Chapter 12 Alterations in Pulmonary Function

Question 1

1) A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology?
1. Prolonged expiratory time
2. Increased lung compliance
3. Reduced tidal volume
4. Hyper-inflated lungs

Answer 1

Answer: 3
Explanation: 1. Expiratory time is dependent upon airflow, which remains normal in the patient with a restrictive lung disorder such as pneumothorax.
2. With restrictive lung disorders such as pneumothorax, the air cannot move into the alveoli because of decreased lung compliance.
3. Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient’s tidal volume will be reduced.
4. Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.

Question 2

2) A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function?
1. Decreased total lung capacity
2. Progressive respiratory alkalosis
3. Increased PaCO2
4. Increased forced expiratory volume (FEV)

Answer 2

Answer: 3
Explanation: 1. The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity.
2. Obstructive pulmonary disorders such as cystic fibrosis tend to produce progressive respiratory acidosis.
3. In obstructive lung disorders such as cystic fibrosis, PaCO2 levels increase because of air trapping.
4. Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV.

Question 3

3) A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a “high-pitched noise” in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder?
1. Chronic obstructive pulmonary disorder (COPD)
2. Asthma
3. Emphysema
4. Pneumonia

Answer 3

Answer: 2
Explanation: 1. COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.
2. The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma.
3. Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.
4. Pneumonia will not “suddenly appear” after exposure to cigarette smoke to cause the onset of the patient’s symptoms.

Question 4

4) The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition?
1. The patient is now able to rest and sleep.
2. The patient’s condition has significantly deteriorated.
3. The patient’s condition shows some slight improvement.
4. The patient’s condition has stabilized significantly.

Answer 4

Answer: 2
Explanation: 1. These findings do not indicate that the patient is resting and now able to sleep.
2. The patient’s condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid-base balance.
3. These findings do not indicate that the patient’s condition is improving.
4. These findings do not indicate significant stabilization of the patient’s condition.

Question 5

5) A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. The patient has ventilation failure.
2. Without treatment the patient’s oxygen saturation is likely to drop rapidly.
3. The patient has decreased airflow.
4. The patient is at risk for respiratory muscle fatigue.
5. Acute respiratory failure is present.

Answer 5

Answer: 2, 4
Explanation: 1. Ventilation failure is reflected by an increased PaCO2.
2. Once the PaO2 drops below 60 mm Hg, oxygen’s affinity to hemoglobin drops.
3. When the patient has ventilatory failure (decreased airflow), carbon dioxide levels increase. This patient has a normal PaCO2.
4. As respiratory rate increases the risk of respiratory muscle fatigue also increases.
5. Currently the patient does not have acute respiratory failure because the PaCO2 is normal.

Question 6

6) The nurse working in an intensive care unit is alert to the development of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). The nurse would monitor which patients most closely for this complication?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. A patient who sustained a severe chest contusion.
2. A patient hospitalized for treatment of drug overdose.
3. A patient who sustained severe head trauma.
4. A patient hospitalized for treatment of pneumonia.
5. A patient diagnosed with sepsis.

Answer 6

Answer: 4, 5
Explanation: 1. Chest contusion can result in ALI/ARDS, but this is not the patient of most concern.
2. Drug overdose can result in ALI/ARDS, but this is not the patient of most concern.
3. Head trauma can result in ALI/ARDS, but this is not the patient of most concern.
4. Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS.
5. Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.

Question 7

7) The nurse is caring for a patient in early acute respiratory distress syndrome (ARDS). Which finding would indicate that the disease is progressing?
1. Increased lung compliance
2. Decrease in heart rate
3. Hypoxemia refractory to oxygen therapy
4. Respiratory acidosis

Answer 7

Answer: 3
Explanation: 1. Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease.
2. The heart rate increases as the work of breathing increases.
3. In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting.
4. In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms.

