MSS Ch 6 Respiratory Disorders Comprehensive Exam

Question 1

Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma?

1. A bronchoscopy.
2. An immunoglobulin E.
3. An arterial blood gas.
4. A bronchodilator reversibility test.

Answer 1

1. A bronchoscope visualizes the bronchial tree under sedation, but it does not confirm the diagnosis of asthma.
2. An immunoglobulin E is a blood test for the presence of an antibody protein indicating allergic reactions.
3. Arterial blood gases analyze levels providing information about the exchange of oxygen and carbon dioxide, but they are not diagnostic of asthma.
4. During a bronchodilator reversibility test, the client’s positive response to a bronchodilator confirms the diagnosis of asthma.

Question 2

Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?

1. “I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks.”
2. “I need to use my Intal, cromolyn, inhaler 15 minutes before I begin my exercise.”
3. “I need to take oral glucocorticoids every day to prevent my asthma attacks.”
4. “If I have an asthma attack, I need to use my Albuterol, a beta2 agonist, inhaler.”

Answer 2

1. Leukotrienes, such as Singulair, should be taken daily to prevent an asthma attack triggered by an allergen response.
2. Cromolyn inhalers, such as Intal, are used to prevent exercise-induced asthma attacks.
3. Glucocorticoids are administered orally or intravenously during acute exacerbations of asthma, not on a daily basis because of the long-term complications of steroid therapy.
4. Albuterol, a beta2 agonist, is used during attacks because of the fast action.

Question 3

Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack?

1. Administer glucocorticoids intravenously.
2. Administer oxygen 5 L per nasal cannula.
3. Establish and maintain a 20-gauge saline lock.
4. Assess breath sounds every 15 minutes.

Answer 3

1. Glucocorticoids are a treatment of choice, but they are not the first intervention.
2. The client is in distress so the nurse must do something for the client’s airway.
3. A saline lock is needed for intravenous fluids, but it is not the first intervention.
4. Assessment is the first step of the nursing process but in distress do not assess.

Question 4

Which isolation procedure should be instituted for the client admitted to rule out severe acute respiratory syndrome (SARS)?

1. Airborne isolation.
2. Droplet isolation
3. Reverse isolation.
4. Strict isolation.

Answer 4

1. Airborne isolation is used when the infectious agent can remain in the air and be transported greater than three (3) feet and includes wearing specially fitted masks to prevent transmission.
2. SARS is an influenza-type virus transmitted by particle droplets. Therefore, the client should be placed in droplet isolation.
3. “Reverse isolation” is a term for using equipment to prevent the client from being exposed to organisms from other people.
4. “Strict isolation” is an old term used to describe isolation to prevent transmission of organisms to other people. It is vague and not used today in infection control standards.

Question 5

The client is admitted with a diagnosis of rule-out severe acute respiratory syndrome (SARS). Which information is most important for the nurse to ask related to this diagnosis?

1. Current prescription and over-the-counter medication use.
2. Dates of and any complications associated with recent immunizations.
3. Any problems with recent or past use of blood or blood products.
4. Recent travel to mainland China, Hong Kong, or Taiwan.

Answer 5

1. This information is important during an admission interview but is not specific to SARS.
2. The information would not be specific to the diagnosis of SARS.
3. This would be important to ask prior to the administration of any blood products, but it is not specific for SARS.
4. Recent travel to mainland China, Taiwan, and Hong Kong is a risk factor for contracting SARS.

Question 6

The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse’s suspicion?

1. The client’s arterial blood gases are within normal limits.
2. The client appears anxious, has dyspnea, and is tachypneic.
3. The client has intercostal retractions and is using accessory muscles.
4. The client’s bilateral lung sounds have crackles and rhonchi.

Answer 6

1. The client would have low arterial oxygen when developing ARDS.
2. Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and in- clude anxiety, dyspnea, and tachypnea.
3. As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retractions and use of accessory muscles.
4. Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

Question 7

Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM?

1. pH 7.38, PaO2 94, PaCO2 44, HCO3 24.
2. pH 7.46, PaO2 82, PaCO2 34, HCO3 22.
3. pH 7.48, PaO2 59, PaCO2 30, HCO3 26.
4. pH 7.33, PaO2 94, PaCO2 44, HCO3 20.

Answer 7

1. This ABG is within normal limits and would not be expected in a client with ARDS.
2. These ABG levels indicate respiratory alka- losis, but the oxygen level is within normal limits and would not be expected in a client with ARDS.
3. ABGs initially show hypoxemia with a PaO2 of less than 60 mm Hg and respiratory alkalosis resulting from tachypnea in a client with ARDS.
4. This ABG is metabolic acidosis and would not be expected in a client with ARDS.

