Respiratory Flashcards
A nurse is assessing a patient with a pleural effusion. Which of the following clinical manifestations should the nurse expect?
A) Hyperresonance on percussion
B) Increased tactile fremitus
C) Diminished breath sounds
D) Chest pain that improves with deep inspiration
Correct Answer: C) Diminished breath sounds
Rationale: Pleural effusion involves an abnormal accumulation of fluid in the pleural space, leading to decreased or absent breath sounds due to reduced lung expansion.
(A) Hyperresonance is seen in pneumothorax, not pleural effusion.
(B) Increased tactile fremitus occurs in conditions like pneumonia, where lung tissue is consolidated. Pleural effusion causes decreased tactile fremitus due to fluid dampening vibrations.
(D) Chest pain in pleural effusion worsens with deep inspiration due to pleural irritation.
A patient with pneumonia develops an empyema. Which of the following interventions should the nurse anticipate?
A) Administration of bronchodilators
B) Initiation of chest tube drainage
C) Encouraging frequent coughing and deep breathing
D) Placing the patient in Trendelenburg position
Correct Answer: B) Initiation of chest tube drainage
Rationale: Empyema is a pleural effusion with pus, often requiring chest tube placement to drain infected fluid.
(A) Bronchodilators are not the primary treatment for empyema; they are used for airway diseases like asthma or COPD.
(C) Encouraging coughing and deep breathing helps with airway clearance but does not directly resolve an empyema.
(D) Trendelenburg position is contraindicated because it can worsen breathing difficulties.
The nurse is caring for a patient with a tension pneumothorax. Which of the following findings requires immediate intervention?
A) Sudden onset of dyspnea
B) Tracheal deviation to the unaffected side
C) Subcutaneous emphysema
D) Chest pain with deep inspiration
Correct Answer: B) Tracheal deviation to the unaffected side
Rationale: Tracheal deviation is a late and life-threatening sign of a tension pneumothorax, indicating increased pressure compressing the heart and great vessels. Emergency needle decompression is required.
(A) Sudden dyspnea is expected but not as critical as tracheal deviation.
(C) Subcutaneous emphysema (air under the skin) is a common finding but not immediately life-threatening.
(D) Chest pain with deep inspiration is seen in pneumothorax but is not as urgent as tracheal deviation.
A patient with a flail chest is experiencing paradoxical chest movement. Which action should the nurse take first?
A) Encourage incentive spirometry
B) Administer humidified oxygen
C) Prepare for mechanical ventilation
D) Assess for subcutaneous emphysema
Correct Answer: B) Administer humidified oxygen
Rationale: Flail chest results in ineffective ventilation, so oxygenation is the priority.
(A) Incentive spirometry is useful but does not address immediate hypoxia.
(C) Mechanical ventilation may be needed if oxygenation fails, but the first step is oxygen administration.
(D) Subcutaneous emphysema is an assessment finding but not a priority intervention.
A nurse is caring for a patient with a chest tube following a hemothorax. Which finding should the nurse report immediately?
A) Continuous bubbling in the water-seal chamber
B) Drainage of 60 mL in the past hour
C) Tidaling in the water-seal chamber
D) The chest tube dressing is dry and intact
Correct Answer: A) Continuous bubbling in the water-seal chamber
Rationale: Continuous bubbling in the water-seal chamber suggests an air leak, which must be addressed immediately.
(B) Drainage of 60 mL per hour is within normal limits.
(C) Tidaling (fluid movement) in the water-seal chamber is expected with breathing.
(D) A dry and intact dressing indicates proper tube placement.
A patient is diagnosed with a chylothorax. Which finding is characteristic of this condition?
A) Pus-filled pleural fluid
B) Straw-colored pleural fluid
C) Milky white pleural fluid
D) Clear-yellow pleural fluid
Correct Answer: C) Milky white pleural fluid
Rationale: Chylothorax is a pleural effusion caused by lymphatic fluid leakage, resulting in milky white fluid with a high lipid content.
