Med Surg Ch 12 + 13

Question 1

What is the purpose of mucus?

Answer 1

To trap particles and bacteria.

Question 2

A patient with emphysema presents to the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. The nurse positions the patient in high Fowler. What action should the nurse take next?

Answer 2

Coach the patient in pursed-lip breathing.

Question 3

The nurse explains that the mechanism that triggers rate and depth of respiration is based on which factor?

Answer 3

. Blood pH.

Question 4

When creating a visual aid to show the mechanics of inhaling, the nurse correctly illustrates which scenario?

Answer 4

The diaphragm moves downward.

Question 5

Which substance decreases the surface tension of the alveolar walls?

Answer 5

. Surfactant

Question 6

Most of the inspired oxygen is carried to the tissues via which component of the body?

Answer 6

Red blood cells

Question 7

The nurse is caring for a patient with an obstructive respiratory disorder. Which of these conditions is an example of an obstructive lung disorder?

Answer 7

Chronic bronchitis

Question 8

The nurse is caring for multiple patients. After reviewing the patients’ histories, the nurse determines that which patient possesses the highest risk of throat cancer?

Answer 8

A male patient who drinks four vodka tonics per day

Question 9

The nurse is preparing to administer the influenza immunization to four patients. Allergy to which substance should cause the nurse to question giving the immunization?

Answer 9

. Eggs

Question 10

While performing an assessment, the nurse auscultates a coarse low-pitched sonorous rattling in the left lower lobe. Based on the presence of this adventitious lung sound, which action should the nurse take next?

Answer 10

instruct the patient to turn, cough, and deep-breathe

Question 11

When the nurse places the diaphragm of the stethoscope over one of the main bronchi, which expected normal breath sound should the nurse hear?

Answer 11

Bronchovesicular sounds

Question 12

the nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action demonstrates appropriate technique?

Answer 12

The nurse suctions the patient for 10 to 15 seconds.

Question 13

the nurse is aware that the patient is in respiratory failure when the blood gas findings contain which values?

Answer 13

. PaO2 46 mm Hg; PaCO2 52 mm Hg

Question 14

The nurse is caring for a patient who was recently admitted with a traumatic head injury. The nurse anticipates that the patient may display which type of respirations?

Answer 14

biot

Question 15

The nurse is caring for a postoperative patient. After instructing the patient to cough and deep-breathe, what action should the nurse take next?

Answer 15

Perform mouth care.

Question 16

A patient is admitted to the medical unit with an acute illness accompanied by a fever for the last 3 days. What will likely be the patient’s respiratory response?

Answer 16

respiratory alkalosis

Question 17

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) who has been in the hospital for
several days. The patient complains of shortness of breath and asks the nurse to turn up his oxygen to compensate for his labored
breathing. What is the best nursing response?

Answer 17

Assess the patient in an attempt to identify the cause of the shortness of breath.

Question 18

The nurse clarifies that when interstitial edema occurs in the lung tissue, it inhibits ventilation by causing which
problem(s)? (Select all that apply.)

Answer 18

a. Thickening alveolar membranes
c. Alveoli filling with fluid
e. Gas failing to diffuse across membrane

Question 19

19. Which manifestation(s) are age-related changes that alter the respiratory system? (Select all that apply.)

Answer 19

a. Weakened cough
b. Kyphosis
d. Decrease in body fluid
e. Muscle weakness

Question 20

For which individual(s) does U.S. Public Health Service recommend the influenza immunization? (Select all that
apply.)

Answer 20

a. Physicians
c. Older adults
d. Chronically ill
e. Nurses

Question 21

21. Which physical signs indicate labored breathing? (Select all that apply.)

Answer 21

a. Grunting on expiration
b. Elevating shoulders and ribs on inspiration
c. Tensing neck and shoulder muscles
d. Substernal retraction

Question 22

The nurse is caring for a patient with a respiratory disorder who complains of anorexia. Which factor(s) may contribute
to the patient’s anorexia? (Select all that apply.)

Answer 22

b. Bad taste in mouth
c. Fear of exacerbate coughing by eating
d. Fatigue
e. Altered sense of smell

Question 23

The nurse uses a visual aid to show the “hinged door” that helps prevent aspiration. This “hinged door” is the
__________.

Answer 23

epiglottis

Question 24

Rapid opening and closing of the glottis combined with movement of the mouth, lips, and tongue is what makes
_____________.

Answer 24

speech

Question 25

the nurse describes the ability of the lungs to respond to change in the volume and pressure of inhaled air by
expanding as lung __________.

Answer 25

compliance

Question 26

Trace the route of a molecule of oxygen inhaled from room air to the point of gas exchange.

Answer 26

d. Oxygen is inhaled through the nose
a. Larynx
c. Trachea
b. Left and right bronchi
e. Bronchioles
f. Alveoli

Question 27

Place in the appropriate sequence the steps of auscultation of the chest.

Answer 27

a. Place diaphragm of stethoscope above clavicles.
c. Move stethoscope from side to side down midline of the chest.
d. Place diaphragm of stethoscope above scapulae.
e. Move stethoscope side to side on either side of the spine.
b. Listen in midaxillary line to level of diaphragm.

Question 28

1. What is the contagion period of a cold?

Answer 28

b. 3 days

Question 29

The nurse is caring for a patient who has had a cold for 1 week. The patient questions why the health care provider
issued a prescription for an antibiotic. Which explanation is best?

Answer 29

c. “The antibiotic will treat the secondary bacterial infection that has developed.”

Question 30

3. The nurse is caring for a patient with suspected sinusitis. Which assessment finding supports this diagnosis?

Answer 30

b. Generalized pain in the upper teeth.

