Hinkle 17

Question 1

1. A client is having the tonsils removed. The client asks the nurse what function the
   tonsils normally serve. Which of the following would be the most accurate response?

A. “The tonsils separate your windpipe from your throat when you swallow.”
B. “The tonsils help to guard the body from invasion of organisms.”
C. “The tonsils make enzymes that you swallow and which aid with digestion.”
D. “The tonsils help with regulating the airflow down into your lungs.”

Answer 1

ANS: B
Rationale: The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These
structures are important links in the chain of lymph nodes guarding the body from
invasion of organisms entering the nose and throat. The tonsils do not aid digestion,
separate the trachea from the esophagus, or regulate airflow to the bronchi.

Question 2

2. The nurse is caring for a client who has just returned to the unit after a colon resection.
   The client is showing signs of hypoxia. The nurse knows that this is probably caused by:

A. nitrogen narcosis.
B. infection.
C. impaired diffusion.
D. shunting.

Answer 2

ANS: D

Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal
surgery and most types of respiratory failure. Impairment of normal diffusion is a less
common cause. Infection would not likely be present at this early stage of recovery, and
nitrogen narcosis only occurs from breathing compressed air.

Question 3

3. The nurse is assessing a client who frequently coughs after eating or drinking. How
   should the nurse best follow up this assessment finding?

A. Obtain a sputum sample.
B. Perform a swallowing assessment.
C. Inspect the client’s tongue and mouth.
D. Assess the client’s nutritional status

Answer 3

ANS: B

Rationale: Coughing after food intake may indicate aspiration of material into the
tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum
sample is relevant in cases of suspected infection. The status of the client’s tongue,
mouth, and nutrition is not directly relevant to the problem of aspiration.

Question 4

4. The ED nurse is assessing a client who is reporting dyspnea. The nurse auscultates the client’s chest and hears wheezing throughout the lung fields. What might this indicate about the client?

A. Bronchoconstriction
B. Pneumonia
C. Hemoptysis
D. Hemothorax

Answer 4

ANS: A

Rationale: Wheezing is a high-pitched, musical sound that is often the major finding in a
client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative
of pneumonia (an infection of the lungs), hemoptysis (the expectoration of blood from
the respiratory tract), or hemothorax (a collection of blood in the space between the
chest wall and the lung).

Question 5

6. The nurse is caring for a client who has returned to the unit following a bronchoscopy.
   The client is asking for something to drink. Which criterion will determine when the nurse
   should allow the client to drink fluids?

A. Presence of a cough and gag reflex
B. Absence of nausea
C. Ability to demonstrate deep inspiration
D. Oxygen saturation of greater than or equal to92%

Answer 5

ANS: A

Rationale: After the procedure, it is important that the client takes nothing by mouth until
the cough reflex returns because the preoperative sedation and local anesthesia impair
the protective laryngeal reflex and swallowing for several hours. Deep inspiration,
adequate oxygen saturation levels, and absence of nausea do not indicate that oral
intake is safe from the risk of aspiration.

Question 6

5. The nurse is caring for a client admitted with an acute exacerbation of chronic
   obstructive pulmonary disease. During assessment, the nurse finds that the client is
   experiencing increased dyspnea. What is the most accurate measurement of the
   concentration of oxygen in the client’s blood?

A. A capillary blood sample
B. Pulse oximetry
C. An arterial blood gas (ABG) study
D. A complete blood count (CBC)

Answer 6

ANS: C

Rationale: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of
oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or
PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the
ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability
of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate
as an ABG. Pulse oximetry is a useful clinical tool, but does not replace ABG measurement
because it is not as accurate. A CBC does not indicate the concentration of oxygen.

Question 7

7. A client with chronic lung disease is undergoing lung function testing. What test result
   denotes the volume of air inspired and expired with a normal breath?

A. Total lung capacity
B. Forced vital capacity
C. Tidal volume
D. Residual volume

Answer 7

ANS: C

Rationale: Tidal volume refers to the volume of air inspired and expired with a normal
breath. Total lung capacity is the maximal amount of air the lungs and respiratory
passages can hold after a forced inspiration. Forced vital capacity is vital capacity
performed with a maximally forced expiration. Residual volume is the maximal amount of
air left in the lung after a maximal expiration.