(A) Pus-filled pleural fluid is seen in empyema.
(B) Straw-colored pleural fluid is common in exudative effusions.
(D) Clear-yellow fluid is seen in transudative effusions.
A nurse is assisting with a thoracentesis. Which position should the patient be placed in?
A) Supine with a pillow under the head
B) High Fowler’s with arms resting on a table
C) Side-lying with the affected lung down
D) Prone with arms above the head
Correct Answer: B) High Fowler’s with arms resting on a table
Rationale: Thoracentesis involves inserting a needle into the pleural space to drain fluid. The best position is sitting upright, leaning over a table, which expands the intercostal spaces for easier needle insertion.
A) Supine positioning is incorrect because it does not allow fluid to pool at the lower lung.
(C) Side-lying position may be used post-procedure but is not ideal during the procedure.
(D) Prone position is inappropriate for thoracentesis
A patient with a spontaneous pneumothorax asks the nurse how this condition developed. Which response by the nurse is most appropriate?
A) “It occurs due to an infection that fills the pleural space with pus.”
B) “It happens when the lung collapses due to a sudden rupture of air-filled sacs.”
C) “It is caused by an accumulation of blood between the lung and chest wall.”
D) “It results from excessive fluid buildup in the pleural space, compressing the lung.”
Correct Answer: B) “It happens when the lung collapses due to a sudden rupture of air-filled sacs.”
Rationale: Spontaneous pneumothorax occurs when blebs (air-filled sacs) rupture, allowing air to enter the pleural space, leading to lung collapse.
(A) Infection with pus in the pleural space describes empyema, not pneumothorax.
(C) Blood accumulation in the pleural space describes hemothorax, not pneumothorax.
(D) Excess fluid buildup describes pleural effusion, not pneumothorax.
Which finding indicates that a tension pneumothorax is worsening?
A) Diminished breath sounds on the affected side
B) Hyperresonance on percussion
C) Deviated trachea to the unaffected side
D) Mild tachycardia and dyspnea
Correct Answer: C) Deviated trachea to the unaffected side
Rationale: Tracheal deviation is a late and life-threatening sign of tension pneumothorax, requiring emergency needle decompression.
(A) Diminished breath sounds are expected but not an indicator of worsening.
(B) Hyperresonance is a sign of trapped air but does not indicate progression.
(D) Mild tachycardia and dyspnea are early symptoms but not as critical as tracheal deviation.
A nurse is preparing a patient for chest tube insertion due to a pneumothorax. Which statement by the patient requires further teaching?
A) “The chest tube will help remove air from my lung.”
B) “I should try to avoid coughing or deep breathing after the procedure.”
C) “The healthcare provider will confirm placement with a chest X-ray.”
D) “I should notify the nurse if I feel sudden chest pain or difficulty breathing.”
Correct Answer: B) “I should try to avoid coughing or deep breathing after the procedure.”
Rationale: Coughing and deep breathing help prevent lung collapse and promote lung re-expansion.
(A) Chest tubes remove air or fluid from the pleural space, which is correct.
(C) A chest X-ray confirms placement, which is standard practice.
(D) Sudden chest pain or difficulty breathing could indicate a complication, requiring immediate assessment.
A patient with a hemothorax has a chest tube connected to a drainage system. The nurse should intervene if which finding is noted?
A) The water-seal chamber fluctuates with respiration.
B) There is continuous bubbling in the water-seal chamber.
C) 100 mL of bloody drainage is noted in the past hour.
D) The chest tube dressing is dry and intact.
Correct Answer: B) There is continuous bubbling in the water-seal chamber.
Rationale: Continuous bubbling indicates an air leak in the system, requiring immediate intervention.
(A) Fluctuation in the water-seal chamber is expected.
(C) Drainage of 100 mL in an hour may be expected in acute bleeding, but continued excessive drainage should be monitored.
(D) A dry, intact dressing indicates proper placement.
Which intervention should the nurse perform after a thoracentesis?