Question 31

The nurse is caring for a 20-year-old patient who recently underwent a tonsillectomy. The patient is fully awake and
clearing his throat frequently but denies pain. Which action is most important for the nurse to take first?

Answer 31

b. Look in the patient’s mouth.

Question 32

The nurse is caring for a patient with sleep apnea. The patient complains that he is constantly fatigued. Which response
is most appropriate for the nurse to make?

Answer 32

b. “Patients with sleep apnea often wake frequently during the night.”

Question 33

The nurse is caring for a patient during the immediate postoperative period following a rhinoplasty. Which finding is
most concerning to the nurse?

Answer 33

c. The nurse notices the patient is swallowing frequently.

Question 34

The nurse is caring for a patient who has a tracheostomy with a one-way valve box. The nurse explains to the CNA that
this valve allows the patient to carry out which function?

Answer 34

Talking

Question 35

8. Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

Answer 35

d. “I understand that you might be apprehensive.”

Question 36

9. The nurse is caring for a patient who underwent a laryngectomy. Which need should the nurse address first?

Answer 36

c. Communication method

Question 37

The nurse is teaching a patient who underwent a laryngectomy. Which statement describes the correct technique for
warming inspired air during cold weather?

Answer 37

b. Cover the stoma with a scarf.

Question 38

11. When teaching a patient about esophageal speech, which technique should the nurse instruct the patient to use first?

Answer 38

d. Swallow air and force it back up through the esophagus.

Question 39

The nurse carefully applies suction prior to deflating the cuff on a cuffed tracheostomy in order to prevent which
complication?

Answer 39

d. Aspiration

Question 40

13. When doing routine cleaning of a double-lumen tracheostomy tube, the nurse should include which action?

Answer 40

d. Clean the inner cannula with a pipe cleaner.

Question 41

14. The nurse is caring for a patient experiencing epistaxis. What action should the nurse take first?

Answer 41

d. Instruct the patient to sit forward and pinch the nose below the bone.

Question 42

The nurse is aware that the patient seeking antibiotic treatment for pharyngitis will only receive the desired medication
if the condition is caused by what type of pathogen?

Answer 42

b. Bacteria

Question 43

The nurse is assisting the physician with the insertion of a new tracheostomy tube. The physician asks for the obturator.
The nurse correctly hands the physician which device?

Answer 43

a. The guide for the tracheostomy tube to be inserted

Question 44

17. Which action(s) may help to reduce the risk of transmitting a common cold? (Select all that apply.)

Answer 44

a. Cover the mouth and nose when sneezing.
b. Wash the hands frequently.
d. Turn the head to the crook of the arm when coughing.

Question 45

18. Which organism(s) are common causative agents for sinusitis? (Select all that apply.)

Answer 45

a. Pneumococci
d. Haemophilus influenzae
e. Streptococci

Question 46

the nurse is teaching an adult post-tonsillectomy patient. Which dietary instructions are most important for the nurse to
include? (Select all that apply.

Answer 46

b. Avoid hot fluids.

d. Avoid foods with red dye.

Question 47

The nurse is assessing an older adult with a family tendency of developing laryngeal cancer. The nurse should ask the
patient about which risk factors? (Select all that apply.)

Answer 47

a. History of smoking
b. Alcohol abuse
c. Exposure to asbestos
d. Occupational exposure to wood dust

Question 48

The nurse is performing discharge teaching for a patient who underwent a microlaryngoscopy with laser removal of
polyps. Which instruction(s) should the nurse include? (Select all that apply.)

Answer 48

b. You can return to work in 3 days.

d. Observe 2 days of voice rest.

Question 49

The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which
action(s) should the nurse perform? (Select all that apply.)

Answer 49

a. Auscultate lungs for retained secretions.
b. Wash hands and open sterile suction kit.
d. Inform the patient about the procedure.
e. Perform suction with sterile supplies.

Question 50

The radical neck resection removes a large amount of tissue on the same side as the lesion. Which statement(s) about
the tissue removed is/are correct? (Select all that apply.)

Answer 50

a. The tissue includes all muscle, lymph nodes, and soft tissue from the lower edge of the mandible to the top of the clavicle.
b. The tissue includes all muscle, lymph nodes, and soft tissue from the top of the trapezius to the midline.
c. The tissue includes all muscle, lymph nodes, and soft tissue from the lower edge of the eye socket to the bottom of the
maxilla, including the zygomatic arch.

Question 51

The nurse is teaching a patient with a newly resolved episode of epistaxis. Which information is important for the nurse
to include? (Select all that apply.)

Answer 51

a. Avoid sneezing.
b. Rest for several hours until all threat of epistaxis is gone.
c. Avoid rubbing the nose.

Question 52

The clinic nurse is giving discharge instructions to the mother of a 10-year-old boy who has been diagnosed with a mild
cold. Which statements indicate that the mother accurately understands the nurse’s instructions? (Select all that apply.)

Answer 52

b. “I will be sure he drinks plenty of apple and orange juice.”
d. “I will be sure he washes his hands well so he doesn’t pass this cold on to his younger sister.”
e. “Since his cold symptoms just started, zinc lozenges may be helpful for him to take.”

Question 53

The nurse encourages a patient with larynx cancer that the “near-total laryngectomy” is a new procedure that preserves
the ability to __________ and to __________.

Answer 53

speak; swallow

Question 54

Place the steps of abdominal thrusts in proper sequence.

Answer 54

d. Check status of breathing.
c. Make a fist.
e. Position fist, thumb foremost, over umbilicus.
a. Wrap hand around fist.
b. Squeeze and thrust five times.