Question 8

8. In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse
   needs to assess a client’s arterial oxygen saturation (SaO2). What procedure will best
   accomplish this?

A. Incentive spirometry
B. Arterial blood gas (ABG) measurement
C. Peak flow measurement
D. Pulse oximetry

Answer 8

ANS: D

Rationale: Pulse oximetry is a noninvasive procedure in which a small sensor is
positioned over a pulsating vascular bed. It can be used during transport and causes the
client no discomfort. An incentive spirometer is used to assist the client with deep
breathing after surgery. ABG measurement can measure SaO2, but this is an invasive
procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air.

Question 9

9. A client asks the nurse why an infection in the upper respiratory system is affecting the
   clarity of the client’s speech. The nurse should describe the role of what structure?

A. Trachea
B. Pharynx
C. Paranasal sinuses
D. Larynx

Answer 9

ANS: C

Rationale: A prominent function of the sinuses is to serve as a resonating chamber in
speech. The trachea, also known as the windpipe, serves as the passage between the
larynx and the bronchi. The pharynx is a tube-like structure that connects the nasal and
oral cavities to the larynx. The pharynx also functions as a passage for the respiratory
and digestive tracts. The major function of the larynx is vocalization through the function
of the vocal cords. The vocal cords are ligaments controlled by muscular movements that
produce sound

Question 10

10. A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position?

A. Review images from the client’s portable chest x-ray.
B. Turn the client to enable assessment of all lung fields.
C. Assess the breath sounds accessible from the anterior chest wall.
D. Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.

Answer 10

ANS: B

Rationale: Assessment of the anterior and posterior lung fields is part of the nurse’s
routine evaluation. If the client is recumbent, it is essential to turn the client to assess all
lung fields so that dependent areas can be assessed for breath sounds, including the
presence of normal breath sounds and adventitious sounds. Failure to examine the
dependent areas of the lungs can result in missing significant findings. A chest x-ray does
not allow assessment of breath sounds. Assessment of only breath sounds accessible
from the anterior chest wall neglects breath sounds that can only be assessed in other
lung fields. All lung fields need to be assessed whether oxygen saturation is low or not.

Question 11

11. A client is undergoing testing to assess for a pleural effusion. Which of the nurse’s
    respiratory assessment findings would be most consistent with this diagnosis?

A. Increased tactile fremitus, egophony, and the chest wall dull on percussion
B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on
percussion
C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant
on percussion

Answer 11

ANS: C

Rationale: Assessment findings consistent with a pleural effusion include affected lung
fields being dull to percussion and absence of breath sounds. A pleural friction rub may
also be present. The other listed signs are not typically associated with a pleural effusion.

Question 12

12. The nurse doing rounds at the beginning of a shift notices a sputum specimen in a
    container sitting on the bedside table in a client’s room. The nurse asks when the client
    produced the sputum specimen, and the client states that the specimen is about 4 hours
    old. What action should the nurse take?

A. Immediately take the sputum specimen to the laboratory.
B. Discard the specimen and assist the client in obtaining another specimen.
C. Refrigerate the sputum specimen and submit it once it is chilled.
D. Add a small amount of normal saline to moisten the specimen.

Answer 12

ANS: B

Rationale: Sputum samples should be submitted to the laboratory as soon as possible.
Allowing the specimen to stand for several hours in a warm room results in the
overgrowth of contaminated organisms and may make it difficult to identify the
pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal
saline are not appropriate actions.

Question 13

15. A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive.
    The client has developed a fever and cough, so a sputum specimen has been obtained.
    The nurse notes that the sputum is greenish and that there is a large quantity of it. The
    nurse notifies the client’s health care provider because these symptoms are suggestive of
    what issue?

A. Pneumothorax
B. Lung tumors
C. Infection
D. Pulmonary edema

Answer 13

ANS: C

Rationale: The nature of the sputum is often indicative of its cause. A profuse amount of
purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the
sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a
lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate
pulmonary edema. A pneumothorax does not result in copious, green sputum.

