Lecture 2: Respiratory Flashcards
A patient presents with progressive dyspnea and decreased breath sounds on the left side. A chest X-ray confirms a pleural effusion. Which clinical finding supports the diagnosis?
A) Hyperresonance on percussion
B) Increased tactile fremitus
C) Dullness on percussion
D) Tracheal deviation toward the affected side
C) Dullness on percussion
Explanation:
Correct Answer: Pleural effusion causes fluid accumulation, resulting in dullness on percussion over the affected area.
Incorrect Options:
A) Hyperresonance is seen with air accumulation, such as in pneumothorax.
B) Tactile fremitus decreases in pleural effusion because fluid dampens vibrations.
D) Tracheal deviation is more characteristic of tension pneumothorax or significant effusions under pressure.
Which pleural effusion type is associated with a clear fluid resulting from increased hydrostatic pressure or decreased oncotic pressure?
A) Transudative
B) Exudative
C) Empyema
D) Chylothorax
A) Transudative
Explanation:
Correct Answer: Transudative effusions result from non-inflammatory causes like congestive heart failure or liver disease, leading to clear fluid accumulation.
Incorrect Options:
B) Exudative effusions are inflammatory and have high protein and LDH.
C) Empyema involves infectious pus accumulation.
D) Chylothorax has lymphatic fluid, which is milky and high in lipids.
The nurse prepares a patient for a thoracentesis. Which position is most appropriate?
A) Supine with head elevated at 45 degrees
B) Prone with arms at the side
C) Sitting upright, leaning forward on a bedside table
D) Side-lying with the affected side up
C) Sitting upright, leaning forward on a bedside table
Explanation:
Correct Answer: This position optimally exposes the posterior lung bases for fluid removal.
Incorrect Options:
A, B, and D) These positions do not provide the same access to pleural fluid
A patient with a history of COPD presents with dyspnea and hyperresonance on percussion. The nurse suspects:
A) Pleural effusion
B) Pneumothorax
C) Pulmonary embolism
D) Hemothorax
B) Pneumothorax
Explanation:
Correct Answer: Pneumothorax is air in the pleural space, causing hyperresonance.
Incorrect Options:
A and D) These cause dullness, not hyperresonance.
C) Pulmonary embolism does not typically alter percussion tones.
The nurse assesses a patient post-thoracentesis. Which finding requires immediate action?
A) BP 110/70 mmHg
B) Oxygen saturation 92%
C) Sudden onset of hypoxemia
D) Pain at the procedure site
C) Sudden onset of hypoxemia
Explanation:
Correct Answer: Hypoxemia may indicate complications like pneumothorax or pulmonary edema.
Incorrect Options:
A and B) These are expected findings.
D) Mild pain is common but not immediately concerning.
Which condition is a medical emergency due to rapid air accumulation and mediastinal shift?
A) Open pneumothorax
B) Tension pneumothorax
C) Chylothorax
D) Hemothorax
B) Tension pneumothorax
Explanation:
Correct Answer: Tension pneumothorax can compress the heart and great vessels, impairing circulation.
Incorrect Options:
A, C, and D) These do not involve the rapid, life-threatening shift of mediastinal structures.
Which finding is most concerning in a patient with chest trauma?
A) Mild tachycardia
B) Diminished breath sounds
C) Tracheal deviation
D) Hyperresonance on percussion
C) Tracheal deviation
Explanation:
Correct Answer: Tracheal deviation signals severe tension pneumothorax requiring immediate intervention.
Incorrect Options:
A, B, and D) These are concerning but not as critical as tracheal deviation.
A patient presents with progressive dyspnea and decreased breath sounds on the left side. A chest X-ray confirms a pleural effusion. Which clinical finding supports the diagnosis?
A) Hyperresonance on percussion
B) Increased tactile fremitus
C) Dullness on percussion
D) Tracheal deviation toward the affected side
C) Dullness on percussion
Explanation:
Correct Answer: Pleural effusion causes fluid accumulation, leading to dullness on percussion.
Incorrect Options:
A) Hyperresonance is seen in pneumothorax due to air accumulation.
B) Tactile fremitus decreases because fluid dampens vibrations.
D) Tracheal deviation is more characteristic of tension pneumothorax or large effusions.
A patient diagnosed with empyema is likely to exhibit which clinical manifestations?