Question 8

8) A patient diagnosed with acute respiratory distress syndrome (ARDS) is being mechanically ventilated with 12 cm of positive end-expiratory pressure (PEEP). On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication?
1. Obstructed endotracheal tube
2. Increased severity of ARDS
3. Decreased cardiac output
4. Pneumothorax

Answer 8

Answer: 4
Explanation: 1. An obstructed endotracheal tube would affect both lung fields.
2. If the disease process was worsening, it would be likely that both lung fields would be involved.
3. Decreased cardiac output would affect vital signs but not breath sounds.
4. A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.

Question 9

9) The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority?
1. Administer pain medication as ordered.
2. Increase intravenous fluids.
3. Evaluate the patient’s oxygen saturation.
4. Help the patient assume a more comfortable position.

Answer 9

Answer: 3
Explanation: 1. The patient’s pain should be treated, but this is not the priority intervention.
2. Intravenous fluids may be increased, but this is not the priority intervention.
3. The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae, and pulse oximetry before calling the physician, and anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a ventilation-perfusion (V-Q) scan, and angiography.
4. Positioning is not the priority intervention.

Question 10

10) The patient’s Wells score indicates intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Monitor daily D-dimer levels.
2. Strictly measure all intake and output.
3. Encourage ambulation.
4. Instruct the patient on use of antiembolism stockings.
5. Prevention of leg injury

Answer 10

Answer: 3, 4, 5
Explanation: 1. D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus.
2. Measuring intake and output will not prevent development of thrombus.
3. Ambulation will help to support circulation and prevent clot development.
4. Proper use of antiembolism stocking is helpful in decreasing development of thrombus.
5. One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma.

Question 11

11) The emergency department has treated two patients in the last day with symptoms that may be H5N1. The nurse manager is updating staff on the pathophysiology of this disease. The manager would evaluate education as effective if which statement was made by a staff member?
1. It is thought that H5N1 is a nonhuman virus that has crossed species.
2. H5N1 is more common in patients also infected with HIV.
3. H5N1 is typically found in swine.
4. H5N1 is related to respiratory syncytial virus (RSV), so young children will be the most likely patients.

Answer 11

Answer: 1
Explanation: 1. It is thought that H5N1 is a virus that has jumped species from birds to man.
2. H5N1 is not specifically associated with HIV.
3. H5N1 is typically found in birds, not swine.
4. H5N1 is not specifically related to RSV.

Question 12

12) The nurse is preparing to participate in evaluation of the severity of a patient’s community-acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. The patient’s respiratory rates for the last several hours
2. BUN results
3. The patient’s history of smoking, if any
4. The patient’s gender
5. The patient’s age

Answer 12

Answer: 1, 2, 5
Explanation: 1. CURB-65 evaluates the patient’s respiratory rate. Rate of 30 or over is scored as a 1.
2. CURB-65 evaluates the patient’s BUN level. BUN greater than 19.6 mg/dL is scored as a 1.
3. Tobacco use history is not considered in CURB-65 scoring.
4. Gender is not considered in CURB-65 scoring.
5. The patient’s age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned.

Question 13

13) The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an anteroposterior (AP) chest x-ray to be done in the x-ray department. How would the nurse transport the patient?
1. Do a portable film in the patient’s room instead of in the x-ray department.
2. Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive.
3. Disconnect the drainage system from the wall suction and transport.
4. Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive.

Answer 13

Answer: 3
Explanation: 1. Changing of a physician’s order is not within the scope of practice of the nurse.
2. Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.
3. The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity.
4. Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.

Question 14

14) A patient has been uncooperative with pulmonary hygiene following thoracic surgery because “it hurts more than I can bear.” Which intervention should the nurse employ?
1. Instruct the patient to cough 3 to 4 times with each exhalation.
2. Assist the patient to a sitting position to lean over the bedside table while coughing.
3. Provide the patient with a pillow to splint the incision while coughing.
4. Guide the patient to cough with the glottis open.

Answer 14

Answer: 4
Explanation: 1. The “cascade” cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort.
2. Positioning the patient over the bedside table might cause injury during coughing.
3. A pillow is too soft to effectively splint the incision for best pain relief.
4. Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the “huff” cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing.