Question 14

13. The nurse is assessing a newly admitted medical client and notes there is a
    depression in the lower portion of the client’s sternum. This client’s health record should
    note the presence of what chest deformity?

A. A barrel chest
B. A funnel chest
C. A pigeon chest
D. Kyphoscoliosis

Answer 14

ANS: B

Rationale: A funnel chest occurs when there is a depression in the lower portion of the
sternum, and this may lead to compression of the heart and great vessels, resulting in
murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter
of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result
of displacement of the sternum and includes an increase in the anteroposterior diameter.
Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding
S-shaped spine, limits lung expansion within the thorax.

Question 15

14. The medical nurse who works on a pulmonology unit is aware that several respiratory
    conditions can affect lung tissue compliance. The presence of what condition would lead
    to an increase in lung compliance?

A. Emphysema
B. Pulmonary fibrosis
C. Pleural effusion
D. Acute respiratory distress syndrome (ARDS)

Answer 15

ANS: A

Rationale: High or increased compliance occurs if the lungs have lost their elasticity and
the thorax is overdistended, such as in emphysema. Conditions associated with
decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary
edema, atelectasis, pulmonary fibrosis, and ARDS.

Question 16

16. A client has been diagnosed with heart failure that has not yet responded to
    treatment. What breath sound should the nurse expect to assess on auscultation?

A. Expiratory wheezes
B. Inspiratory wheezes
C. Rhonchi
D. Crackles

Answer 16

ANS: D

Rationale: Crackles reflect underlying inflammation or congestion and are often present
in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and
wheezes are associated with airway obstruction, which is not a part of the
pathophysiology of heart failure.

Question 17

17. A client has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular
    disorders such as multiple sclerosis may lead to a decreased vital capacity. What does
    vital capacity measure?

A. The volume of air inhaled and exhaled with each breath
B. The volume of air in the lungs after a maximal inspiration
C. The maximal volume of air inhaled after normal expiration
D. The maximal volume of air exhaled from the point of maximal inspiration

Answer 17

ANS: D

Rationale: Vital capacity is measured by having the client take in a maximal breath and
exhale fully through a spirometer. Vital lung capacity is the maximal volume of air
exhaled from the point of maximal inspiration, and neuromuscular disorders such as
multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the
volume of air inhaled and exhaled with each breath. The volume of air in the lungs after
a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal
volume of air inhaled after normal expiration.

Question 18

19. The nurse is caring for an older client in the PACU. The client has had a bronchoscopy,
    and the nurse is monitoring for complications related to the administration of topical
    lidocaine. For what complication related to the administration of large doses of topical
    lidocaine in older adults should the nurse assess?

A. Decreased urine output and hypertension
B. Headache and vision changes
C. Confusion and lethargy
D. Jaundice and elevated liver enzymes

Answer 18

ANS: C

Rationale: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and
vocal cords and into the trachea to suppress the cough reflex and minimize discomfort
during a bronchoscopy. After the procedure, the nurse will assess for confusion and
lethargy in an older adult, which may be due to the large doses of lidocaine given during
the procedure. The other listed signs and symptoms are not specific to this problem.

Question 18

18. While assessing an acutely ill client’s respiratory rate, the nurse assesses four normal
    breaths followed by an episode of apnea lasting 20 seconds. How should the nurse
    document this finding?

A. Eupnea
B. Apnea
C. Biot respiration
D. Cheyne-Stokes

Answer 18

ANS: C

Rationale: The nurse will document that the client is demonstrating a Biot respiration
pattern. Biot respiration is characterized by periods of normal breathing (three to four
breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute).
Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the
rate and depth of breathing increase and then decrease until apnea occurs. Biot
respiration is not characterized by the increase and decrease in the rate and depth, as
characterized by Cheyne–Stokes. Eupnea is a normal breathing pattern of 12 to 18
breaths per minute.

Question 19

20. While assessing a client who has pneumonia, the nurse has the client repeat the letter
    E while the nurse auscultates. The nurse notes that the client’s voice sounds are distorted
    and that the letter A is audible instead of the letter E. How should this finding be
    documented?

