Chapter 19: Management of Patients with Chest and Lower Respiratory Tract Disorders

Question 1

1. A perioperative nurse is caring for a postoperative client. The client has a shallow
   respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should
   address the client’s increased risk for what complication?
   A. Acute respiratory distress syndrome (ARDS)
   B. Atelectasis
   C. Aspiration
   D. Pulmonary embolism

Answer 1

ANS: B
Rationale: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and
shallow breathing.

Question 2

2. A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical
   complication. The nurse’s assessment reveals that the client has an increased work of
   breathing due to copious tracheobronchial secretions. What should the nurse encourage
   the client to do?
   A. Increase oral fluids unless contraindicated.
   B. Call the nurse for oral suctioning, as needed.
   C. Lie in a low Fowler or supine position.
   D. Increase activity.

Answer 2

ANS: A
Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove
tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

Question 3

3. The nurse is caring for a client who has been in a motor vehicle accident and is
   suspected of having developed pleurisy. Which assessment finding would best
   corroborate this diagnosis?
   A. The client is experiencing painless hemoptysis.
   B. The client’s arterial blood gases (ABGs) are normal, but the client demonstrates
   increased work of breathing.
   C. The client’s oxygen saturation level is below 88%, but the client denies
   shortness of breath.
   D. The client’s pain intensifies when the client coughs or takes a deep breath.

Answer 3

ANS: D
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The client’s
ABGs would most likely be abnormal, and shortness of breath would be expected. Painless hemoptysis is not characteristic of pleurisy.

Question 4

4. The nurse caring for a client recently diagnosed with lung disease encourages the
   client not to smoke. What is the primary rationale behind this nursing action?
   A. Smoking decreases the amount of mucus production.
   B. Smoke particles compete for binding sites on hemoglobin.
   C. Smoking causes atrophy of the alveoli.
   D. Smoking damages the ciliary cleansing mechanism.

Answer 4

ANS: D
Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.

Question 5

5. The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While
   assisting with a subclavian vein central line insertion, the nurse notes that the client’s
   oxygen saturation is rapidly dropping. The client reports shortness of breath and
   becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further
   assessment finding would support the presence of a pneumothorax?
   A. Diminished or absent breath sounds on the affected side
   B. Paradoxical chest wall movement with respirations
   C. Sudden loss of consciousness
   D. Muffled heart sounds

Answer 5

ANS: A
Rationale: In the case of a simple 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. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

Question 6

6. The nurse in the intensive care unit is caring for a client with pulmonary hypertension.
   Which finding should the nurse expect to assess?
   A. Pulmonary artery pressure greater than 20 mm Hg
   B. Flat neck veins
   C. Dyspnea at rest
   D. Enlarged spleen6. The nurse in the intensive care unit is caring for a client with pulmonary hypertension.
   Which finding should the nurse expect to assess?
   A. Pulmonary artery pressure greater than 20 mm Hg
   B. Flat neck veins
   C. Dyspnea at rest
   D. Enlarged spleen

Answer 6

ANS: C
Rationale: The main symptom in pulmonary hypertension is dyspnea. At first dyspnea occurs with exertion, then eventually at rest. A client with pulmonary hypertension will
have a pulmonary artery pressure greater than 25 mm Hg at rest and distended neck veins secondary to right-sided heart failure. The nurse would expect the liver, not the spleen, to be enlarged secondary to engorgement in pulmonary hypertension.

Question 7

7. A new employee asks the occupational health nurse about measures to prevent
   inhalation exposure to toxic substances. What should the nurse recommend?
   A. “Position a fan blowing toxic substances away from you to prevent you from
   being exposed.”
   B. “Wear protective attire and devices when working with a toxic substance.”
   C. “Make sure that you keep your immunizations up to date to prevent respiratory
   diseases resulting from toxins.”
   D. “Always wear a disposable paper face mask when you are working with inhalable
   toxins.”

Answer 7

ANS: B
Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do
not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes
throughout the area.

Question 8

8. An x-ray of a trauma client reveals rib fractures, and the client is diagnosed with a
   small flail chest injury. Which intervention should the nurse include in the client’s plan of
   care?
   A. Initiate chest physiotherapy.
   B. Immobilize the ribs with an abdominal binder.
   C. Prepare the client for surgery.
   D. Immediately sedate and intubate the client.