A) Clear pleural fluid and hyperresonance
B) Fever, night sweats, and purulent pleural fluid
C) Milky pleural fluid and shortness of breath
D) High protein pleural fluid and cyanosis
B) Fever, night sweats, and purulent pleural fluid
Explanation:
Correct Answer: Empyema involves an infectious process, leading to fever, night sweats, and pus in the pleural space.
Incorrect Options:
A) Empyema fluid is purulent, not clear.
C) Milky pleural fluid is characteristic of chylothorax.
D) While empyema fluid is high in protein, cyanosis is not a hallmark sign.
The nurse prepares a patient for a thoracentesis. Which position is most appropriate?
A) Supine with head elevated at 45 degrees
B) Prone with arms at the side
C) Sitting upright, leaning forward on a bedside table
D) Side-lying with the affected side up
C) Sitting upright, leaning forward on a bedside table
Explanation:
Correct Answer: This position optimally exposes the posterior lung bases for fluid removal.
Incorrect Options:
A, B, and D) These positions do not provide access to pleural fluid efficiently.
Which type of pleural effusion is caused by inflammation and has straw-colored fluid?
A) Transudative
B) Exudative
C) Empyema
D) Chylothorax
B) Exudative
Explanation:
Correct Answer: Exudative effusions result from inflammation and contain straw-colored fluid, high in protein and LDH.
Incorrect Options:
A) Transudative effusions are clear and caused by non-inflammatory conditions.
C) Empyema involves purulent fluid.
D) Chylothorax fluid is milky.
Which assessment finding is consistent with a pneumothorax?
A) Dullness on percussion
B) Increased tactile fremitus
C) Hyperresonance on percussion
D) Bilateral breath sounds
C) Hyperresonance on percussion
Explanation:
Correct Answer: Pneumothorax involves air in the pleural space, leading to hyperresonance.
Incorrect Options:
A) Pneumothorax causes hyperresonance, not dullness.
B) Tactile fremitus is decreased due to air blocking vibrations.
D) Breath sounds are diminished or absent on the affected side.
A patient with a tension pneumothorax exhibits which hallmark sign?
A) Hypotension and tracheal deviation
B) Clear pleural fluid and decreased breath sounds
C) Fever and dullness to percussion
D) Cyanosis and bilateral lung sounds
A) Hypotension and tracheal deviation
Explanation:
Correct Answer: Tension pneumothorax causes increased intrapleural pressure, leading to hypotension and tracheal deviation.
Incorrect Options:
B) Decreased breath sounds are present, but not clear fluid.
C) Fever and dullness indicate an effusion or empyema.
D) Bilateral breath sounds are not present in pneumothorax.
Which intervention is most appropriate for an open pneumothorax?
A) Apply an occlusive dressing taped on all sides
B) Insert a needle for decompression
C) Stabilize the object in place with a bulky dressing
D) Perform a thoracotomy
C) Stabilize the object in place with a bulky dressing
Explanation:
Correct Answer: Stabilizing the object prevents further air entry and lung collapse.
Incorrect Options:
A) Dressings for open pneumothorax should only be taped on three sides.
B and D) These are not the first interventions for open pneumothorax.
The nurse is caring for a patient with a hemothorax. Which clinical manifestation is expected?
A) Hyperresonance on percussion
B) Decreased breath sounds on the affected side
C) Clear pleural fluid on thoracentesis
D) Tracheal deviation away from the affected side
B) Decreased breath sounds on the affected side
Explanation:
Correct Answer: Blood accumulation limits lung expansion, reducing breath sounds.
Incorrect Options:
A) Hemothorax causes dullness, not hyperresonance.
C) Hemothorax involves blood, not clear fluid.
D) Tracheal deviation occurs in tension pneumothorax.
What is the purpose of the water-seal chamber in a chest drainage system?
A) Collect fluid from the pleural space
B) Monitor suction applied to the chest tube
C) Prevent air from entering the pleural space
D) Regulate fluid drainage from the chest
C) Prevent air from entering the pleural space
Explanation:
Correct Answer: The water-seal chamber acts as a one-way valve, allowing air to exit but not re-enter.
Incorrect Options:
A, B, and D) These describe other components of the chest drainage system.
Which complication can occur during thoracentesis if more than 1.2 liters of fluid is removed?
