Chapter 31: Acute Disorders of the Lower Respiratory Tract Nursing School Test Banks

Chapter 31: Acute Disorders of the Lower Respiratory Tract
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. A patient asks the nurse how air goes from the nose to the lung. The nurse draws the route according to which sequence?
a. Trachea, larynx, bronchi
b. Pharynx, trachea, bronchi, alveoli
c. Bronchi, trachea, bronchioles
d. Larynx, trachea, alveoli, bronchi
ANS: B
The route of inspired air is pharynx, trachea, bronchi, and alveoli.

DIF: Cognitive Level: Knowledge REF: p. 558 OBJ: N/A
TOP: Physiology of Ventilation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. A nurse charts that a patient has had periods of tachypnea during the night. What does this means in regard to the respiration rate?
a. Below 12 breaths/min
b. Uneven, with periods of apnea
c. Gradually deepening, then shallow, and then periods of apnea
d. Above 20 breaths/min
ANS: D
Tachypnea is a respiration rate above 20 breaths/min. Option a describes bradypnea, option b describes Biot respirations, and option c describes Cheyne-Stokes respirations.

DIF: Cognitive Level: Comprehension REF: p. 559 OBJ: 1
TOP: Respiration Rate KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A 90-year-old patient complains to the nurse of shortness of breath after walking up a flight of stairs. What age-related change should the nurse explain results in this problem?
a. Flexible rib cage
b. High-arched diaphragm
c. Increased chest movement
d. Enlarged bronchioles
ANS: D
Enlarged bronchioles require the inspiration of greater amounts of air. Other age-related changes make increased inspiration difficult.

DIF: Cognitive Level: Comprehension REF: p. 558 OBJ: 2
TOP: Age-Related Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. What should the nurse exclude when documenting the findings in the functional assessment portion of the nursing assessment for a patient with a respiratory disorder?
a. Occupation
b. Usual diet
c. Smoking history
d. Previous respiratory disorders
ANS: D
Previous respiratory disorders are assessed in the medical history portion of the assessment.

DIF: Cognitive Level: Comprehension REF: p. 560 OBJ: 1
TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. To auscultate breath sounds in the right middle lobe from the anterior aspect, the nurse should place the diaphragm of the stethoscope at which intercostal space?
a. Second
b. Third
c. Fourth
d. Fifth
ANS: D
The fifth intercostal space is the optimal position for auscultating the right middle lobe.

DIF: Cognitive Level: Application REF: p. 561 OBJ: 3
TOP: Breath Sounds KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. What should the nurse suspect regarding the bronchus when auscultating coarse crackles in the lower right lobe?
a. Partially filled with fluid
b. Narrowed by spasm
c. Partially filled with thick mucus
d. Completely obstructed
ANS: A
Coarse crackles are indicative of fluid in the bronchi. Many times these sounds can be cleared by coughing.

DIF: Cognitive Level: Application REF: p. 561 OBJ: 1
TOP: Breath Sounds KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

7. A worried patient asks the nurse to explain the advantage of a fluoroscopy. What is the nurses best response regarding fluoroscopy?
a. Shows respiratory function in motion
b. Helps the physician evaluate ventilation-perfusion ratio
c. Allows the physician to take tissue samples
d. Facilitates the removal of fluid from the bronchi
ANS: A
A fluoroscopy allows the visualization of both lungs while the patient is in the process of ventilation.

DIF: Cognitive Level: Comprehension REF: p. 563 OBJ: 3
TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. Which nursing intervention is inappropriate in the immediate postprocedure care of a patient who has had a fiberoptic bronchoscopy?
a. Place the patient in a semi-Fowler position.
b. Offer fluids to assess swallowing ability.
c. Assess for diminished breath sounds.
d. Assess for stridor.
ANS: B
Patients are placed on nothing by mouth diet until the gag reflex returns.

DIF: Cognitive Level: Application REF: p. 564 OBJ: 3
TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

9. What is the importance of the nurse closely monitoring bilateral breath sounds and chest movement after a thoracentesis?
a. Fluid may quickly accumulate as a result of inflammation.
b. The lung may have been punctured during the procedure.
c. Severe bronchospasm may cause atelectasis.
d. Asthma may result after the procedure.
ANS: B
A possibility exists that the lung could have been punctured during the procedure. Bronchospasm, fluid collection, and asthma are not concerns related to a thoracentesis.