Answer 8

ANS: A
Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes chest physiotherapy and controlling pain. Intubation is required only for severe flail chest injuries, not small flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment. Immobilization of the ribs with an abdominal binder is not necessary for a small flail chest injury.

Question 9

9. A client has tested positive for tuberculosis (TB). While providing client teaching, which
   information should the nurse prioritize?
   A. The importance of adhering closely to the prescribed medication regimen
   B. The disease being a lifelong, chronic condition that will affect activities of daily
   living (ADLs)
   C. TB being self-limiting but taking up to 2 years to resolve
   D. The need to work closely with the occupational and physical therapists

Answer 9

ANS: A
Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

Question 10

10. The nurse is assessing an adult client following a motor vehicle accident. The nurse
    observes that the client has an increased use of accessory muscles and is reporting chest
    pain and shortness of breath. The nurse should recognize the possibility of which
    condition?
    A. Pneumothorax
    B. Cardiac ischemia
    C. Acute bronchitis
    D. Aspiration

Answer 10

ANS: A
Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of
the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client’s recent trauma
they are inconsistent with cardiac ischemia, bronchitis, and aspiration.

Question 11

11. The nurse is caring for a client suspected of having acute respiratory distress
    syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of
    this disease to differentiate the client’s symptoms from those of a cardiac etiology?
    A. Carboxyhemoglobin level
    B. Brain natriuretic peptide (BNP) level
    C. C-reactive protein (CRP) level
    D. Complete blood count

Answer 11

ANS: B
Rationale: Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery
catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an
inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

Question 12

12. The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line
    measure to prevent atelectasis development in the client. What is an example of a
    first-line measure to minimize atelectasis?
    A. Incentive spirometry
    B. Intermittent positive-pressure breathing (IPPB)
    C. Positive end-expiratory pressure (PEEP)
    D. Bronchoscopy

Answer 12

ANS: A
Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

Question 13

13. While planning a client’s care, the nurse identifies nursing actions to minimize the
    client’s pleuritic pain. Which intervention should the nurse include in the plan of care?
    A. Administer an analgesic before coughing and deep breathing.
    B. Ambulate the client at least three times daily.
    C. Arrange for a soft-textured diet and increased fluid intake.
    D. Encourage the client to speak as little as possible.

Answer 13

ANS: A
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Because deep
breathing and coughing prevent atelectasis, the client should be given an analgesic prior to performing these respiratory exercises. A soft diet is not necessarily indicated, and
there is no need for the client to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.

Question 14

14. The perioperative nurse is writing a care plan for a client who has returned from
    surgery 2 hours ago. Which measure should the nurse implement to most decrease the
    client’s risk of developing pulmonary emboli (PE)?
    A. Early ambulation
    B. Increased dietary intake of protein
    C. Maintaining the client in a supine position
    D. Administering aspirin with warfarin

Answer 14

ANS: A
Rationale: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client’s risk for bleeding.

Question 15

15. The school nurse is presenting a class on smoking cessation at the local high school.
    A participant in the class asks the nurse about the risk of lung cancer in those who smoke.
    What response related to risk for lung cancer in smokers is most accurate?
    A. “The younger you are when you start smoking, the higher your risk of lung
    cancer.”
    B. “The risk for lung cancer never decreases once you have smoked, which is why
    smokers need annual chest x-rays.”
    C. “The risk for lung cancer is determined mostly by what type of cigarettes you
    smoke.”
    D. “The risk for lung cancer depends primarily on the other risk factors for cancer
    that you have.”

Answer 15

ANS: A
Rationale: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of
smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant
variable, but this is not the most important factor.

Question 16

16. The nurse is assessing a client who has a 35 pack-year history of cigarette smoking.
    In light of this known risk factor for lung cancer, which statement by the client should
    prompt the nurse to refer the client for further assessment?
    A. “Lately, I have this cough that just never seems to go away.”
    B. “I find that I don’t have nearly the stamina that I used to.”
    C. “I seem to get nearly every cold and flu that goes around my workplace.”
    D. “I never used to have any allergies, but now I think I’m developing allergies to
    dust and pet hair.”

Answer 16

ANS: A
Rationale: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. A new onset of allergies, frequent respiratory infections, and fatigue are not characteristic early signs of lung cancer.