A) Pulmonary embolism
B) Pulmonary edema
C) Hypovolemia
D) Tension pneumothorax
B) Pulmonary edema
Explanation:
Correct Answer: Removing large amounts of fluid rapidly can cause a shift in intrapleural pressure, leading to pulmonary edema.
Incorrect Options:
A, C, and D) These are not directly associated with fluid removal during thoracentesis.
Which intervention is priority for a patient with flail chest?
A) Place the patient in a supine position
B) Administer humidified oxygen
C) Perform needle decompression
D) Apply a chest binder
B) Administer humidified oxygen
Explanation:
Correct Answer: Flail chest compromises oxygenation, making oxygen administration critical.
Incorrect Options:
A, C, and D) These are not immediate priorities for flail chest.
Which chest tube complication requires immediate intervention?
A) Continuous bubbling in the suction chamber
B) Tidaling in the water-seal chamber
C) Disconnection of the chest tube from the system
D) Fluid drainage of 50 mL/hour
C) Disconnection of the chest tube from the system
Explanation:
Correct Answer: Disconnection risks air re-entry into the pleural space, causing lung collapse.
Incorrect Options:
A and B) These are expected findings.
D) This drainage amount is within normal limits.
Which type of pneumothorax is caused by ruptured blebs?
A) Open
B) Closed
C) Tension
D) Hemothorax
B) Closed
Explanation:
Correct Answer: Closed pneumothorax can occur from spontaneous bleb rupture without external injury.
Incorrect Options:
A) Open pneumothorax involves an external chest wall injury.
C) Tension pneumothorax involves rapid air accumulation.
D) Hemothorax involves blood in the pleural space.
What should the nurse do if a patient with a chest tube reports severe respiratory distress?
A) Clamp the chest tube immediately
B) Notify the healthcare provider
C) Remove the chest tube and apply a sterile dressing
D) Assess for dislodgement or blockage
D) Assess for dislodgement or blockage
Explanation:
Correct Answer: Dislodgement or blockage can cause respiratory distress and must be corrected.
Incorrect Options:
A and C) Clamping or removing the tube can worsen the situation.
B) While notifying the provider is important, assessment is the priority.
A patient with a chylothorax asks about the fluid appearance. The nurse responds:
A) “It will be clear and odorless.”
B) “It is milky and contains lipids.”
C) “It will be yellow and straw-colored.”
D) “It contains blood and is thick.”
B) “It is milky and contains lipids.”
Explanation:
Correct Answer: Chylothorax fluid is milky due to its high lipid content.
Incorrect Options:
A) Clear fluid is seen in transudative effusions.
C) Straw-colored fluid is characteristic of exudative effusions.
D) Bloody, thick fluid is seen in hemothorax or empyema.
A patient presents with pleuritic chest pain that worsens with inspiration, progressive dyspnea, and dullness on percussion. Which intervention should the nurse prioritize?
A) Administer antibiotics as prescribed
B) Position the patient in high Fowler’s position
C) Perform chest physiotherapy
D) Administer bronchodilators as prescribed
B) Position the patient in high Fowler’s position
Explanation:
Correct Answer: High Fowler’s position improves lung expansion and eases breathing.
Incorrect Options:
A) Antibiotics are helpful for infections but are not the priority for immediate relief.
C) Chest physiotherapy is contraindicated in pleural effusion.
D) Bronchodilators are not the treatment for fluid accumulation.
Which finding is most consistent with a diagnosis of empyema?
A) Straw-colored pleural fluid
B) Milky, lipid-rich pleural fluid
C) Purulent pleural fluid with fever and weight loss
D) Clear pleural fluid with no significant cells
C) Purulent pleural fluid with fever and weight loss
Explanation:
Correct Answer: Empyema is an infectious pleural effusion, characterized by purulent fluid and systemic signs of infection.
Incorrect Options:
A and D) Straw-colored and clear fluids are associated with exudative and transudative effusions, respectively.
B) Milky fluid indicates chylothorax.
A patient with a closed pneumothorax asks how this condition occurs. What is the best response by the nurse?
A) “It occurs when air enters through a chest wound.”
B) “It happens due to air leaking from damaged alveoli.”
C) “It is caused by blood collecting in the pleural space.”
D) “It occurs when the pleura fills with lymphatic fluid.”