Question 8

The nurse is planning the activities for the client diagnosed with asbestosis. Which activity should the nurse schedule at 0900 if breakfast is served at 0800?

1. Assist with the client’s bath and linen change.
2. Administer an inhalation bronchodilator treatment.
3. Provide the client with a one (1)-hour rest period.
4. Have respiratory therapy perform chest physiotherapy.

Answer 8

1. Bathing is too strenuous an activity immediately after eating.
2. Inhalation bronchodilators should be administered one (1) hour after meals. The nurse should realize the client will require 20 to 30 minutes to eat, and scheduling these activities at 0900 would not give the client sufficient time to digest the food or rest before the activity.
3. Periods of rest should be alternated with periods of activity.
4. Chest physiotherapy should be performed at least one (1) hour after meals. The nurse should realize the client will require 20 to 30 minutes to eat, and scheduling these activities at 0900 would not give the client sufficient time to digest the food or rest before the activity.

Question 9

Which data requires immediate intervention by the nurse for the client diagnosed with asbestosis?

1. The client develops an S3 heart sound.
2. The client has clubbing of the fingers.
3. The client is fatigued in the afternoon.
4. The client has basilar crackles in all lobes.

Answer 9

1. The appearance of S3 heart sounds indicates the client is developing heart failure, which is a medical emergency.
2. Clubbing of the fingers indicates the client has a chronic respiratory condition, but this would not require immediate intervention.
3. Fatigue is a common occurrence in clients with respiratory conditions, such as asbestosis, as a result of the effort required to breathe.
4. Bibasilar crackles are common symptoms experienced by clients with asbestosis and do not require immediate intervention.

Question 10

Which clinical manifestation would the nurse assess in the client newly diagnosed with intrinsic lung cancer?

1. Dysphagia.
2. Foul-smelling breath.
3. Hoarseness.
4. Weight loss.

Answer 10

1. Dysphagia is a late sign of intrinsic lung cancer.
2. Foul-smelling breath is a late sign of intrinsic lung cancer.
3. Hoarseness is an early clinical manifestation of intrinsic lung cancer. “Intrinsic” means the tumor is on the vocal cord.
4. Weight loss is a late sign of most types of cancers, not just intrinsic lung cancer.

Question 11

Which priority intervention should the nurse implement for the client diagnosed with coal workers’ pneumoconiosis?

1. Monitor the client’s intake and output.
2. Assess for black-streaked sputum.
3. Monitor the white blood cell count daily.
4. Assess the client’s activity level every shift.

Answer 11

1. Fluids should be encouraged to help to liquefy sputum; therefore, intake and output should be monitored, but this is not the priority intervention.
2. Black-streaked sputum is a classic sign of coal workers’ pneumoconiosis (black lung), and the sputum should be assessed for color and amount. Remember Maslow’s hierarchy of needs when answering priority questions.
3. The client’s white blood cells should be monitored to assess for infection, but it is not priority and is not done daily.
4. Activity tolerance is important to assess for clients with all respiratory diseases, but it is not the priority intervention.

Question 12

Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy?

1. “I must avoid hair spray and powders.”
2. “I should take a shower instead of a tub bath.”
3. “I will need to cleanse around the stoma daily.”
4. “I can use an electric larynx to speak.”

Answer 12

1. The client should not let any spray or powder enter the stoma because it goes directly into the lung.
2. The client should not allow water to enter the stoma; therefore, the client should take a tub bath, not a shower.
3. The stoma site should be cleansed to help prevent infection.
4. The client’s vocal cords were removed; therefore, the client must use an alternate form of communication.

Question 13

The occupational nurse for a mining company is planning a class on the risks of working with toxic substances to comply with the “Right to Know” law. Which information should the nurse include in the presentation? Select all that apply.

1. A client who smokes cigarettes has a drastically increased risk for lung cancer.
2. Floors need to be clean and dust needs to be wet to prevent transfer of dust.
3. The air needs to be monitored at specific times to evaluate for exposure.
4. Surface areas need to be painted every year to prevent the accumulation of dust.
5. Employees should wear the appropriate personal protective equipment.

Answer 13

1. Clients who smoke cigarettes and work with toxic substances have increased risk of lung cancer because many of the substances are carcinogenic.
2. When floors and surfaces are kept clean, toxic dust particles, such as asbestos and silica, are controlled and this decreases exposure. Covering areas with water controls dust.
3. The quality of air is monitored to determine what toxic substances are present and in what amount. The information is then used in efforts to minimize the amount of exposure.
4. Applying paint to a surface does not eliminate or minimize exposure and can trap more dust.
5. Employees must wear protective coverings, goggles, and other equipment needed to eliminate exposure to the toxic substances.