Question 17

17. A client presents to the walk-in clinic reporting a dry, irritating cough and production
    of a small amount of mucus-like sputum. The client also reports soreness in the chest in
    the sternal area. The nurse should suspect that the primary care provider will assess the
    client for which health problem?
    A. Pleural effusion
    B. Pulmonary embolism
    C. Tracheobronchitis
    D. Tuberculosis

Answer 17

ANS: C
Rationale: Initially, the client with tracheobronchitis has a dry, irritating cough and expectorates a scant amount of mucoid sputum. The client may report sternal soreness
from coughing and have fever or chills, night sweats, headache, and general malaise. Pleural effusion and pulmonary embolism do not normally cause sputum production and would likely cause acute shortness of breath. Hemoptysis is characteristic of tuberculosis.

Question 18

18. A hospital has been the site of an increased incidence of hospital-acquired pneumonia
    (HAP). What is an important measure for the prevention of HAP?
    A. Administration of prophylactic antibiotics
    B. Administration of pneumococcal vaccine to vulnerable individuals
    C. Obtaining culture and sensitivity swabs from all newly admitted clients
    D. Administration of antiretroviral medications to clients over age 65

Answer 18

ANS: B
Rationale: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A one-time vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all clients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.

Question 19

19. When assessing for substances that are known to harm workers’ lungs, the
    occupational health nurse should assess their potential exposure to which of the
    following?
    A. Organic acids
    B. Solvents
    C. Asbestos
    D. Gypsum

Answer 19

ANS: C
Rationale: Pneumoconiosis is a general term given to any lung disease caused by dusts that are breathed in and then deposited deep in the lungs causing damage. Pneumoconiosis is usually considered an occupational lung disease, and includes asbestosis, silicosis, and coal workers’ pneumoconiosis, also known as “Black Lung Disease.” Asbestos is among the more common causes of pneumoconiosis. Organic acids, solvents, and gypsum do not have this effect.

Question 20

20. A client presents to the emergency department after being in a boating accident
    about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being
    able to breathe enough. The nurse notes that the client is restless and tachycardic with an
    elevated blood pressure. This client may be in the early stages of which respiratory
    problem?
    A. Pneumoconiosis
    B. Pleural effusion
    C. Acute respiratory failure
    D. Pneumonia

Answer 20

ANS: C
Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger,
tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

Question 21

21. The nurse is caring for an adult client recently diagnosed with the early stages of lung
    cancer. The nurse is aware that the preferred method of treating clients with non–small
    cell tumors is what method?
    A. Chemotherapy
    B. Radiation
    C. Surgical resection
    D. Bronchoscopic opening of the airway

Answer 21

ANS: C
Rationale: Surgical resection is the preferred method of treating clients with localized non–small cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

Question 22

22. A client is receiving thrombolytic therapy for the treatment of pulmonary emboli.
    What is the best way for the nurse to assess the client’s oxygenation status at the
    bedside?
    A. Obtain serial ABG samples.
    B. Monitor pulse oximetry readings.
    C. Perform chest auscultation.
    D. Monitor incentive spirometry volumes.

Answer 22

ANS: B
Rationale: The nurse assesses the client with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the
oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside. PFTs and incentive spirometry volumes do not accurately reveal oxygenation status.

Question 23

23. A client with thoracic trauma is admitted to the ICU. The nurse notes the client’s chest
    and neck are swollen and there is a crackling sensation when palpated. The nurse
    consequently identifies the presence of subcutaneous emphysema. If this condition
    becomes severe and threatens airway patency, what intervention is indicated?
    A. A chest tube
    B. A tracheostomy
    C. An endotracheal tube
    D. A feeding tube

Answer 23

ANS: B
Rationale: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air
on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.

Question 24

24. The occupational health nurse is assessing an employee who has just had respiratory
    exposure to a toxin. What should the nurse assess? Select all that apply.
    A. Time frame of exposure
    B. Type of respiratory protection used
    C. Immunization status
    D. Breath sounds
    E. Intensity of exposure

Answer 24

ANS: A, B, D, E
Rationale: Key aspects of any assessment of clients with a potential occupational respiratory history include job and job activities, exposure levels, general hygiene, time
frame of exposure, effectiveness of respiratory protection used, and direct versus indirect exposures. The client’s current respiratory status would also be a priority.
Occupational lung hazards are not normally influenced by immunizations.