B) “It happens due to air leaking from damaged alveoli.”
Explanation:
Correct Answer: Closed pneumothorax is commonly caused by ruptured blebs or alveoli, leading to air leaking into the pleural space.
Incorrect Options:
A) Describes open pneumothorax.
C) Describes hemothorax.
D) Describes chylothorax.
A nurse is monitoring a patient with a chest tube. Which observation requires immediate intervention?
A) Tidaling in the water-seal chamber
B) Continuous bubbling in the water-seal chamber
C) Drainage of 100 mL/hour
D) Absence of drainage for 4 hours
B) Continuous bubbling in the water-seal chamber
Explanation:
Correct Answer: Continuous bubbling in the water-seal chamber indicates an air leak and requires intervention.
Incorrect Options:
A) Tidaling is an expected finding.
C and D) These findings depend on the patient’s clinical condition and may not indicate a problem.
Which nursing intervention is priority for a patient with flail chest?
A) Apply a chest binder
B) Perform chest physiotherapy
C) Administer humidified oxygen
D) Prepare for thoracentesis
C) Administer humidified oxygen
Explanation:
Correct Answer: Humidified oxygen optimizes oxygenation, which is critical in flail chest.
Incorrect Options:
A and B) These are not appropriate interventions for flail chest.
D) Thoracentesis is not indicated in flail chest.
The nurse is preparing a patient for a thoracentesis. Which teaching is most appropriate?
A) “You will be lying flat during the procedure.”
B) “The fluid removal may cause immediate relief of breathing difficulty.”
C) “This procedure is done under general anesthesia.”
D) “You may eat a full meal before the procedure.”
B) “The fluid removal may cause immediate relief of breathing difficulty.”
Explanation:
Correct Answer: Removing fluid relieves lung compression and improves breathing.
Incorrect Options:
A) The patient is positioned upright, leaning forward.
C) Local anesthesia is used.
D) Fasting may be required before the procedure.
A patient is admitted with a chylothorax. What intervention is most likely included in the treatment plan?
A) Administer antibiotics
B) Provide a low-fat diet
C) Perform needle decompression
D) Insert a subclavian catheter
B) Provide a low-fat diet
Explanation:
Correct Answer: A low-fat diet reduces lymphatic flow and supports treatment.
Incorrect Options:
A) Antibiotics are unnecessary for non-infectious chylothorax.
C and D) These are not primary treatments for chylothorax.
What is the primary reason for administering oxygen in a tension pneumothorax?
A) Prevent tracheal deviation
B) Increase oxygen delivery to tissues
C) Treat the underlying air leak
D) Reduce anxiety and dyspnea
B) Increase oxygen delivery to tissues
Explanation:
Correct Answer: Oxygen improves tissue perfusion compromised by decreased cardiac output.
Incorrect Options:
A and C) Oxygen does not address these issues.
D) Although it may help with dyspnea, the priority is tissue oxygenation.
Which finding suggests a complication after a thoracentesis?
A) Oxygen saturation of 98%
B) Diminished breath sounds on the affected side
C) Chest pain and rapid breathing
D) Small amounts of straw-colored drainage
C) Chest pain and rapid breathing
Explanation:
Correct Answer: Chest pain and rapid breathing may indicate pneumothorax or pleural injury.
Incorrect Options:
A, B, and D) These are expected findings post-procedure.
A nurse is caring for a patient with an open pneumothorax. What is the priority intervention?
A) Remove the object causing the wound
B) Cover the wound with a three-sided dressing
C) Perform CPR
D) Insert a chest tube immediately
B) Cover the wound with a three-sided dressing
Explanation:
Correct Answer: A three-sided dressing allows air to escape while preventing air re-entry.
Incorrect Options:
A) Removing the object may worsen the injury.
C and D) These are not immediate interventions for an open pneumothorax.
A patient with a diagnosis of pleural effusion reports sharp, localized chest pain that worsens with deep breathing. What is the nurse’s priority intervention?
A) Administer prescribed antibiotics
B) Position the patient leaning forward
C) Encourage incentive spirometry use
D) Prepare for thoracentesis
D) Prepare for thoracentesis
Explanation:
Correct Answer: Thoracentesis directly addresses the fluid causing the pleural effusion and relieves symptoms.
Incorrect Options:
A) Antibiotics are used for infectious causes but do not address immediate symptoms.
