side effect of rifampin (Rifadin), not
pyrazinamide.
109.ANSWER: D
Respiratory effort is stimulated in client's with COPD by hypoxemia. Answer A and C are incorrect because higher levels would rob the client of the drive to breathe. Answer B is an incorrect statement.
Respiratory effort is stimulated in client's with COPD by hypoxemia. Answer A and C are incorrect because higher levels would rob the client of the drive to breathe. Answer B is an incorrect statement.
110.ANSWER: C
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. If he's sick or under some stress he could have a relapse of the disease. He'll be positive when tested.
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. If he's sick or under some stress he could have a relapse of the disease. He'll be positive when tested.
111.ANSWER: D
A: Although this is important, the microorganisms must be
eliminated by the use of medication.
B: Although this is important, the microorganisms must be
eliminated by the use of medication.
C: Although this is important, the microorganisms must be
eliminated by the use of medication.
D: Tubercle bacilli are particularly resistant to treatment
and can remain dormant for prolonged periods; medication must be taken
consistently as ordered for prolonged periods.
112.ANSWER: B
The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound.
The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound.
A: Starting oxygen therapy may be
necessary later but does not have the same priority on admission as closing the
wound.
C: The data provided do not support the need for a
tracheostomy.
D: Preparing for endotracheal intubation may be necessary
later but does not have the same priority on admission as closing the wound.
113.ANSWER: C
To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
114.ANSWER: D
The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment so the nurse can't change the route without a new order from the physician.
The client's needs are preeminent, so the nurse should administer the nebulizer treatment immediately. The nurse can deal with the respiratory therapist's lack of response after the client's condition is stabilized. There is no need to involve the physician in personnel issues. Staying with the client is important, but it isn't a substitute for administering the needed bronchodilator. The order is for a nebulizer treatment so the nurse can't change the route without a new order from the physician.
115.ANSWER: A
Respiratory acidosis is associated with hypoventilation, which in this client suggests intake of a drug that suppresses the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening.
Respiratory acidosis is associated with hypoventilation, which in this client suggests intake of a drug that suppresses the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening.
116.ANSWER: C
ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it doesn't cause ARDS. Renal failure also doesn't cause ARDS.
ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it doesn't cause ARDS. Renal failure also doesn't cause ARDS.
117.ANSWER: C
Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.
Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.
118.ANSWER: A
A 10-mm induration strongly suggests a positive response in this tuberculosis screening test — so, a 15-mm induration clearly requires further evaluation. The remaining options aren't positive reactions to the test and require no further evaluation.
A 10-mm induration strongly suggests a positive response in this tuberculosis screening test — so, a 15-mm induration clearly requires further evaluation. The remaining options aren't positive reactions to the test and require no further evaluation.
119.ANSWER: D
Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide, they may stop breathing.
Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide, they may stop breathing.
A: Oxygen flow rate is not diminished at high levels when
administered through a nasal cannula.
B: The client’s ability to absorb oxygen administered at a
higher level is not affected.
C: Increased oxygen levels and decreased carbon dioxide
levels cannot cause cells to burst.
120.ANSWER: D
The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
121.ANSWER: B
Fluctuations of fluid in the water-seal chamber will stop when the lung has expanded, the tubing is occluded, or the suction apparatus malfunctions.
Fluctuations of fluid in the water-seal chamber will stop when the lung has expanded, the tubing is occluded, or the suction apparatus malfunctions.
122.ANSWER: C
Tachycardia is listed as one of the primary side effects of Brethine. The mother may report feeling like "her heart is beating out of her chest." The fetal and maternal heart rates should be monitored. Usually, the tachycardia is mild in nature.
Tachycardia is listed as one of the primary side effects of Brethine. The mother may report feeling like "her heart is beating out of her chest." The fetal and maternal heart rates should be monitored. Usually, the tachycardia is mild in nature.
A: The action of the Brethine is to relax smooth muscles.
The uterine muscle is smooth in nature.
B: Epistaxis or nosebleeds are not associated with Brethine
administration.
D: Dysuria or painfUl urination is associated with urinary
tract infections and not with the use of Brethine.
123.ANSWER: C
An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.18 to 0.21.
An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.18 to 0.21.
124.ANSWER: C
Gently rotate 360 degree; too long can cause hypoxia, dysrhythmias; hyperoxygenate before, during and after
Gently rotate 360 degree; too long can cause hypoxia, dysrhythmias; hyperoxygenate before, during and after
A: not done
B: no suction when inserted
D: not involved with breathing pattern
ADDITIONAL INFO: Pneumonia: infection of the lungs due to
viruses/bacteria, aspiration of food/fluids or inhalation of toxic chemicals.
S/S: fever, chills, hemoptysis, dyspnea, fatigue. Treatment: antibiotics.
Nursing responsibilities: T, C, DB, Fowler's position. Suction to remove
secretions and provide open airway. Complications: infection, trauma,
hypoxemia, dysrhythmias. Use 12 - 14 French catheter. Suction pressure less
than 120 mmHg.
125.ANSWER: B
Semi-Fowler's position allows for downward displacement of the diaphragm and relaxation of the abdominal muscles, which are needed for good ventilatory excursion. The hand placement supports the operative area and splints it without causing pain from pressure.
Semi-Fowler's position allows for downward displacement of the diaphragm and relaxation of the abdominal muscles, which are needed for good ventilatory excursion. The hand placement supports the operative area and splints it without causing pain from pressure.
A: Trendelenburg's position is contraindicated because
abdominal contents pushing against the diaphragm will decrease effective lung
volume.
C: Keeping the bed flat does not allow the diaphragm to
descend.
D: Positioning the client on the operative side prevents
maximum inflation of the left lung. Placing the hands on the operative area
before inhalation can restrict thoracic movement.
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