A. Bronchophony
B. Egophony
C. Whispered pectoriloquy
D. Sonorous wheezes

Answer 19

ANS: B

Rationale: This finding would be documented as egophony, which can be best assessed
by instructing the client to repeat the letter E. The distortion produced by consolidation
transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal
resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very
subtle finding that is heard only in the presence of rather dense consolidation of the
lungs. Sound is so enhanced by the consolidated tissue that even whispered words are
heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.

Question 20

21. The clinic nurse is caring for a client who has been diagnosed with emphysema and
    who has just had a pulmonary function test (PFT) ordered. The client asks, “What exactly
    is this test for?” What would be the nurse’s best response?

A. “A PFT measures how much air moves in and out of your lungs when you
breathe.”
B. “A PFT measures how much energy you get from the oxygen you breathe.”
C. “A PFT measures how elastic your lungs are.”
D. “A PFT measures whether oxygen and carbon dioxide move between your lungs
and your blood.”

Answer 20

ANS: A

Rationale: PFTs are routinely used in clients with chronic respiratory disorders. They are
performed to assess respiratory function and to determine the extent of dysfunction.
Such tests include measurements of lung volumes, ventilatory function, and the
mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can
often be implied from PFTs, but they are not directly assessed. Energy obtained from
respiration is not measured directly.

Question 21

22. A client is being treated for a pulmonary embolism, and the medical nurse is aware
    that the client experienced an acute disturbance in pulmonary perfusion. This involved an
    alteration in which aspect of normal physiology?

A. Maintenance of constant osmotic pressure in the alveoli
B. Maintenance of muscle tone in the diaphragm
C. pH balance in the pulmonary veins and arteries
D. Adequate flow of blood through the pulmonary circulation

Answer 21

ANS: D

Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary
circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic
pressure.

Question 22

23. The nurse is performing a respiratory assessment of an adult client and is
    distinguishing between vesicular, bronchovesicular, and bronchial (tubular) breath
    sounds. How should the nurse distinguish between these normal breath sounds?

A. Their location over a specific area of the lung
B. The volume of the sounds
C. Whether they are heard on inspiration or expiration
D. Whether or not they are continuous breath sounds

Answer 22

ANS: A

Rationale: Normal breath sounds are distinguished by their location over a specific area
of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular)
breath sounds. Breath sounds are not distinguished solely on the basis of volume. Normal
breath sounds are heard on both inspiration and expiration, and are continuous.

Question 23

24. A client has been diagnosed with pulmonary hypertension, in which the capillaries in
    the alveoli are squeezed excessively. The nurse should recognize a disturbance in what
    aspect of normal respiratory function?

A. Acid–base balance
B. Perfusion
C. Diffusion
D. Ventilation

Answer 23

ANS: B

Rationale: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are
sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the
capillaries are squeezed. This does not constitute a disturbance in ventilation (air
movement), diffusion (gas exchange), or acid–base balance.

Question 24

25. A client is scheduled to have excess pleural fluid aspirated with a needle to relieve
    dyspnea. The client inquires about the normal function of pleural fluid. What should the
    nurse describe?

A. It allows for full expansion of the lungs within the thoracic cavity.
B. It prevents the lungs from collapsing within the thoracic cavity.
C. It limits lung expansion within the thoracic cavity.
D. It lubricates the movement of the thorax and lungs.

Answer 24

ANS: D

Rationale: The pleural fluid, located between two membranes known as the visceral
pleura (which cover the lungs) and the parietal pleura (which line the thorax), serves to
lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic
cavity with each breath. The pleural fluid does not allow full expansion of the lungs,
prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.

Question 25

26. The nurse is caring for a client with a lower respiratory tract infection. When planning
    a focused respiratory assessment, the nurse should know that this type of infection most
    often causes which type of impairment?

A. Impaired gas exchange
B. Collapsed bronchial structures
C. Necrosis of the alveoli
D. Closed bronchial tree

Answer 25

ANS: A

Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial
and alveolar structures needed for gas exchange. A lower respiratory tract infection does
not collapse bronchial structures or close the bronchial tree. An infection does not cause
necrosis of lung tissues.