Question 14

Which data are significant when assessing a client diagnosed with rule-out Legionnaires’ disease?

1. The amount of cigarettes smoked a day and the age when started.
2. Symptoms of aching muscles, high fever, malaise, and coughing.
3. Exposure to a saprophytic water bacterium transmitted into the air.
4. Decreased bilateral lung sounds in the lower lobes.

Answer 14

1. Smoking cigarettes is important to assess in any respiratory disease. Legionnaires’ disease is contracted with a bacterium, not by smoking.
2. Aching muscles, high fever, malaise, and coughing are symptoms of most respiratory illnesses, including influenza and pneumo- nia, but these symptoms are not specific to Legionnaires’ disease.
3. Legionnaires’ disease is caused by a saprophytic water bacterium that is transmitted through the air from places where these bacteria are found: rivers, lakes, evaporative condensers, respiratory apparatuses, or water distribution centers.
4. Abnormal breath sounds can be heard in many respiratory illnesses.

Question 15

Which assessment data indicate to the nurse the client diagnosed with Legionnaires’ disease is experiencing a complication?

1. The client has an elevated body temperature.
2. The client has <30 mL urine output an hour.
3. The client has a decrease in body aches.
4. The client has an elevated white blood cell count.

Answer 15

1. The temperature is elevated and does not indicate a complication.
2. Multiple organ failure is a common complication of Legionnaires’ disease. Renal failure should be suspected as a complication if the client does not have a urine output of 30 mL/hr.
3. A decrease in body aches does not indicate a complication.
4. An elevation of white blood cells is expected in a client with Legionnaires’ disease and is not a complication.

Question 16

Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching?

1. “If I lose weight I may not need treatment for sleep apnea.”
2. “The CPAP machine holds my airway open with pressure.”
3. “The CPAP will help me stay awake during the day while I am at work.”
4. “It is all right to have a couple of beers because I have this CPAP machine.”

Answer 16

1. The contributing factors to developing sleep apnea are obesity, smoking, drinking alcohol, and a short neck. In some situations, modifying lifestyle will improve sleep apnea.
2. Many clients need a continuous positive airway pressure (CPAP) machine, which continuously administers positive pressure to assist sleep during the night.
3. When clients have sleep apnea, the buildup of carbon dioxide causes the client to arouse constantly from sleep to breathe. This, in turn, causes the client to be sleepy during the day.
4. Drinking alcohol before sleep sedates the client, causing the muscles to relax, which, in turn, causes an obstruction of the client’s airway. Drinking alcohol should be avoided even if the client uses a CPAP machine.

Question 17

The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?

1. The client diagnosed with congestive heart failure.
2. The client with a documented allergy to eggs.
3. The client who has had an anaphylactic reaction to penicillin.
4. The client who has an elevated blood pressure and pulse.

Answer 17

1. There would be no reason to question administering a vaccine to a client with heart failure.
2. In clients who are allergic to egg protein, a significant hypersensitivity response may occur when they are receiving the influenza vaccine.
3. There would be no reason to question administering a vaccine to a client who has had a reaction to penicillin.
4. There would be no reason to question administering a vaccine to a client who has elevated blood pressure and pulse.

Question 18

The nurse is preparing the client for a polysomnography to confirm sleep apnea. Which preprocedure instruction should the nurse include?

1. The client should not eat or drink past midnight.
2. The client will receive a sedative for relaxation.
3. The client will sleep in a laboratory for evaluation.
4. The client will wear a monitor at home for this test.

Answer 18

1. Preparation for the polysomnography does not require being NPO after midnight.
2. The examination is a recording of the natural sleep of the client. No sedative is administered.
3. The polysomnography is completed in a sleep laboratory to observe all the stages of sleep. Equipment is attached to the client to monitor depth and stage of sleep and movement, respira- tory effort, and oxygen saturation level during sleep.
4. The client could perform this test at home, but the evaluation is not as reliable and the visual observation is not included; therefore, this is not recommended.

Question 19

The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question?

1. Administer intravenous fluids of normal saline at 125 mL/hr.
2. Provide supplemental oxygen per nasal cannula at 2 L/min.
3. Continuous telemetry monitoring with strips every four (4) hours.
4. Administer a loop diuretic intravenously every six (6) hours.

Answer 19

1. Normal mean pulmonary artery pressure is about 15 mm Hg and an elevation indicates right ventricular heart failure or cor pulmonale, which is a comorbid condition of chronic obstructive pulmonary disease. The nurse should question this order because the rate is too high.
2. Supplemental oxygen should be administered at the lowest amount; therefore, this order should not be questioned.
3. Clients with hypoxia and cor pulmonale are at risk for dysrhythmias, so monitoring the ECG is an appropriate intervention.
4. Loop diuretics are administered to decrease the fluid and decrease the circulatory load on the right side of the heart; therefore, this order would not be questioned.