B) Positioning can help but is not definitive management.
C) Incentive spirometry may not be effective in the presence of significant fluid accumulation.
Which clinical finding is most indicative of a tension pneumothorax?
A) Bilateral diminished breath sounds
B) Tracheal deviation toward the unaffected side
C) Hyperresonance over the lung bases
D) Pleural friction rub
B) Tracheal deviation toward the unaffected side
Explanation:
Correct Answer: Tension pneumothorax creates increased intrathoracic pressure, causing a mediastinal shift and tracheal deviation.
Incorrect Options:
A) Breath sounds are diminished on the affected side, not bilaterally.
C) Hyperresonance is present, but tracheal deviation is more definitive.
D) Pleural friction rub is not associated with pneumothorax.
The nurse notes continuous bubbling in the water-seal chamber of a patient’s chest tube system. What action should the nurse take?
A) Clamp the chest tube
B) Notify the healthcare provider
C) Check for leaks in the system
D) Increase the suction pressure
C) Check for leaks in the system
Explanation:
Correct Answer: Continuous bubbling suggests an air leak, and the system should be inspected for potential sources of air entry.
Incorrect Options:
A) Clamping the tube can worsen complications.
B) Notifying the provider is secondary after assessment.
D) Suction adjustments will not resolve an air leak.
A patient with a hemothorax reports shortness of breath. What clinical manifestation does the nurse expect to find?
A) Dullness to percussion over the affected area
B) Hyperresonance to percussion over the affected area
C) Bilateral crackles on auscultation
D) Wheezing throughout all lung fields
A) Dullness to percussion over the affected area
Explanation:
Correct Answer: Hemothorax involves blood in the pleural space, causing dullness on percussion.
Incorrect Options:
B) Hyperresonance occurs in pneumothorax, not hemothorax.
C and D) Crackles and wheezing are not hallmarks of hemothorax.
Which nursing action is most appropriate after assisting with the insertion of a chest tube?
A) Clamp the chest tube for 30 minutes
B) Apply a vented dressing over the insertion site
C) Verify chest tube placement with a chest X-ray
D) Encourage the patient to ambulate immediately
C) Verify chest tube placement with a chest X-ray
Explanation:
Correct Answer: A chest X-ray confirms proper placement of the chest tube and lung re-expansion.
Incorrect Options:
A) Clamping is not recommended unless specifically ordered.
B) Vented dressings are used for open pneumothorax, not chest tube sites.
D) Ambulation should wait until the patient is stable.
A patient with a suspected flail chest is admitted to the emergency department. Which finding supports this diagnosis?
A) Paradoxical chest wall movement
B) Diminished breath sounds on the affected side
C) Tracheal deviation toward the unaffected side
D) Hemoptysis
A) Paradoxical chest wall movement
Explanation:
Correct Answer: Flail chest causes paradoxical movement, where the chest wall moves inward during inspiration and outward during expiration.
Incorrect Options:
B) Diminished breath sounds may occur but are not specific.
C) Tracheal deviation occurs in tension pneumothorax, not flail chest.
D) Hemoptysis is not typical of flail chest.
A patient with pleural effusion is scheduled for a thoracentesis. Which pre-procedure instruction should the nurse provide?
A) “You will need to lie flat for the procedure.”
B) “Do not eat or drink anything for 8 hours before the procedure.”
C) “You will be asked to sit up and lean forward.”
D) “General anesthesia will be used during the procedure.”
C) “You will be asked to sit up and lean forward.”
Explanation:
Correct Answer: Sitting up and leaning forward exposes the pleural space for fluid removal.
Incorrect Options:
A) Lying flat is not used for thoracentesis.
B) Fasting is unnecessary.
D) Local anesthesia, not general anesthesia, is used.
A nurse is caring for a patient with a suspected chylothorax. What assessment finding is most consistent with this condition?
A) Clear pleural fluid on thoracentesis
B) Milky fluid with high lipid content
C) Purulent fluid with a foul odor
D) Straw-colored fluid with high protein content
B) Milky fluid with high lipid content
Explanation:
Correct Answer: Chylothorax involves lymphatic fluid leakage, which appears milky and lipid-rich.
Incorrect Options:
A) Clear fluid is seen in transudative effusions.
C) Purulent fluid indicates empyema.