Question 26

27. The nurse is performing a respiratory assessment of a client who has been
    experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable
    to impaired gas exchange. On what factor does adequate gas exchange primarily
    depend?

A. An appropriate perfusion–diffusion ratio
B. An adequate ventilation–perfusion ratio
C. Adequate diffusion of gas in shunted blood
D. Appropriate blood nitrogen concentration

Answer 26

ANS: B

Rationale: Adequate gas exchange depends on an adequate ventilation–perfusion ratio.
There is no perfusion–diffusion ratio. Adequate gas exchange does not depend on the
diffusion of gas in shunted blood or a particular concentration of nitrogen.

Question 27

28. The nurse is caring for a client with lung metastases who just underwent a
    mediastinotomy. What is the nurse’s priority postprocedure care?

A. Assisting with pulmonary function testing (PFT)
B. Maintaining the client’s chest tube
C. Administering oral suction as needed
D. Performing chest physiotherapy

Answer 27

ANS: B

Rationale: Chest tube drainage is required after mediastinotomy. PFT may be needed,
but it would be a lower priority than maintaining the chest tube. The client would need
chest tube drainage after a mediastinotomy, not oral suctioning. Given that the client is
healing from the incision made during the procedure, chest physiotherapy would be
inappropriate at this time.

Question 28

29. The nurse is caring for a client who has a pleural effusion and who underwent a
    thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment
    for which of the following?

A. Sputum production
B. Shortness of breath
C. Throat discomfort
D. Epistaxis

Answer 28

ANS: B

Rationale: Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined
with an endoscope and fluid and tissues can be obtained for analysis. Follow-up care in
the health care facility and at home involves monitoring the client for shortness of breath
(which might indicate a pneumothorax). All of the listed options are relevant assessment
findings, but shortness of breath is the most serious complication.

Question 29

30. A gerontologic nurse is analyzing the data from a client’s focused respiratory
    assessment. The nurse is aware that the amount of respiratory dead space increases with
    age. What is the effect of this physiologic change?

A. Increased diffusion of gases
B. Decreased diffusion capacity for oxygen
C. Decreased shunting of blood
D. Increased ventilation

Answer 29

ANS: B

Rationale: The amount of respiratory dead space increases with age. Combined with
other changes, this results in a decreased diffusion capacity for oxygen with increasing
age, producing lower oxygen levels in the arterial circulation. Decreased shunting and
increased ventilation do not occur with age.

Question 30

31. The nurse is assessing the respiratory status of a client who is experiencing an
    exacerbation of emphysema symptoms. When preparing to auscultate, what breath
    sounds should the nurse anticipate?

A. Rhonchi during expiration
B. Wheezing with discontinuous breath sounds
C. Faint breath sounds with prolonged expiration
D. Faint breath sounds with fine crackles

Answer 30

ANS: C

Rationale: The breath sounds of the client with emphysema are faint or often completely
inaudible. When they are heard, the expiratory phase is prolonged. Fine crackles are soft,
high-pitched, discontinuous popping sounds heard in mid to late inspiration that are
associated with interstitial pneumonia, restrictive pulmonary disease, or bronchitis.
Wheezing is a continuous, musical, high-pitched, shrill sound associated with chronic
bronchitis or bronchiectasis. Rhonchi are deep, lower-pitched rumbling sounds, with a
snoring quality, that are associated with secretions or a tumor.

Question 31

32. The client has just had an MRI ordered because a routine chest x-ray showed
    suspicious areas in the right lung. The health care provider suspects bronchogenic
    carcinoma. An MRI would most likely assess for which condition in this client?

A. Alveolar dysfunction
B. Forced vital capacity
C. Tidal volume
D. Chest wall invasion

Answer 31

ANS: D

Rationale: MRI is used to characterize pulmonary nodules; to help stage bronchogenic
carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in
interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary
hypertension. Imaging would not focus on the alveoli (as would be the case in alveolar
dysfunction) because the problem is in the bronchi. A static image such as MRI cannot
inform pulmonary function tests.

Question 32

33. A sputum study has been ordered for a client who has developed coarse chest
    crackles and a fever. At what time would it be best for the nurse to collect the sample?