Question 15

15) The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. How would the nurse describe the major health concern for this patient?
1. “The patient’s breathing pattern is not sufficient.”
2. “The patient does not have a clear airway.”
3. “If the patient continues to breathe in this manner, pneumonia is a real risk.”
4. “The patient is not exchanging oxygen and carbon dioxide correctly.”

Answer 15

Answer: 1
Explanation: 1. The patient has documented shallow breathing, indicative of a problem with breathing pattern.
2. There is no evidence that the patient’s airway is not clear at this time.
3. Pneumonia is not the major concern for this patient.
4. It is not possible to determine the status of gas exchange without additional laboratory tests.

Question 16

16) A patient has inability to clear thick secretions from her airway. Which nursing interventions are appropriate to address this problem?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Encourage bedrest to conserve energy.
2. Administer pain medications as needed.
3. Position the patient on the unaffected side.
4. Encourage the patient to provide as much self-care as possible.
5. Encourage slow, deep breaths.

Answer 16

Answer: 2, 4
Explanation: 1. Bedrest will impair the patient’s ability to mobilize secretions. Activity as tolerated will help mobilize secretions.
2. The nurse should treat the patient’s pain but avoid oversedation.
3. Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involves both lungs and the trachea.
4. Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions.
5. Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated to help clear the airway.

Question 17

17) A patient recovering from thoracic surgery is demonstrating evidence of impaired oxygenation and ventilation. His breathing is shallow and his oxygen saturation is dropping. Which nursing intervention is most suited to addressing this issue?
1. Teach the patient to use the incentive spirometer every 1 to 2 hours.
2. Suction as necessary.
3. Splint the chest when coughing.
4. Encourage fluids up to 2.5 liters per day.

Answer 17

Answer: 1
Explanation: 1. Using the incentive spirometer correctly every 1 to 2 hours will help to improve oxygenation and ventilation.
2. There is no evidence that the patient’s airway is compromised so suctioning is not the best intervention.
3. Using a splint with coughing will help reduce pain so that the airway can be cleared. This is not the primary intervention needed.
4. Increasing fluids will help to thin secretions so that they are more easily mobilized. This is not the primary intervention needed

Question 18

18) An older adult presents to the emergency department in septic shock. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic?
1. Whenever the drug is received from the pharmacy
2. After the preliminary results of the sputum specimen are obtained
3. Within 30 minutes of the order being received
4. Within 1 hour of diagnosis

Answer 18

Answer: 4
Explanation: 1. There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient’s diagnosis and need to start the antibiotic quickly.
2. The nurse should not wait for sputum specimen results.
3. There is no standard by which the antibiotic must be started within 30 minutes of the order being received.
4. Standards indicate that antibiotic therapy for pneumonia should be started within 1 hour of diagnosis if the patient is also in shock.

Question 19

19) A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses tidaling in the water-seal chamber. What nursing action is indicated?
1. Collaborate with the healthcare provider regarding need to reinstitute the external suction.
2. Check the connections between the chest tube and the drainage system.
3. No action is necessary as this is an expected occurrence.
4. Have the patient cough forcefully.

Answer 19

Answer: 3
Explanation: 1. There is no need for external suction.
2. The nurse should always check these connections, but there is no special need for that action related to this assessment.
3. The tidaling in this patient likely indicates successful reinflation of the lung, which is the desired outcome.
4. This assessment does not indicate that coughing is necessary.

Question 20

20) A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection, the nurse notes that the patient’s trachea is slight displaced toward the left. Which nursing intervention is priority?
1. Have the patient release his arm and sit up straight for reassessment.
2. Notify the emergency room physician immediately.
3. Auscultate the patient’s lung fields.
4. Position the patient flat in bed without a pillow

Answer 20

Answer: 2
Explanation: 1. Reassessment is not the priority in this situation.
2. Deviation of the trachea away from the injured side indicates pressure on the affected side, which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient’s condition.
3. The nurse will auscultate the lungs, but another intervention is the priority.
4. This position is not indicated for this patient. Positioning is not the immediate priority.