Question 20

The nurse and an unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? Select all that apply.

1. Keep the head of the bed elevated.
2. Encourage deep breathing exercises.
3. Record pulse oximeter reading.
4. Assess level of conscious.
5. Auscultate breath sounds.

Answer 20

1. Keeping the head of the bed elevated maximizes lung excursion and improves gas exchange and can be delegated.
2. Encouraging breathing exercises can be delegated.
3. Recording pulse oximeter readings can be delegated. Evaluating is the responsibility of the nurse.
4. Assessment cannot be delegated. Confusion is one of the first symptoms of hypoxia.
5. Auscultation is a technique of assessment and cannot be delegated.

Question 21

The nurse is preparing the plan of care for the client who had a pleurodesis. Which collaborative intervention should the nurse include?

1. Monitor the amount and color of drainage from the chest tube.
2. Perform a complete respiratory assessment every two (2) hours.
3. Administer morphine sulfate, an opioid analgesic, intravenously.
4. Keep a sterile dressing and bottle of sterile normal saline at the bedside.

Answer 21

1. Monitoring the amount and color of drainage from the chest tube is an independent nursing intervention.
2. Respiratory assessment is an independent intervention.
3. Administering medication is a collaborative intervention because it requires a health-care provider’s order.
4. Keeping supplies at the bedside is aninde- pendent intervention the nurse may take in case the chest tube becomes dislodged.

Question 22

Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy?

1. Alteration in comfort.
2. Altered level of conscious.
3. Alteration in elimination pattern.
4. Knowledge deficit.

Answer 22

1. Pain and discomfort are major problems for a client who had a thoracotomy because the chest wall has been opened and closed.
2. The client would be on a mechanical ventilator and have an adequate airway; therefore, altered consciousness would not be an appropriate client problem.
3. Altered elimination problem is not specific for the client with a thoracotomy.
4. A knowledge deficit problem is not an appropriate problem for the client who is one (1) day postoperative thoracotomy because the client is on a ventilator.

Question 23

The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?

1. Assess respiratory rate and depth.
2. Provide for adequate rest period.
3. Administer oxygen as prescribed.
4. Teach slow abdominal breathing.

Answer 23

1. The assessment of respiratory rate and depth is the priority intervention because tachypnea and dyspnea may be early indicators of respiratory compromise.
2. Rest reduces metabolic demands, fatigue, and the work of breathing, which promotes a more effective breathing pattern, but it is not priority over assessment.
3. Oxygen therapy increases the alveolar oxygen concentration, reducing hypoxia and anxiety, but it is not priority over assessment.
4. This breathing pattern promotes lung expansion, but it is not priority over assessment.

Question 24

The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first?

1. Take the client’s vital signs.
2. Check the client’s pulse oximeter reading.
3. Administer oxygen via a nasal cannula.
4. Notify the respiratory therapist STAT.

Answer 24

1. Taking the client’s vital signs will not help the client’s shortness of breath and difficulty in breathing.
2. Checking the pulse oximeter reading will not help the client’s shortness of breath and difficulty breathing.
3. After elevating the head of the bed, the nurse should administer oxygen to the client who is in respiratory difficulty.
4. Notifying the respiratory therapist will not help the client’s shortness of breath and difficulty breathing.

Question 25

The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions (PVCs). Which intervention should the nurse implement first?

1. Request STAT arterial blood gases.
2. Administer lidocaine intravenous push.
3. Assess for possible causes.
4. Request a STAT electrocardiogram.

Answer 25

1. ABGs may show hypoxia, which is a cause of PVCs, but it is not the first intervention the nurse should implement.
2. Lidocaine is the treatment of choice for PVCs, but it is not the first intervention.
3. The nurse should assess for possible causes of the PVCs; these causes may include hypoxia or hypokalemia.
4. An ECG further evaluates the heart function, but it is not the first intervention

Question 26

The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse?

1. The client refuses to perform shoulder exercises.
2. The client complains of a sore throat and is hoarse.
3. The client has crackles that clear with cough.
4. The client is coughing up pink frothy sputum.

Answer 26

1. The client refusing to perform shoulder exercises is pertinent, but it does not require immediate intervention.
2. Sore throats and hoarseness are common postintubation and would not require immediate intervention.
3. Crackles that clear with coughing would not require immediate intervention.
4. Pink frothy sputum indicates pulmonary edema and would require immediate intervention.

Question 27

Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? Select all that apply.