D) Straw-colored fluid is associated with exudative effusions.
What is the primary goal of needle decompression in tension pneumothorax?
A) Remove excess fluid from the pleural space
B) Stabilize blood pressure
C) Relieve intrapleural pressure
D) Prevent hemothorax
C) Relieve intrapleural pressure
Explanation:
Correct Answer: Needle decompression immediately reduces intrapleural pressure, allowing lung re-expansion and relieving pressure on the heart and vessels.
Incorrect Options:
A) This is the goal of thoracentesis for fluid.
B) Blood pressure may stabilize secondary to pressure relief but is not the direct goal.
D) Hemothorax prevention is unrelated.
The nurse is monitoring a patient with a chest tube. Which finding requires urgent intervention?
A) Tidaling in the water-seal chamber
B) No fluctuation in the water-seal chamber
C) Intermittent bubbling in the suction control chamber
D) Drainage of 75 mL in the past hour
B) No fluctuation in the water-seal chamber
Explanation:
Correct Answer: Absence of tidaling may indicate an obstruction or lung re-expansion and warrants further assessment.
Incorrect Options:
A and C) These are expected findings.
D) This drainage is within normal limits.
A nurse is caring for a patient with an exudative pleural effusion. What intervention is most appropriate for managing the underlying condition?
A) Administer diuretics as prescribed
B) Prepare the patient for thoracentesis
C) Apply a three-sided dressing
D) Begin antibiotic therapy as prescribed
D) Begin antibiotic therapy as prescribed
Explanation:
Correct Answer: Exudative pleural effusions often result from infections or inflammation, making antibiotics a key treatment.
Incorrect Options:
A) Diuretics are more relevant for transudative effusions caused by fluid overload.
B) Thoracentesis may provide temporary relief but does not treat the underlying infection.
C) A three-sided dressing is used for open pneumothorax, not pleural effusions.
A patient with a spontaneous closed pneumothorax has decreased breath sounds and reports chest discomfort. What is the initial nursing priority?
A) Prepare the patient for a thoracotomy
B) Administer prescribed oxygen therapy
C) Encourage deep breathing exercises
D) Position the patient flat on their back
B) Administer prescribed oxygen therapy
Explanation:
Correct Answer: Administering oxygen improves tissue oxygenation when lung expansion is compromised.
Incorrect Options:
A) Thoracotomy is not the initial intervention for a closed pneumothorax.
C) Deep breathing may worsen symptoms without resolving the issue.
D) Flat positioning can increase discomfort and impair breathing.
A patient is scheduled for a thoracentesis to relieve symptoms of pleural effusion. During the procedure, the patient reports dizziness and lightheadedness. What is the nurse’s priority action?
A) Continue to monitor vital signs
B) Inform the healthcare provider immediately
C) Stop the procedure and lay the patient flat
D) Decrease the amount of fluid being removed
D) Decrease the amount of fluid being removed
Explanation:
Correct Answer: Rapid removal of fluid can cause hypotension or re-expansion pulmonary edema, so the amount of fluid should be reduced gradually.
Incorrect Options:
A) Monitoring is essential, but action is needed immediately.
B and C) Informing the provider and repositioning are secondary to addressing the root cause.
A patient with a hemothorax develops hypotension and decreased oxygen saturation. Which intervention is priority?
A) Administer a blood transfusion
B) Increase oxygen flow
C) Prepare for chest tube insertion
D) Elevate the patient’s legs
C) Prepare for chest tube insertion
Explanation:
Correct Answer: Chest tube insertion helps drain the blood and relieve pressure in the pleural space, improving oxygenation and stabilizing circulation.
Incorrect Options:
A) Blood transfusion may be needed later but is not the initial priority.
B) While oxygen is important, resolving the cause of hypoxia takes precedence.
D) Leg elevation does not address the underlying issue.
Which assessment finding in a patient with a chest tube requires immediate action?
A) Continuous bubbling in the suction chamber
B) Absence of tidaling in the water-seal chamber
C) Serosanguinous drainage of 50 mL/hour
D) Intermittent bubbling in the water-seal chamber
B) Absence of tidaling in the water-seal chamber
Explanation:
Correct Answer: No tidaling indicates an obstruction in the chest tube or complete lung re-expansion, which requires further assessment.
Incorrect Options:
A and D) Bubbling may indicate air removal or a leak but is not always critical.
