patient with a respiratory disorder

Question 1

when are rapid and deeper respirations stimulated by the respiratory center of the brain

Answer 1

when carbon dioxide levels increase

Question 2

what is the most appropriate nursing intervention for a patient requiring finger probe pulse oximetry

Answer 2

remove the sensor between oxygen saturation readings

Question 3

the walls of the thoracic cavity are lined with a serous membrane composed of tough endotheilial cells; what is this membrane called

Answer 3

parietal pleura

Question 4

a 73 yr old patient is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breathe. what is the name of this abnormal condition, in which there is discomfort in breathing in any but an erect sitting position

Answer 4

orthopnea

Question 5

A 45 year old patient is being evaluated to rule out pulmonary tuberculosis (TB). which finding is most closely associated with TB

Answer 5

night sweats

Question 6

The health care workers caring for a patient with active TB are instructed in methods of protecting themselves from contracting TB. What does the Centers for Disease Control and Prevention currently recommend for health care workers who care for TB-infected patients

Answer 6

wear a small-micron, fitted filtration mask

Question 7

the health care provider ordered a blood culture and sputum specimen for a patient who has pneumonia. when should the nurse collect these specimens

Answer 7

• the morning after admission

- before initiation of antibiotic therapy

Question 8

A 62 year old patient has just returned to her room after a bronchoscopy. No food or fluids shall be given after the examination until which event has occurred

Answer 8

the patients gag reflex returns

Question 9

A 45 year old, second day postoperative patient is recovering from thoracic surgery. Which therapeutic nursing intervention would the nurse carry out first

Answer 9

help the patient cough and deep breathe by splinting the anterior and posterior chest

Question 10

which nursing diagnosis for a client with an acute asthma attach has the highest priority

Answer 10

ineffective airway clearance related to bronchoconstriction and increased mucous production

Question 11

A 52 year old patient had a laryngetomy due to cancer of the larynx. Discharge instructions are given to the patient and his family. Which response, by written communication from the patient or verbal response by the family, indicates that the instructions need to be clarified

Answer 11

report swelling, pain, or excessive drainage

Question 12

where do most pulmonary embolisms (PEs) orginate

Answer 12

deep-vein thrombosis (DVT)

Question 13

which health promotion activities planned by a nurse working with a group of community-dwelling senior citizens would be most likely to prevent influenza and pneumonia

Answer 13

• indoor exercise programs during the winter months
• Influenza vaccine clinics at the senior citizen centers
• teaching effective handwashing

Question 14

A patient was seen in a clinic for an episode of epistaxis which was controlled by placement of anterior nasal packing. during discharge teaching what instructions will the nurse discuss with the patient

Answer 14

leave the packing in place for 7 to 10 days until it is removed by the health care provider

Question 15

how is TB spread

Answer 15

inhaling the TB bacteria after a person with TB coughs, speaks, or sneezes

Question 16

a patient with TB has a nursing diagnosis of noncompliance. what does the nurse recognize as the most common etiologic factor

Answer 16

fatigue and lack of energy to manage self care

Question 17

to obtain optimal results from pulse oximetry, which statements are correct

Answer 17

• do not attach the transducer to an extremity that has a blood preassure cuff in place
• hypothermia, hypotension, and vasoconstriction can affect readings
• reduced body temperature will affect readings

Question 18

ineffective airway clearance, related to tracheobronchial obstruction or secretions, is a nursing diagnosis for a patient with COPD, which nursing interventions are correct

Answer 18

• offer small, frequent high-calorie, high- protein feedings
• encourage generous fluid intake
• have the patient turn and cough every 2 hours
• teach effective coughing technique

Question 19

ineffective breathing pattern, related to decreased lung expansion during an acute attack of asthma, is an appropriate nursing diagnosis. which nursing interventions are correct

Answer 19

• remain with patient during acute attack to decrease fear and anxiety
• incorporate rest period into activities and interventions
• maintain semi-fowler position to facilitate ventiliation

Question 20

what does the patient with respiratory acidosis demonstrate

Answer 20

• disorientation

- pH less than 7.35

Question 21

patient teaching after a tonsillectomy and adenoidectomy would include which instructions

Answer 21

• avoid attempting to clear the throat, coughing, and sneezing
• avoid vigorous nose blowing for 1 to 2 weeks
• notify the health care provider in case of increased pain, fever, or bleeding

Question 22

if the patient has an epistaxis, what is the correct nursing intervention

Answer 22

• place the patient in fowler postion with the head foward
• place ice compresses over the nose
• encourage slow, deep breathing through the mouth

Question 23

In pulmonary edema, what is often included in medical management

Answer 23

• furosemide ( lasix) IV
• oxygen therapy
• orthopneic position

Question 24

an appropriate nursing diagnosis for a patient with pulmonary edema is excess fluid volume, related to altered tissue permeability. which nursing interventions for this diagnosis are correct