A) Position the patient flat on their back for two hours.
B) Encourage the patient to drink fluids rapidly.
C) Monitor for signs of pneumothorax.
D) Apply heat packs to the puncture site
Correct Answer: C) Monitor for signs of pneumothorax.
Rationale: Thoracentesis involves fluid removal from the pleural space, which can lead to pneumothorax due to lung puncture.
(A) Keeping the patient flat is incorrect; they should be in an upright position.
(B) Drinking fluids is not relevant to this procedure.
(D) Heat packs are not necessary; a sterile dressing is applied instead
A patient with flail chest is experiencing paradoxical chest wall movement. The nurse should anticipate which intervention?
A) Immediate needle decompression
B) High-flow oxygen therapy
C) Chest tube insertion
D) Administration of thrombolytic therapy
Correct Answer: B) High-flow oxygen therapy
Rationale: Flail chest results in impaired ventilation, so oxygenation is the priority.
(A) Needle decompression is for tension pneumothorax, not flail chest.
(C) Chest tubes are not always needed for flail chest unless a pneumothorax is present.
(D) Thrombolytics are for blood clots, not flail chest.
Which patient is at highest risk for developing a spontaneous pneumothorax?
A) A 40-year-old obese male with asthma
B) A 22-year-old tall, thin male who smokes
C) A 65-year-old female with hypertension
D) A 30-year-old male with a history of pleural effusion
Correct Answer: B) A 22-year-old tall, thin male who smokes
Rationale: Spontaneous pneumothorax most commonly occurs in tall, thin males who smoke, due to the rupture of blebs.
A patient with a tension pneumothorax is undergoing needle decompression. What is the priority assessment after the procedure?
A) Lung sounds and respiratory status
B) Blood pressure and heart rate
C) Chest tube output
D) Capillary refill time
Correct Answer: A) Lung sounds and respiratory status
Rationale: After needle decompression, assessing lung sounds and breathing ensures the lung is re-expanding properly.
The nurse is teaching a patient about pleural effusion. Which statement indicates correct understanding?
A) “It is caused by air trapped in the pleural space.”
B) “It can be caused by infections, cancer, or heart failure.”
C) “It occurs when the diaphragm becomes paralyzed.”
D) “It only occurs in patients who are bedridden for long periods.”
Correct Answer: B) “It can be caused by infections, cancer, or heart failure.”
Rationale: Pleural effusion has multiple causes, including infection, malignancy, and heart failure.
A patient with a chest tube suddenly develops severe shortness of breath and absent breath sounds on the affected side. What is the nurse’s priority action?
A) Clamp the chest tube immediately
B) Notify the healthcare provider
C) Assess the chest tube for disconnection
D) Increase the suction setting
Correct Answer: C) Assess the chest tube for disconnection
Rationale: Sudden severe SOB and absent breath sounds may indicate chest tube dislodgement, leading to tension pneumothorax. Checking for disconnection is the priority action before further interventions.
A patient with pleural effusion is scheduled for a thoracentesis. The nurse understands that which potential complication is the most serious?
A) Pain at the insertion site
B) Hypotension
C) Pneumothorax
D) Mild shortness of breath
Correct Answer: C) Pneumothorax
Rationale: Pneumothorax is the most serious complication of thoracentesis, as lung puncture can cause air to enter the pleural space, leading to lung collapse.
(A) Pain is expected but not life-threatening.
(B) Hypotension may occur with excessive fluid removal but is less critical than pneumothorax.
(D) Mild SOB may happen but should resolve after the procedure.
Which of the following interventions is most appropriate for a patient with a pleural effusion who is experiencing respiratory distress?
A) Position the patient supine
B) Encourage deep breathing exercises
C) Prepare the patient for a thoracentesis
D) Administer antihistamines for symptom relief
Correct Answer: C) Prepare the patient for a thoracentesis
Rationale: Thoracentesis removes excess fluid from the pleural space, relieving respiratory distress.