1. Perform postural drainage and percussion every four (4) hours.
2. Modify activities to accommodate daily physiotherapy.
3. Increase fluid intake to one (1) liter daily to thin secretions.
4. Recognize and report signs and symptoms of respiratory infections.
5. Avoid anyone suspected of having an upper respiratory infection.

Answer 27

1. Clients and family members should be taught chest physiotherapy, including postural drainage, chest percussion, and vibration and breathing techniques to keep the lungs clear of the copious secretions
2. Daily activities should be modified to accommodate the client’s treatments.
3. Clients should increase fluids up to 3,000 mL each day to thin secretions and ease expectoration.
4. Clients should be taught the signs and symptoms of infections to report to the health-care provider.
5. Clients with CF are susceptible to respiratory infections and should avoid anyone who is suspected of having an infection.

Question 28

Which clinical manifestation indicates to the nurse the child has cystic fibrosis?

1. Wheezing with a productive cough.
2. Excessive salty sweat secretions.
3. Multiple vitamin deficiencies.
4. Clubbing of all fingers.

Answer 28

1. Wheezing and productive coughs are symptoms experienced by clients with respiratory diseases, but they are not specific to cystic fibrosis.
2. The excessive excretion of salt from the sweat glands is specific to cystic fibrosis. Repeated values greater than 60 mEq/L of sweat chloride is diagnostic for CF.
3. Multiple vitamin deficiencies are experienced with some pulmonary diseases, but they are not specific to cystic fibrosis.
4. Clubbing of the fingers is an indicator of chronic hypoxia, but it is not specific to the diagnosis of cystic fibrosis.

Question 29

The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?

1. The client has an elevation in the blood glucose.
2. The client has a decrease in sputum production.
3. The client has an increase in the temperature.
4. The client appears restless and is irritable.

Answer 29

1. An elevation in the blood glucose level is a common side effect of corticosteroids and does not indicate effectiveness of the treatment for bronchiolitis obliterans.
2. A decrease in sputum production indicates that the client is improving and the medication is effective; long-term use of corticosteroids is indicated for a client with bronchiolitis obliterans.
3. An elevated temperature indicates the client is becoming worse; therefore, the medication is not effective.
4. Restlessness and irritability can be side effects of treatment with corticosteroids or they could be signs of hypoxemia, which would indicate the medication is not effective.

Question 30

The nurse is discharging the client diagnosed with bronchiolitis obliterans. Which priority intervention should the nurse include?

1. Refer the client to the American Lung Association.
2. Notify the physical therapy department to arrange for activity training.
3. Arrange for oxygen therapy to be used at home.
4. Discuss advance directives with the client.

Answer 30

1. The American Lung Association is an excellent resource for educational material, but it is not the priority intervention for the client.
2. Physical therapy is an appropriate intervention, but it is not the priority intervention.
3. The client with bronchiolitis obliterans will need long-term use of oxygen.
4. Advance directives are an important intervention, but are not the priority intervention.

Question 31

The client admitted for recurrent aspiration pneumonia is at risk for bronchiectasis. Which intervention should the nurse anticipate the health-care provider to order?

1. Administer intravenous antibiotics for seven (7) days.
2. Insert a subclavian line and initiate total parenteral nutrition.
3. Provide a low-calorie and low-sodium restricted diet.
4. Encourage the client to turn, cough, and deep breathe frequently.

Answer 31

1. Antibiotics should be administered intravenously for seven (7) to 10 days. Bronchiectasis is an irreversible condition caused by repeated damage to the bronchial walls secondary to repeated aspiration of gastric contents.
2. Total parenteral nutrition is not an expected treatment for a client with bronchiectasis.
3. Clients should have a high-calorie and high-protein diet as a result of high expenditure of energy used to breathe and tissue healing.
4. Turning, coughing, and deep breathing are appropriate independent nursing inter- ventions but do not require a health-care provider’s order.

Question 32

Which collaborative intervention should the nurse implement when caring for the client diagnosed with bronchiectasis?

1. Prepare the client for an emergency tracheostomy.
2. Discuss postoperative teaching for a lobectomy.
3. Administer bronchodilators with postural drainage.
4. Obtain informed consent form for chest tube insertion.

Answer 32

1. Medical treatment for bronchiectasis does not include a tracheostomy.
2. Removing a lobe of the lung is not the expected medical treatment for a client with bronchiectasis.
3. Administering bronchodilators is a collaborative intervention (requiring an order from a health-care provider) appropriate for this client.
4. Insertion of chest tubes is not an expected treatment for bronchiectasis.

Question 33

The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?