Answer 24

• assess indicators of patients fluid volume status, such as breath sound, skin turgor and pedal, sacral, and periobital edema
• monitor intake and output accurately
• administer diuretic as ordered
• weigh daily

Question 25

the nurse should educate the patient in the proper techniques to use for the collection of a sputum specimen. which guidelines are correct

Answer 25

• explain to the patient the need to bring the sputum up from the lungs
• notify staff as soon as specimen is collected so it can be sent to the laboratory without delay
• place sputum specimen in sterile container

Question 26

medical management and nursing interventions for the patient with pulmonary embolism usually include

Answer 26

• administration of intravenous heparin per protocol
• semi fowlers position
• oxygen by mask or nasal cannula

Question 27

Which nursing intervention does the nurse add to the care plan to help a patient with thick sputum mobilize and expectorate those secretions?

Answer 27

Drink 3 to 4 L of water a day.

Question 28

A 62-year-old patient is seen in the emergency department with an epistaxis. When a patient has an epistaxis, the correct nursing interventions would be

Answer 28

place the patient in Fowler’s position with the head forward.

Elevate head of bed. Place patient in Fowler’s position with the head forward. Compression of nostrils should be for 10-15 minutes. Hot compresses will increase bleeding-ice should be applied.

Question 29

A 68-year-old male patient has chronic obstructive pulmonary disease (COPD). He has a markedly increased need for protein and calories to maintain an adequate nutritional status. To help him get the nutrition he needs, the nurse would encourage him to

Answer 29

rest 30 minutes before eating.

The nurse can assist the patient in maintaining nutritional intake by advising rest for 30 minutes before eating.

Question 30

An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. The chest radiograph reveals an accumulation of fluid in the pleural space, which the physician removes by performing a thoracentesis. The nurse correctly records the purulent exudate as:

Answer 30

empyema.

If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.

Question 31

The circulation of the lungs is through the

Answer 31

pulmonary arteries and pulmonary veins.

The lungs receive their blood supply, which comes directly from the heart, through the pulmonary arteries. The blood, now rich in oxygen, is returned to the heart for circulation to the body via the pulmonary veins to the left atrium.

Question 32

A 52-year-old patient has had a laryngectomy in treatment of cancer. A nursing diagnosis for the patient with a laryngectomy would be social isolation related to impaired verbal communication related to removal of the larynx. The correct nursing intervention would be

Answer 32

provide a pad and pencil or magic slate available.

Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation.

Question 33

Which instruction by the nurse is inappropriate for teaching the proper technique for collection a sputum specimen?

Answer 33

Collect specimens after meals.

Collecting specimens before meals will avoid possible emesis from coughing after eating.

Question 34

The patient has been admitted for possible carcinoma of the larynx. The first sign or symptom that may be present in carcinoma of the larynx is often

Answer 34

persistent hoarseness.

Progressive or persistent hoarseness is an early sign.

Question 35

A patient, age 69, has emphysema. On assessing him, the nurse notes the presence of a “barrel chest.” This pathology results from a(n)

Answer 35

increased anteroposterior diameter caused by overinflation of the alveoli.

The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation).

Question 36

The _________ are the structures of the lung in which gas exchange occurs.

Answer 36

alveoli

The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place.

Question 37

The nurse is caring for a patient with a diagnosis of pleural effusion. The physician is most likely to order a ______________ to remove fluid from around the lungs so that the patient may breathe more easily

Answer 37

thoracentesis

Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort.

Question 38

Identify the purposes of chest drainage: (Select all that apply)

Answer 38

Drains air, blood and fluid from pleural space
Restores positive pressure in chest cavity
Allows route for medication administration

A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavity’s normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water-seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space.

Question 39

Which interventions are health promotions to prevent pneumonia? (Select all that apply.)

Answer 39

• Encourage elder patients to receive influenza and pneumococcal vaccines.
• Provide for good health habits (nutrition, hygiene, exercise).
• Check for placement before administering tube feedings.

Older adults should receive pneumococcal and influenza vaccines. Good health habits are the basis for preventing disease. Aspiration can occur if the nasogastric tube is not correctly placed in the stomach. New stroke patients should be assisted with eating until the gag reflex is established.

Question 40

Interventions that contribute to comfort in patients experiencing dyspnea include: (Select all that apply)

Answer 40

• Breathing exercises
• Acupuncture
• Visualization
• Massage

Breathing exercises, acupuncture, visualization and massage help decrease the level of dyspnea by using distraction and relaxation methods to provide the patient with some control.

Question 41

A patient, age 22, is admitted with acute asthma. It is important to monitor his oxygen saturation levels. The quickest way to assess his saturation of oxygen is to

Answer 41

use pulse oximetry.

In acute asthma, oxygen therapy should be started immediately, and its administration should be monitored by pulse oximetry. Pulse oximetry is noninvasive and provides continuous monitoring of SaO2.