A. Immediately after a meal
B. First thing in the morning
C. At bedtime
D. After a period of exercise

Answer 32

ANS: B

Rationale: Sputum samples ideally are obtained early in the morning before the client has
had anything to eat or drink.

Question 33

34. The ED nurse is assessing the respiratory function of a client who presented with
    acute shortness of breath. Auscultation reveals continuous wheezes during inspiration
    and expiration. This finding is most suggestive of what condition?

A. Pleurisy
B. Emphysema
C. Asthma
D. Pneumonia

Answer 33

ANS: C

Rationale: Wheezes are commonly associated with asthma. They do not normally
accompany pleurisy, emphysema, or pneumonia.

Question 34

36. A client currently has normal hemoglobin levels, but significantly decreased SaO2 and
    PaO2 levels. What is an implication of this physiologic state?

A. The client’s tissue demands may be met, but the client will be unable to respond
to physiological stressors.
B. The client’s short-term oxygen needs will be met, but the client will be unable to
expel sufficient CO2.
C. The client will experience tissue hypoxia with no sensation of shortness of breath
or labored breathing.
D. The client will experience respiratory alkalosis with no ability to compensate.

Answer 34

ANS: A

Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg
(SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for
physiologic stresses that increase tissue oxygen demand. If a serious incident occurs
(e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the
intake of oxygen from the lungs, tissue hypoxia results

Question 35

35. The nurse is caring for a client who has been scheduled for a bronchoscopy. How
    should the nurse prepare the client for this procedure?

A. Administer a bolus of IV fluids.
B. Arrange for the insertion of a peripherally inserted central catheter.
C. Administer nebulized bronchodilators every 2 hours until the test.
D. Withhold food and fluids for several hours before the test

Answer 35

ANS: D

Rationale: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk
of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators,
and a central line are unnecessary

Question 36

37. A medical client rings the call bell and expresses alarm to the nurse, stating, “I’ve just
    coughed up this blood. That can’t be good, can it?” How can the nurse best determine
    whether the source of the blood was the client’s lungs?

A. Obtain a sample and test the pH of the blood, if possible.
B. Try to see if the blood is frothy or mixed with mucus.
C. Perform oral suctioning to see if blood is obtained.
D. Swab the back of the client’s throat to see if blood is present.

Answer 36

ANS: B

Rationale: Though not definitive, blood from the lung is usually bright red, frothy, and
mixed with sputum. Testing the pH of nonarterial blood samples is not common practice
and would not provide important data. Similarly, oral suctioning and swabbing the client’s
mouth would not reveal the source.

Question 37

38. The nurse is completing a client’s health history with regard to potential risk factors
    for lung disease. What interview question addresses the most significant risk factor for
    respiratory diseases?

A. “Have you ever been employed in a factory, smelter, or mill?”
B. “Does anyone in your family have any form of lung disease?”
C. “Do you currently smoke, or have you ever smoked?”
D. “Have you ever lived in an area that has high levels of air pollution?”

Answer 37

ANS: C

Rationale: Smoking is the single most important contributor to lung disease, exceeding
the significance of environmental, occupational, and genetic factors.

Question 38

39. A client on the medical unit reports experiencing significant dyspnea, despite not
    having recently performed any physical activity. What assessment question should the
    nurse ask the client while preparing to perform a physical assessment?

A. “On a scale from 0 to 10, how bad would you rate your shortness of breath?”
B. “When was the last time you ate or drank anything?”
C. “Are you feeling any nausea along with your shortness of breath?”
D. “Do you think that some medication might help you catch your breath?”

Answer 38

ANS: A

Rationale: Gauging the severity of the client’s dyspnea is an important part of the nursing
process. Oral intake and nausea are much less important considerations. The nurse must
perform assessment prior to interventions such as providing medication.

Question 39

40. The nurse has assessed a client’s family history for three generations. The presence
    of which respiratory disease would justify this type of assessment?

A. Asthma
B. Obstructive sleep apnea
C. Community-acquired pneumonia
D. Pulmonary edema

Answer 39

ANS: A

Rationale: Asthma is a respiratory illness that has genetic factors. Sleep apnea,
pneumonia, and pulmonary edema lack genetic risk factors.