Question 25

25. A client has just been diagnosed with small cell lung cancer. The client asks the nurse
    why the doctor is not offering surgery as a treatment for the cancer. Which fact about
    lung cancer treatment should inform the nurse’s response?
    A. The cells in small cell cancer of the lung are not large enough to visualize in
    surgery.
    B. Small cell lung cancer is self-limiting in many clients, and surgery should be
    delayed.
    C. Clients with small cell lung cancer are not normally stable enough to survive
    surgery.
    D. Small cell cancer of the lung grows rapidly and metastasizes early and
    extensively.

Answer 25

ANS: D
Rationale: Surgery is primarily used for non-small cell lung cancer, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult
visualization and a client’s medical instability are not the limiting factors. Lung cancer is not a self-limiting disease.

Question 26

26. A client who was involved in a workplace accident sustained a penetrating wound of
    the chest that led to acute respiratory failure. Which goal of treatment should the care
    team prioritize when planning this client’s care?
    A. Facilitation of long-term intubation
    B. Restoration of adequate gas exchange
    C. Attainment of effective coping
    D. Self-management of oxygen therapy

Answer 26

ANS: B
Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.

Question 27

27. A client is brought to the emergency department by ambulance after a motor vehicle
    accident in which the client received blunt trauma to the chest. The client is in acute
    respiratory failure, intubated, and transferred to the intensive care unit (ICU). Which
    assessment parameters should the nurse monitor most closely? Select all that apply.
    A. Coping
    B. Level of consciousness
    C. Oral intake
    D. Arterial blood gases
    E. Vital signs

Answer 27

ANS: B, D, E
Rationale: Trauma clients are usually treated in the ICU. The nurse assesses the client’s respiratory status by monitoring the level of responsiveness, arterial blood gases, pulse
oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment but would become more important later during recovery.

Question 28

28. A client has just been diagnosed with lung cancer. After the health care provider
    discusses treatment options and leaves the room, the client asks the nurse how the
    treatment is decided upon. What would be the nurse’s best response?
    A. “The type of treatment depends on the client’s age and health status.”
    B. “The type of treatment depends on what the client wants when given the
    options.”
    C. “The type of treatment depends on the cell type of the cancer, the stage of the
    cancer, and the client’s health status.”
    D. “The type of treatment depends on the discussion between the client and the
    health care provider of which treatment is best.”

Answer 28

ANS: C
Rationale: Treatment of lung cancer depends on the cell type, the stage of the disease, and the client’s physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the client’s age or the client’s preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the client and the health care provider of which treatment is best, though this discussion will take place.

Question 29

29. A firefighter was trapped in a fire and is admitted to the intensive care unit for smoke
    inhalation. After 12 hours, the firefighter is exhibiting signs of acute respiratory distress
    syndrome (ARDS) and is intubated. Which other supportive measure should be initiated
    in this client?
    A. Psychological counseling
    B. Nutritional support
    C. High-protein oral diet
    D. Occupational therapy

Answer 29

ANS: B
Rationale: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and
mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation.
Counseling and occupational therapy would not be priorities during the acute stage of ARDS.

Question 30

30. An 87-year-old client has been hospitalized with pneumonia. Which nursing action
    would be a priority in this client’s plan of care?
    A. Nasogastric intubation
    B. Administration of probiotic supplements
    C. Bed rest
    D. Cautious hydration

Answer 30

ANS: D
Rationale: Supportive treatment of pneumonia in the older adults includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the
older adults); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation. Mobility is not normally discouraged and an NG tube is not necessary in most cases. Probiotics may or may not be prescribed for the client.

Question 31

31. The nurse caring for a client with an endotracheal tube recognizes several
    disadvantages of an endotracheal tube. What would the nurse recognize as a
    disadvantage of endotracheal tubes?
    A. Cognition is decreased.
    B. Daily arterial blood gases (ABGs) are necessary.
    C. Slight tracheal bleeding is anticipated.
    D. The cough reflex is depressed.

Answer 31

ANS: D
Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the client’s cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

Question 32

32. The medical nurse is creating the care plan of a client with a tracheostomy requiring
    mechanical ventilation. Which nursing action is most appropriate?
    A. Keep the client in a low Fowler position.
    B. Perform tracheostomy care at least once per day.
    C. Maintain continuous bed rest.
    D. Monitor cuff pressure every 8 hours.