Question 42

A patient, age 54, is on postoperative day 2 after undergoing an open cholecystectomy. Immediately after the surgery, she vomited and may have aspirated some emesis. The nurse is concerned that the patient will develop pneumonia. In planning for her care, the nurse suspects the patient may have

Answer 42

aspiration pneumonia.

Aspiration pneumonia occurs most commonly as a result of aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure, drugs, alcohol, anesthesia, acute infection, or shock.

Question 43

The patient, age 91, has COPD and complains of dyspnea and fatigue. Activity intolerance, related to an imbalance between the oxygen supply and demand, is a nursing diagnosis for COPD. Which nursing intervention would be inappropriate?

Answer 43

Plan care to provide optimum rest.

Nursing interventions will be directed at attempting to decrease the patient’s anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living.

Question 44

The surgeon administers nasal epinephrine to a patient after nasal surgery. The nurse explains to the patient that this is done primarily to

Answer 44

reduce the possibility of bleeding.

1:1,000 epinephrine promotes local vasoconstriction and reduced the possibility of bleeding. Epinephrine does act as a bronchodilator, but is used primarily for vasoconstriction post nasal surgery.

Question 45

The nurse identifies a nursing diagnosis of Ineffective airway clearance for a patient, age 64, who has undergone a pneumonectomy. A common etiology for this nursing diagnosis in patients who have had a pneumonectomy is

Answer 45

surgical incision pain.

Nursing interventions are often directed at postsurgical interventions, including facilitating recovery and preventing complications by promoting effective airway clearance through frequent repositioning, coughing, and deep breathing. Surgical incisional pain prevents the patient from breathing deeply and coughing effectively.

Question 46

Which expected outcome(s) would indicate improvement in a patient with emphysema? (Select all that apply.)

Answer 46

Patent airway
Normal arterial blood gases (for this patient)
Decreased dyspnea

Patient will maintain patent airway as evidenced by decreased rhonchi, wheezes, tachypnea, dyspnea, and arterial blood gas (ABG) values within limits (for this patient).

Question 47

The patient has COPD. To teach him pursed-lip breathing, the nurse should instruct him to inhale slowly through his

Answer 47

nose, then exhale more slowly through pursed lips.

The nurse should instruct the patient and family on effective breathing techniques (such as pursed-lip breathing) and relaxation exercises for anxiety control. The patient should inhale through the nose and exhale through pursed lips. The exhalation should be 2 – 3 times longer than the inhalation.

Question 48

A patient, age 68, has a long history of COPD and is admitted to the hospital with cor pulmonale. He says his doctor said his heart was failing and asks whether he is having a heart attack. Which explanation by the nurse is most correct?

Answer 48

“You aren’t having a heart attack, but your heart has been damaged by changes in your lungs caused by your respiratory disease.”

Question 49

Which position is the most beneficial for a patient after surgery for creation of a tracheostomy?

Answer 49

Mid-Fowler’s

Maintain head of bed elevation of 30 degrees or higher (mid-Fowler’s).

Question 50

Prevention of acute respiratory complications in surgical patients is a nursing goal that involves which intervention?

Answer 50

Teaching all preoperative patients how to use incentive spirometers and how to cough and deep breathe effectively.

Postoperatively, patients should be reminded to cough, deep breathe, and change positions every 1 to 2 hours.

Question 51

During discharge teaching of a pulmonary emphysema patient who is going home with oxygen, what does the nurse emphasize?

Answer 51

“Keep low flow oxygen at 1 to 2 L by nasal cannula.”

Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body’s own respiratory regulatory centers.

Question 52

What does a nurse teach an adult male who has had a tonsillectomy?

Answer 52

Avoid coughing and clearing the throat during the first week postoperatively.

Question 53

The nurse is caring for a patient with bronchiectasis. Based on an understanding of the pathologic changes that occur with this disease, which intervention to promote clearance of respiratory secretions does the nurse plan?

Answer 53

Postural drainage

Encourage postural drainage. Suction the patient as needed and provide assistance in turning, coughing, and deep breathing every 2 hours. Assist with chest physiotherapy.

Question 54

Which are signs of respiratory distress?

Answer 54

Abdominal breathing, SaO2 89%

Observe the patient’s facial expressions and signs of respiratory distress such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing.

Question 55

When a patient has experienced a pneumothorax, chest auscultation reveals

Answer 55

bilateral unequal breath sounds, with no breath sounds over the affected area.

Question 56

The removal of fluid from the pleural space by thoracentesis presents a possible danger in removing fluid too rapidly. How much fluid removal is recommended at one time?

Answer 56

1,300 to 1,500 mL at one time

A possible danger from the thoracentesis procedure is removing fluid too rapidly; less than 1,300 to 1,500 mL at one time is recommended.