1. A red area is a positive reading that means the client has tuberculosis.
2. The skin test is the only procedure needed to diagnose tuberculosis.
3. A positive reading means exposure to the tuberculosis bacilli.
4. Do not get another skin test for one (1) year if the skin test is positive.

Answer 33

1. A red and raised area at the injection site indicates that the client has been exposed to tuberculosis bacilli, but it does not indicate active disease.
2. The skin test indicates the client has been exposed to the tuberculosis bacilli, but further tests must be performed to confirm the diagnosis of tuberculosis.
3. A positive reading indicates the client has been exposed to the bacilli.
4. Once a positive reading occurs, then the client should never receive a Tb skin test again

Question 34

The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?

1. A decrease in the white blood cells in the sputum.
2. The client’s symptoms are improving.
3. No change in the chest x-ray.
4. The skin test is now negative.

Answer 34

1. Antitubercular medications target the tubercular bacilli, not white blood cells.
2. As the bacilli are being destroyed, the client should begin to feel better and have fewer symptoms.
3. At six (6) weeks, the chest x-ray may not have changes.
4. The skin test will always be positive.

Question 35

The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first?

1. Notify the respiratory therapist immediately.
2. Check the ventilator to determine the cause.
3. Elevate the head of the client’s bed.
4. Assess the client’s oxygen saturation.

Answer 35

1. The nurse needs to notify the respiratory therapist to check the ventilator, but it is not the first intervention.
2. The nurse must determine what is causing the alarm; a high or low alarm will make a difference in the nurse’s action.
3. Elevating the head of the bed will help lung expansion, but it is not the first intervention.
4. The ventilator alarm indicates something is wrong, and the nurse must first determine if the problem is with the ventilator or the client.

Question 36

The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced?

1. Myocardial infarction.
2. Pneumonia.
3. Pulmonary embolus.
4. Pneumothorax.

Answer 36

1. The nurse would not suspect a myocardial infarction for a client with a DVT who suddenly has chest pain.
2. These signs and symptoms should not make the nurse think the client has pneumonia.
3. Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary artery, and causes the chest pain; the client often feels as if he or she is going to die.
4. Chest pain is a sign of pneumothorax, but it is not a complication of deep vein thrombosis.

Question 37

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication?

1. The client’s partial thromboplastin time (PTT) is 38.
2. The client’s international normalized ratio (INR) is 5.
3. The client’s prothrombin time (PT) is 22.
4. The client’s erythrocyte sedimentation rate (ESR) is 10.

Answer 37

1. The PTT is not monitored to determine a serum therapeutic level for warfarin; nor- mal is 30 to 45.
2. The INR therapeutic range is 2 to 3 for a client receiving warfarin. The INR may be allowed to go to 3.5 if the client has a mechanical cardiac valve, but nothing in the stem of the question indicates this.
3. The PT is monitored for oral anticoagulant therapy and should be 1.5 to 2 times the normal of 12; therefore, 22 is within therapeutic range and would not warrant the nurse questioning administering this medication.
4. The ESR is not monitored for oral anticoagulant therapy.

Question 38

The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first?

1. Milk the chest tube.
2. Check the tubing for kinks.
3. Instruct the client to cough.
4. Assess the insertion site.

Answer 38

1. No fluctuation in the water-seal chamber four (4) hours postinsertion indicates the tubing is blocked; the nurse can milk the chest tube, but it is not the first action.
2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle.
3. Coughing may help push a clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere.
4. The insertion site can be assessed, but it will not help determine why there is no fluctuation in the water-seal drainage compartment.

Question 39

The health-care provider has ordered a continuous intravenous infusion of aminophylline. The client weighs 165 pounds. The infusion order is 0.3 mg/kg/hr. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. At which rate should the nurse set the pump? _______

Answer 39

11 mL/hr.

First, convert pounds to kilograms:
165 pounds ÷ 2.2 = 75 kg
Then, determine how many milligrams of aminophylline per hour should be administered:
0.3 mg × 75 kg = 22.5 mg/hr
Then, determine how much aminophylline is delivered per milliliter: 500mg÷250mL=2mg/1mL
If 2 mg/1 mL is delivered, then to deliver the prescribed 22.5 mg/hr, the rate must be set at:
22.5 ÷ 2 = 11.25 mL/hr
Less than 0.5 should be rounded down, 0.5 and above is rounded up.

Question 40

The client diagnosed with a cold is taking an antihistamine. Which statement indicates to the nurse the client needs more teaching concerning the medication?

1. “If my mouth gets dry I will suck on hard candy.”
2. “I will not drink beer or any type of alcohol.”
3. “I need to be careful when I drive my car.”
4. “This medication will make me sleepy.”