DIF: Cognitive Level: Comprehension REF: p. 564 | p. 569
OBJ: 3 TOP: Diagnostic Tests
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

10. Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?
a. 1 day after injection with a 10-mm area of redness and swelling
b. 2 days after injection with a 5-mm area of redness and swelling
c. 4 days after injection with a 3-mm area of redness and swelling
d. 5 days after injection with a 2-mm area of redness and swelling
ANS: B
A positive reading of a TB skin test is an area of redness and swelling of 5 mm or larger 24 to 48 hours after injection.

DIF: Cognitive Level: Comprehension REF: p. 564 OBJ: 3
TOP: Diagnostic Tests KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. A nurse performs an Allen test before performing the arterial stick for an arterial blood gas. What does this test assess?
a. Respiratory function
b. Tidal volume
c. Concentration of oxygen
d. Perfusion of the hand
ANS: D
The perfusion of the hand by the radial and ulnar arteries is assessed because the puncture of the radial artery might cause it to occlude.

DIF: Cognitive Level: Comprehension REF: p. 565 OBJ: 3
TOP: Diagnostic Tests KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

12. A patient who is severely dyspneic and cyanotic enters the emergency department. What rate should a nurse administer oxygen to the patient?
a. 2 L to preserve the hypoxic drive
b. 6 L to relieve the dyspnea
c. 8 L, humidified, to liquefy secretions
d. 10 L, humidified aerosol, to dilate the bronchi
ANS: A
Low-dose oxygen is a safe initial dose to ensure that the hypoxic drive be preserved, especially for a patient whose history is unknown.

DIF: Cognitive Level: Application REF: p. 572 OBJ: 4
TOP: Oxygen Administration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

13. Which assessment indicates to the nurse that the chest tube in a water seal drainage device is working correctly?
a. Constant bubbling in the suction control chamber
b. Decrease of accumulation in the drainage chamber
c. Fluctuation of the column of water in the water seal
d. Constant bubbling in the water seal chamber
ANS: C
The fluctuation of the level in the water seal indicates patency of the tubes with the reinflating lung. Constant bubbling in the wet suction control is normal. Constant bubbling in the water seal indicates an air leak. Decreasing drainage is normal.

DIF: Cognitive Level: Comprehension REF: p. 575-576 OBJ: 4
TOP: Water Seal Drainage KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. Which assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage device should require intervention?
a. Dependent loops in the chest tube
b. Patient in a semi-Fowler position
c. Changing level of water in the water seal chamber
d. Increased level of drainage to 20 mL in 8 hours
ANS: A
Dependent loops in the chest tube can collect drainage and occlude the system.

DIF: Cognitive Level: Application REF: p. 575-576 OBJ: 4
TOP: Water Seal Drainage KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. A home health nurse that is caring for an 88-year-old patient with severe hypertension in addition to a respiratory problem notices several drugs on the bedside table. Which medication should the nurse suggest the patient avoid?
a. Aspirin
b. Colace
c. Expectorant
d. Decongestant
ANS: D
Decongestants increase the blood pressure.

DIF: Cognitive Level: Application REF: p. 578 OBJ: 5
TOP: Respiratory Drugs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

16. How should a nurse position a patient who had a left pneumonectomy in the morning in an effort to enhance gas exchange?
a. On the right side
b. On the left side
c. In a semi-Fowler position
d. In a flat position with a small pillow
ANS: C
Elevation of the head helps gas exchange in the patient with a new pneumonectomy. A complete side-lying position on the unaffected side may cause mediastinal shift.

DIF: Cognitive Level: Application REF: p. 577 OBJ: 5
TOP: Postpneumonectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. A patient with acute bronchitis is being discharged with a prescription for an antimicrobial medication to be taken for the next 14 days. What should the nurse stress when providing discharge teaching?
a. Take the drug on an empty stomach before meals.
b. Complete the entire course as prescribed.
c. Maintain a thorough oral hygiene regimen.
d. Maintain a daily fluid intake of 500 mL.
ANS: B
The entire course of the prescription should be taken to destroy the pathogen completely; otherwise, the pathogen may become resistant to the drug.