C) This is a normal drainage amount.
A patient with flail chest reports pain when breathing. Which nursing intervention is most effective in promoting oxygenation?
A) Encourage the use of incentive spirometry
B) Administer prescribed pain medications
C) Position the patient side-lying on the unaffected side
D) Prepare for intubation and mechanical ventilation
B) Administer prescribed pain medications
Explanation:
Correct Answer: Pain control allows the patient to take deeper, more effective breaths, improving oxygenation.
Incorrect Options:
A) Incentive spirometry is difficult without adequate pain management.
C) Positioning may help, but pain control is more critical.
D) Intubation is reserved for severe cases.
A patient has been diagnosed with a tension pneumothorax. Which finding is expected?
A) Decreased breath sounds on both sides
B) Tracheal deviation toward the unaffected side
C) Hyperresonance over the unaffected side
D) Increased tactile fremitus over the affected area
B) Tracheal deviation toward the unaffected side
Explanation:
Correct Answer: Tracheal deviation occurs due to pressure buildup, shifting mediastinal structures.
Incorrect Options:
A and C) Findings are localized to the affected side.
D) Tactile fremitus decreases over the affected side.
The nurse observes a patient with pleural effusion experiencing decreased chest movement on the right side. What is the priority diagnostic test?
A) Chest X-ray
B) Arterial blood gas analysis
C) Pulmonary function tests
D) Computed tomography (CT) scan
A) Chest X-ray
Explanation:
Correct Answer: A chest X-ray is the most efficient test for identifying fluid accumulation in pleural effusions.
Incorrect Options:
B, C, and D) These tests provide additional information but are not first-line diagnostics.
Which intervention should the nurse implement to prevent complications in a patient with a chest tube?
A) Clamp the chest tube when repositioning the patient
B) Encourage frequent ambulation
C) Ensure the drainage system remains below chest level
D) Milk the chest tube every hour
C) Ensure the drainage system remains below chest level
Explanation:
Correct Answer: Keeping the system below chest level prevents backflow of air or fluid into the pleural space.
Incorrect Options:
A) Clamping increases the risk of tension pneumothorax.
B) Ambulation is encouraged but not specific to chest tube complications.
D) Milking the tube is not recommended unless prescribed.
A nurse is caring for a patient with empyema who has a chest tube. Which observation suggests effective treatment?
A) Decreased oxygen saturation levels
B) Reduced purulent drainage over time
C) Continuous bubbling in the water-seal chamber
D) Increased respiratory rate and shallow breathing
B) Reduced purulent drainage over time
Explanation:
Correct Answer: Reduced purulent drainage indicates resolution of the infection.
Incorrect Options:
A and D) These findings suggest deterioration.
C) Continuous bubbling indicates an air leak, not resolution.
A patient with a pleural effusion has decreased breath sounds and dyspnea. What is the nurse’s priority action?
A) Perform percussion to detect dullness
B) Prepare the patient for thoracentesis
C) Teach the patient deep breathing exercises
D) Administer a bronchodilator as prescribed
B) Prepare the patient for thoracentesis
Explanation:
Correct Answer: Thoracentesis is the definitive intervention to relieve symptoms by removing excess fluid.
Incorrect Options:
A) While percussion can confirm findings, it does not resolve symptoms.
C) Deep breathing is less effective with fluid compressing the lungs.
D) Bronchodilators are not the primary treatment for pleural effusion.
Which clinical manifestation is expected in a patient with a tension pneumothorax?
A) Decreased breath sounds bilaterally
B) Tracheal deviation toward the unaffected side
C) Dullness on percussion over the affected area
D) Pleural friction rub on auscultation
B) Tracheal deviation toward the unaffected side
Explanation:
Correct Answer: Tension pneumothorax increases intrapleural pressure, causing a mediastinal shift and tracheal deviation.
Incorrect Options:
A) Breath sounds are decreased only on the affected side.
C) Hyperresonance, not dullness, is noted in pneumothorax.
D) Pleural friction rub is not typical in pneumothorax.
The nurse notes continuous bubbling in the water-seal chamber of a chest drainage system. What is the best action?
A) Notify the healthcare provider
B) Secure all connections in the system
C) Clamp the chest tube immediately
D) Replace the entire drainage system
B) Secure all connections in the system
Explanation:
Correct Answer: Continuous bubbling in the water-seal chamber indicates an air leak, and checking the connections can identify and resolve the problem.