Answer 40

1. Antihistamines dry respiratory secretions through an anticholinergic effect; therefore, the client will have a dry mouth.
2. Antihistamines cause drowsiness; therefore, the client should not drink any type of alcohol.
3. Antihistamines cause drowsiness, so the client should not drive or operate any type of machinery.
4. Antihistamines cause drowsiness; therefore, the client understands the teaching.

Question 41

The client with a cold asks the nurse, “Is it all right to take echinacea for my cold?” Which statement is the nurse’s best response?

1. “You should discuss that with your health-care provider.”
2. “No, you should not take any type of herbal medicine.”
3. “Yes, but do not take it for more than 3 days.”
4. “Echinacea may help with the symptoms of your cold.”

Answer 41

1. The nurse can answer client’s questions concerning herbal medication. Passing the buck should be eliminated as a possible correct answer.
2. The nurse should not be judgmental. If the client does not have comorbid condi- tions, is not taking other medications, or is not pregnant, herbal medications may be helpful in treating the common cold.
3. Echinacea should not be taken for more than two (2) weeks, not three (3) days. Nothing cures the common cold; the cold must run its course.
4. Echinacea is an herb that may reduce the duration and symptoms of the common cold, but nothing cures the common cold. If the client does not have comorbid conditions, is not taking other medications, and is not pregnant, herbal medications may be helpful in treating the common cold.

Question 42

Which intervention should the nurse implement for the client experiencing bronchospasms?

1. Administer intravenous epinephrine, a bronchodilator.
2. Administer Albuterol, a bronchodilator, via nebulizer.
3. Request a STAT portable chest x-ray at the bedside.
4. Insert a small nasal trumpet in the right nostril.

Answer 42

1. Epinephrine is administered intravenously during an arrest in a code situation, but it is not a treatment of choice for bronchospasms.
2. Albuterol given via nebulizer is adminis- tered to stop the bronchospasms. If the client continues to have the bron- chospasms, intubation may be needed.
3. A STAT portable x-ray will be ordered, but the goal is to prevent respiratory arrest.
4. Nasal trumpet airways would not be helpful in stopping the bronchospasm and respiratory arrest

Question 43

The nurse is caring for a female client who is anxious, has a respiratory rate of 40, and is complaining of her fingers tingling and her lips feeling numb. Which intervention should the nurse implement first?

1. Have the client take slow, deep breaths.
2. Instruct her to put her head between her legs.
3. Determine why she is feeling so anxious.
4. Administer Xanax, an antianxiety agent.

Answer 43

1. The client is hyperventilating and blowing off too much CO2, which is why her fingers are tingling and her mouth is numb; she needs to retain CO2 by taking slow deep breaths.
2. Putting the head between the legs sometimes helps a client who is going to faint, but it is not the first intervention.
3. The client is hyperventilating; determining why is not appropriate at this time.
4. Medications take up to 30 minutes to one (1) hour to work and are not the first intervention for the client who is hyperventilating.

Question 44

The client diagnosed with pneumonia has arterial blood gases of pH 7.33, PaO2 94, PaCO2 47, HCO3 25. Which intervention should the nurse implement?

1. Administer sodium bicarbonate.
2. Administer oxygen via nasal cannula.
3. Have the client cough and deep breathe.
4. Instruct the client to breathe into a paper bag.

Answer 44

1. Sodium bicarbonate is administered for metabolic acidosis.
2. The arterial oxygen level is within normal limits (80 to 100); therefore, the client does not need oxygen.
3. The client is retaining CO2, which causes respiratory acidosis, and the nurse should help the client remove the CO2 by instructing the client to cough and deep breathe.
4. Breathing into a paper bag is not recommended for clients in respiratory acidosis.

Question 45

The nurse is assessing the client diagnosed with a lung abscess. Which information supports this diagnosis of lung abscess?

1. Tympanic sounds elicited by percussion over the site.
2. Inspiratory and expiratory wheezes heard over the upper lobes.
3. Decreased breath sounds with a pleural friction rub.
4. Asymmetric movement of the chest wall with inspiration.

Answer 45

1. Dull sounds would be heard over the site of a lung abscess as a result of the solid mass.
2. Crackles may be heard, but wheezes indicate a narrowing of airways, not exudate-filled airways.
3. Diminished or absent sounds are heard with intermittent pleural friction rubs. A lung abscess is the accumulation of pus in an area where pneumonia was present that becomes encapsulated and can extend to the bronchus or pleural space.
4. Even with a lung abscess, the chest should move symmetrically.

Question 46

The public health department nurse is caring for the client diagnosed with active tuberculosis who has been placed on directly observed therapy (DOT). Which statement best describes this therapy?