DIF: Cognitive Level: Comprehension REF: p. 583 OBJ: 6
TOP: Acute Bronchitis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

18. Which group of patients should a nurse advise to have a vaccination with conjugated pneumococcal?
a. Adults with diabetes
b. Persons 65 years and older
c. Parents of children younger than 24 months
d. Persons with cardiovascular disorders
ANS: C
The conjugated product is especially designed for young children. Unconjugated vaccine is recommended for older adults and those with cardiovascular disorders.

DIF: Cognitive Level: Comprehension REF: p. 585 OBJ: 5
TOP: Pneumonia Vaccine KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

19. What action should a nurse implement to reduce the risk of aspiration in a patient receiving continuous enteral feedings at a rate of 70 mL/hr?
a. Check the position of the tube during every shift.
b. Notify the charge nurse or physician about a residual volume of 20 mL.
c. Elevate the patients head during and for 10 minutes after feeding.
d. Position the patient on the left side after the feeding.
ANS: B
A residual of more than 20% of the hourly rate should be reported so that the rate can be reduced (70 mL multiplied by 0.20 = 14).

DIF: Cognitive Level: Application REF: p. 588 OBJ: 5
TOP: Aspiration Pneumonia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. What symptoms should a nurse expect to see in a patient with hypoxemia?
a. Restlessness, tachycardia, and tachypnea
b. Bradycardia, cyanosis, and restlessness
c. Dyspnea, flushed face, and tachycardia
d. Cyanosis, nausea, and bradycardia
ANS: A
The universal symptoms of hypoxemia, regardless of cause, are restlessness, tachycardia, and tachypnea.

DIF: Cognitive Level: Comprehension REF: p. 571 | p. 592
OBJ: 6 TOP: Hypoxemia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. A patient comes to the emergency department with a sucking chest wound. Which type of dressing should the nurse apply to begin the process of lung reinflation?
a. Petroleum dressing covered with an airtight bandage
b. No dressing at all
c. Pillow weighted down with a sandbag
d. Air-occlusive dressing taped on three sides (vented dressing)
ANS: D
The vented dressing occludes air from entering but allows air to escape, avoiding a tension pneumothorax and mediastinal shift.

DIF: Cognitive Level: Application REF: p. 589 OBJ: 6
TOP: Pneumothorax Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. What should a nurse prepare when assessing paradoxical movement in a patient with a flail chest who has significant dyspnea?
a. Thoracotomy
b. Intubation
c. Thoracentesis
d. Body cast
ANS: B
A patient with an unstable chest usually requires intubation and mechanical ventilation.

DIF: Cognitive Level: Application REF: p. 592-293 OBJ: 6
TOP: Flail Chest KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

23. Which intervention would be inappropriate for decreasing the risk of further emboli in a patient with a pulmonary embolism?
a. Carefully applying compression stockings
b. Performing passive range-of-motion exercises, especially of the lower limbs
c. Placing pillows under the knees to elevate the legs
d. Ambulating frequently
ANS: C
Nothing should be placed under the knees; doing so might impair circulation.

DIF: Cognitive Level: Application REF: p. 594 OBJ: 6
TOP: Pulmonary Embolism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

24. How should a nurse position a patient during a thoracentesis?
a. Side-lying with bed in a Trendelenburg position
b. High Fowler position with feet elevated
c. Sitting on the side of the bed bent over bedside table
d. Prone with the bed elevated
ANS: C
The patient sits on the side of the bed and leans the upper torso over the bedside table with the head resting on folded arms or pillows. If the patient is unable to sit up, then a side-lying position with the head of the bed elevated 30 degrees may be used.