Incorrect Options:
A) Notifying the provider is secondary to troubleshooting.
C) Clamping the chest tube can worsen complications.
D) Replacing the system is unnecessary unless the leak cannot be resolved.
A patient with a chylothorax is prescribed a low-fat diet. Why is this intervention beneficial?
A) It reduces inflammation in the pleural space
B) It decreases lymphatic fluid production
C) It prevents bacterial infection
D) It promotes reabsorption of pleural fluid
B) It decreases lymphatic fluid production
Explanation:
Correct Answer: A low-fat diet minimizes lymphatic fluid production, reducing chylothorax severity.
Incorrect Options:
A) Inflammation is not the primary issue in chylothorax.
C) Diet does not prevent infection.
D) Pleural fluid reabsorption is not directly influenced by diet.
A patient with a hemothorax develops hypotension and tachycardia. What is the nurse’s priority action?
A) Administer prescribed fluids
B) Increase oxygen flow
C) Monitor drainage output
D) Prepare for blood transfusion
A) Administer prescribed fluids
Explanation:
Correct Answer: Administering fluids stabilizes circulation and addresses hypovolemia caused by the hemothorax.
Incorrect Options:
B) Oxygen improves oxygenation but does not address volume loss.
C) Monitoring output is essential but not the immediate priority.
D) Transfusion may be needed later but is secondary to fluid resuscitation.
The nurse is caring for a patient with flail chest. Which assessment finding is most concerning?
A) Paradoxical chest wall movement
B) Increased respiratory rate
C) SpO₂ 88% on room air
D) Pain with deep breathing
C) SpO₂ 88% on room air
Explanation:
Correct Answer: Low oxygen saturation indicates inadequate oxygenation, which requires immediate intervention.
Incorrect Options:
A and B) These are expected findings but not as critical as hypoxemia.
D) Pain is common but less urgent than oxygenation issues.
What is the primary purpose of the water-seal chamber in a chest drainage system?
A) Collect pleural fluid
B) Regulate suction pressure
C) Prevent air from entering the pleural space
D) Monitor fluid drainage
C) Prevent air from entering the pleural space
Explanation:
Correct Answer: The water-seal chamber acts as a one-way valve, allowing air to exit but preventing re-entry into the pleural space.
Incorrect Options:
A, B, and D) These describe functions of other parts of the system.
A patient with a pleural effusion reports sharp chest pain and dyspnea. Which diagnostic test is most appropriate to confirm the diagnosis?
A) Arterial blood gas (ABG) analysis
B) Chest X-ray
C) Spirometry
D) Bronchoscopy
B) Chest X-ray
Explanation:
Correct Answer: A chest X-ray is the first-line diagnostic tool to confirm pleural effusion by visualizing fluid accumulation.
Incorrect Options:
A) ABG assesses oxygenation but does not identify fluid.
C) Spirometry evaluates lung function, not fluid presence.
D) Bronchoscopy visualizes airways but does not detect pleural effusion.
What finding would indicate the effectiveness of a chest tube in a patient with a pneumothorax?
A) Continuous bubbling in the water-seal chamber
B) Increased respiratory distress
C) Improved breath sounds on the affected side
D) Absence of tidaling in the water-seal chamber
C) Improved breath sounds on the affected side
Explanation:
Correct Answer: Improved breath sounds indicate re-expansion of the lung and effective air removal.
Incorrect Options:
A) Continuous bubbling suggests an air leak.
B) Respiratory distress indicates complications.
D) Absence of tidaling may mean obstruction or resolution but requires further assessment.
Which clinical manifestation suggests progression from pneumothorax to tension pneumothorax?
A) Decreased breath sounds bilaterally
B) Tracheal deviation toward the unaffected side
C) Hyperresonance on percussion over both lung fields
D) Pleuritic chest pain
B) Tracheal deviation toward the unaffected side
Explanation:
Correct Answer: Tracheal deviation is a hallmark sign of tension pneumothorax caused by increased pressure.
Incorrect Options:
A) Breath sounds are decreased only on the affected side.
C) Hyperresonance is localized to the affected side.
D) Pleuritic pain is associated with general pneumothorax, not tension pneumothorax progression.