1. The nurse accounts for all medications administered to the client.
2. The nurse must complete federal, state, and local forms for this client.
3. The nurse must report the client to the Centers for Disease Control.
4. The nurse must watch the client take the medication daily.

Answer 46

1. Nurses are responsible for accounting for medications, but it is not the rationale for DOT.
2. Nurses complete forms as required by all governmental agencies, but this is not the rationale for DOT.
3. Documentation of events concerning the client’s treatment is completed, but this is not the rationale for DOT.
4. To ensure the compliance with all medications regimens, the health department has adapted a directly observed therapy (DOT) where the nurse actually observes the client taking the medication every day.

Question 47

Which intervention should the nurse implement first when caring for a client with a respiratory disorder?

1. Administer a respiratory treatment.
2. Check the client’s radial pulses daily.
3. Monitor the client’s vital signs daily.
4. Assess the client’s capillary refill time.

Answer 47

1. The nurse should gather data before implementing an intervention.
2. The radial pulse would indicate the cardiovascular status of the client, not the respiratory status, and the nurse should assess the apical pulse.
3. Daily vital signs would not indicate the respiratory status of the client.
4. Assessing the client’s capillary refill time has the highest priority for the nurse because it indicates the oxygenation of the client.

Question 48

The nurse is preparing to hang the next bag of aminophylline, a bronchodilator, for the client diagnosed with asthma. The current theophylline level is 18 mcg/mL. Which intervention should the nurse implement?

1. Hang the next bag and continue the infusion.
2. Do not hang the next bag and decrease the rate.
3. Notify the health-care provider of the level.
4. Confirm the current serum theophylline level.

Answer 48

1. The therapeutic level is 10 to 20 mcg/mL; therefore, the nurse should hang the bag and continue the infusion to maintain the aminophylline level.
2. There is no reason not to hang the next bag of aminophylline.
3. There is no need to notify the health-care provider for a level of 18 mcg/mL.
4. There is no need for the nurse to confirm the laboratory results.

Question 49

Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection?

1. Monitor the client’s current temperature.
2. Monitor the client’s white blood cells.
3. Determine if a culture has been collected.
4. Determine the compatibility of fluids.

Answer 49

1. The client’s current temperature would not affect the administration of the antibiotic.
2. The client’s white blood cells may be elevated because of the infection, but this would not affect administering the medication.
3. A culture needs to be collected prior to the first dose of antibiotic, or the culture and sensitivity will be skewed and the appropriate antibiotic needed to treat the respiratory infection may not be identified.
4. Compatibility of fluids should be assessed prior to administering each intravenous antibiotic, but when administering the first dose of an antibiotic, the nurse must check to make sure the sputum culture was obtained.

Question 50

Which nursing interventions should the nurse implement for the client who has a respiratory disorder? Select all that apply.

1. Administer oxygen via a nasal cannula.
2. Assess the client’s lung sounds.
3. Encourage the client to cough and deep breathe.
4. Monitor the client’s pulse oximeter reading.
5. Increase the client’s fluid intake.

Answer 50

1. A client with a respiratory disorder may have decreased oxygen saturation; therefore, administering oxygen via a nasal cannula is appropriate.
2. The client’s lung sounds should be assessed to determine how much air is being exchanged in the lungs.
3. Coughing and deep breathing will help the client expectorate sputum, thus clearing the bronchial tree.
4. The pulse oximeter evaluates how much oxygen is reaching the periphery.
5. Increasing fluids will help thin secretions, making them easier to expectorate.

Question 51

The client in the intensive care unit (ICU) on a mechanical ventilator is bucking the ventilator, causing the alarms to sound, and is in respiratory distress. Which assessment data should the nurse obtain? List in the order of priority.

1. Assess the ventilator alarms.
2. Assess the client’s pulse oximetry reading.
3. Assess the client’s lung sounds.
4. Assess for symmetry of the client’s chest expansion.
5. Assess the client’s endotracheal tube for secretions.

Answer 51

In order of priority: 5, 2, 3, 4, 1.

5. The most common cause of bucking the ventilator is obstructed airway, which could be secondary to secretions in the airway, so assessing the client would be most appropriate.
6. Clients in the ICU are constantly monitored by pulse oximetry; therefore, the nurse should determine if the client has decreased oxygen saturation and if so, the nurse should start to “bag” the client. The client is in respiratory distress.
7. The nurse should assess the client’s lung fields to determine if air movement is occurring since the client is in respiratory distress.
8. A complication of mechanical ventilation is a pneumothorax, and the nurse should assess for this since the client is in respiratory distress.
9. The machine is alerting the nurse there is a problem with the client; since the client is in respiratory distress, the client should be assessed first. If the client were not in distress, then the nurse should assess the machine first to determine which alarm is sounding.