DIF: Cognitive Level: Application REF: p. 569 OBJ: 3
TOP: Thoracentesis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

25. How does the ventilator function of positive end-expiratory pressure assist the patient?
a. Keeps pressure in the lungs after expiration
b. Delivers 100% oxygen on inspiration
c. Allows the patient to control expiratory pressure
d. Delivers an inhalant medication under positive pressure
ANS: A
The positive end-expiratory pressure setting keeps the pressure in the lungs above the atmospheric pressure, which prevents atelectasis.

DIF: Cognitive Level: Knowledge REF: p. 574-575 OBJ: 3
TOP: Mechanical Ventilators KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

26. How should a nurse explain that the breathing pattern has been altered when a patient complains of tachypnea? (Select all that apply.)
a. Increased pH levels stimulate chemoreceptors in the aorta and carotid arteries, which stimulates the phrenic nerve.
b. Decreased oxygen level signals the phrenic nerve to alter the respiration rate.
c. Muscles of respiration respond to the stimulus.
d. The brain has become hypoxic and causes an alteration in the respiration rate.
e. Deflated lung tissue results in an altered respiration rate.
ANS: B, C
A decreased oxygen level stimulates the phrenic nerve to signal the muscles of respiration to do the work of breathing. A decreasing pH level is the stimulus to the chemoreceptors. Neither the brain nor the lungs signal for tachypnea.

DIF: Cognitive Level: Comprehension REF: p. 558 OBJ: 1
TOP: Respiration Center KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. What assessment findings would indicate respiratory dysfunction when examining a patient with respiratory difficulty? (Select all that apply.)
a. Flushed facial skin
b. Cyanotic nail beds
c. Abdominal distention
d. Curved spine
e. Clubbed fingers
ANS: B, C, E
Clues to respiratory dysfunction are a distended abdomen, cyanotic nail beds, and clubbed fingers from inadequate oxygenation.

DIF: Cognitive Level: Comprehension REF: p. 563 OBJ: 1
TOP: Clues to Respiratory Dysfunction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

28. Which instructions should a nurse provide to a patient just before a scheduled spirometry test? (Select all that apply.)
a. Avoid smoking 4 to 6 hours before test.
b. Do not use bronchodilator medications for at least 4 hours.
c. Exercise for a few minutes.
d. Drink 2 glasses of fluid.
e. Avoid eating.
ANS: A, B
Patients should not smoke, use bronchodilators, or exercise just before the test. Normal-sized meals and drinking fluids do not adversely affect the test.

DIF: Cognitive Level: Comprehension REF: p. 567 OBJ: 3
TOP: Spirometry KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

COMPLETION

29. Assessment of 24-year-old driver after an automobile accident, who is complaining of right-sided chest pain and is dyspneic, reveals the following:
Respirations: 26 breaths/min
Significant pain on inspiration
Hand is pressed to the rib area; large bruise is forming on the right chest
Blood pressure: 182/98 mm Hg
Based on these assessments, the nurse suspects _____.

ANS:
fractured ribs
The placement of the bruise and the pain on inspiration are the main clues to the rib fracture.

DIF: Cognitive Level: Analysis REF: p. 592 OBJ: 5
TOP: Rib Fracture KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. A nurse computes the number of pack years of a 24-year-old man who has smoked packs of cigarettes every day since he was 15 years old. This patient has _____ pack years.

ANS:
13.5
Pack years are calculated by multiplying the number of years of smoking by the number of packs smoked each day. A 24-year-old patient who has smoked since he was 15 years of age = 9 years multiplied by 1.5 = 13.5.

DIF: Cognitive Level: Application REF: p. 560 OBJ: 1
TOP: Pack Years KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

OTHER

31. What instructions should a nurse give to a patient when teaching deep breathing and coughing techniques? (Place the options in the appropriate sequence. Separate letters by a comma and space as follows: A, B, C, D.)
A. Place the hand on the abdomen to check the rise and fall.
B. Inhale through the nose, pause 1 to 3 seconds, and then exhale through the mouth.
C. Assume a semi-Fowler position.
D. Take 4 to 6 deep breaths.
E. Cough deeply.

ANS:
C, A, B, D, E
The exercise is performed in a sequence to ensure open bronchioles and a good deep cough.

DIF: Cognitive Level: Application REF: p. 570 OBJ: 3
TOP: Deep Breathing and Coughing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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