Answer 32

ANS: D
Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours, not once per day, because of the risk of infection. The client should be encouraged to ambulate, if possible, not maintain continuous bed rest, and a low Fowler position is not indicated.

Question 33

33. A nurse is educating a client in anticipation of a procedure that will require a
    water-sealed chest drainage system. What should the nurse tell the client and the family
    that this drainage system is used for?
    A. Maintaining positive chest-wall pressure
    B. Monitoring pleural fluid osmolarity
    C. Providing positive intrathoracic pressure
    D. Removing excess air and fluid

Answer 33

ANS: D
Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain
positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.

Question 34

34. The nurse is preparing to wean a client from the ventilator. Which assessment
    parameter is most important for the nurse to assess?
    A. Fluid intake for the last 24 hours
    B. Arterial blood gas (ABG) levels
    C. Prior outcomes of weaning
    D. Electrocardiogram (ECG) results

Answer 34

ANS: B
Rationale: Before weaning a client from mechanical ventilation, it is 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 relevant, but 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.

Question 35

35. While assessing the client, the nurse observes constant bubbling in the water-seal
    chamber of the client’s closed chest-drainage system. Which conclusion should the nurse
    reach?
    A. The system is functioning normally.
    B. The client has a pneumothorax.
    C. The system has an air leak.
    D. The chest tube is obstructed.

Answer 35

ANS: C
Rationale: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales.
There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal
chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have
intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

Question 36

36. While caring for a client with an endotracheal tube, the nurse should normally provide
    suctioning how often?
    A. Every 2 hours when the client is awake
    B. When adventitious breath sounds are auscultated
    C. When there is a need to prevent the client from coughing
    D. When the nurse needs to stimulate the cough reflex

Answer 36

ANS: B
Rationale: It is usually necessary to suction the client’s secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when
adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm
and cause trauma to the tracheal mucosa.

Question 37

37. The nurse is discussing activity management with a client who is postoperative
    following thoracotomy. What instructions should the nurse give to the client regarding
    activity immediately following discharge?
    A. Walk 1 mile (1.6 km) 3 to 4 times a week.
    B. Use weights daily to increase arm strength.
    C. Walk on a treadmill 30 minutes daily.
    D. Perform shoulder exercises five times daily.

Answer 37

ANS: D
Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the client on the importance of performing shoulder exercises five times daily. The client should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

Question 38

38. A critical care nurse is caring for a client with an endotracheal tube who is on a
    ventilator. The nurse knows that meticulous airway management of this client is
    necessary. What is the main rationale for this?
    A. Maintaining a patent airway
    B. Preventing the need for suctioning
    C. Maintaining the sterility of the client’s airway
    D. Increasing the client’s lung compliance

Answer 38

ANS: A
Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in
long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning,
to maintain sterility or to increase compliance because none of these are important if the client’s airway is not patent.

Question 39

39. The critical care nurse and the other members of the care team are assessing the
    client to see if the client is ready to be weaned from the ventilator. What are the most
    important predictors of successful weaning that the nurse should identify?
    A. Stable vital signs and arterial blood gases (ABGs)
    B. Pulse oximetry above 80% and stable vital signs
    C. Stable nutritional status and ABGs
    D. Normal level of consciousness

Answer 39

ANS: A
Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional
status is important, but vital signs and ABGs are even more significant. Clients who are weaned may or may not have a normal level of consciousness.

Question 40

40. The OR nurse is setting up a water-seal chest drainage system for a client who has
    just had a thoracotomy. The nurse knows that the amount of suction in the system is
    determined by the water level. At what suction level should the nurse set the system?
    A. 20 cm H2O
    B. 15 cm H2O
    C. 10 cm H2O
    D. 5 cm H2O

Answer 40

ANS: A
Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

Question 41

41. The nurse is preparing to discharge a client after thoracotomy. The client is going
    home on oxygen therapy and requires wound care. As a result, the client will receive
    home care nursing. Which information should the nurse include in discharge teaching for
    this client?
    A. Safe technique for self-suctioning of secretions
    B. Technique for performing postural drainage
    C. Correct and safe use of oxygen therapy equipment
    D. How to provide safe and effective tracheostomy care

Answer 41

ANS: C
Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or intravenous medications) may be continued at home. Therefore, the nurse needs to instruct the client and family in their correct and safe use. The scenario does not indicate the client needs suctioning,
postural drainage, or tracheostomy care.