(A) Supine positioning may worsen breathing.
(B) Deep breathing helps lung expansion but does not remove fluid.
(D) Antihistamines are not useful for pleural effusions.
A patient with a chest tube for a pneumothorax suddenly has continuous bubbling in the water-seal chamber. What is the priority action?
A) Increase the suction pressure
B) Assess the system for an air leak
C) Clamp the chest tube
D) Encourage coughing and deep breathing
Correct Answer: B) Assess the system for an air leak
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, requiring assessment and correction.
The nurse is teaching a patient about transudative pleural effusions. Which statement by the patient indicates correct understanding?
A) “This type of effusion is caused by an inflammatory response.”
B) “My heart failure likely caused this fluid buildup.”
C) “It is associated with infections like pneumonia.”
D) “This condition is caused by an increase in lung compliance.”
Correct Answer: B) “My heart failure likely caused this fluid buildup.”
Rationale: Transudative pleural effusions are non-inflammatory and often result from heart failure, liver disease, or kidney disease.
A nurse is caring for a patient with a hemothorax. Which assessment finding requires immediate intervention?
A) Decreased breath sounds
B) Respiratory rate of 22 breaths/min
C) Tracheal deviation
D) Mild chest discomfort
Correct Answer: C) Tracheal deviation
Rationale: Tracheal deviation indicates tension pneumothorax, a medical emergency requiring needle decompression.
A patient is being treated for an open pneumothorax. What is the priority nursing intervention?
A) Apply a vented dressing over the wound
B) Insert a chest tube immediately
C) Encourage the patient to deep breathe
D) Position the patient on the affected side
Correct Answer: A) Apply a vented dressing over the wound
Rationale: A vented dressing (three-sided dressing) prevents additional air from entering the pleural space while allowing trapped air to escape.
Which assessment finding is most concerning in a patient with flail chest?
A) Paradoxical chest movement
B) Respiratory rate of 18 breaths/min
C) Diminished breath sounds bilaterally
D) Pain at the fracture site
Correct Answer: A) Paradoxical chest movement
Rationale: Paradoxical movement indicates severe impairment of ventilation, which may require mechanical ventilation.
Which of the following patients is at greatest risk for developing a spontaneous pneumothorax?
A) A patient with a history of asthma
B) A tall, thin, young male smoker
C) A patient with uncontrolled hypertension
D) A patient with an upper respiratory infection
Correct Answer: B) A tall, thin, young male smoker
Rationale: Spontaneous pneumothorax most commonly occurs in tall, thin young males who smoke due to the rupture of subpleural blebs.
A patient is diagnosed with empyema. The nurse anticipates which primary intervention?
A) Thoracentesis
B) Antibiotic therapy and drainage
C) Incentive spirometry
D) Bronchodilator therapy
Correct Answer: B) Antibiotic therapy and drainage
Rationale: Empyema is an infectious pleural effusion that requires antibiotics and chest tube drainage.
A patient is admitted with a tension pneumothorax. What is the priority intervention?
A) Administer high-flow oxygen
B) Perform an emergency needle decompression
C) Place the patient in Trendelenburg position
D) Obtain a CT scan
Correct Answer: B) Perform an emergency needle decompression
Rationale: Tension pneumothorax requires immediate decompression to release trapped air and prevent cardiovascular collapse.
Question 1
A tension pneumothorax can cause a mediastinal shift, leading to ________________ deviation.
Answer: Tracheal
A patient with a flail chest exhibits ________________ chest movement, meaning the fractured segment moves opposite to the rest of the chest during breathing.
Answer: Paradoxical
In a chylothorax, the pleural fluid appears ________________ due to its high lipid content.
Answer: Milky white
A patient with pleural effusion is positioned in a ________________ position for a thoracentesis to allow optimal fluid drainage.
Answer: Sitting upright and leaning forward
In a chest tube drainage system, the ________________ chamber prevents air from re-entering the pleural space by acting as a one-way valve.
Answer: Water-seal
