SITUATION: RESPIRATORY PROBLEMS

KEY
1. ANSWER: C
The position that allows for the greatest amount of lung expansion is siitng up and leaning slightly forward. This
position can be facilitated by allowing the client to rest his or her arms on a bedside table. The position that also
facilitates lung expansion, but not to the same degree, is high fowler’s. Both the prone and the trendelenburg position
tend to decrease full lung expansion due to increased pressure of abdominal contents on the diaphragm.

2. ANSWER: B
Increased lung volumes (TLC, FRC, RV) and decreased airflow – vital capacity (VC) and forced expiratory volume in 1
second (FEV1)- are functional problems consistent with obstructive lung disease. In restrictive lung disease, volumes
generally decreased. Vascular lung disease has no effect on ventilator capacity but directly affects diffusion of gases;
that is, pulmonary infarction decreases blood flow to the lungs, so some alveoli that are ventilated are no longer
perfused. Restrictive lung disease is incorrect

3. ANSWER: D
A wheeze is a high-pitched, musical chest sound produced by airflow in narrowed bronchioles. It is primarily an
expiratory sound and is always, not rarely, considered pathological. Rhonchi are medium-pitched sonorous sounds
produced by airflow obstruction in larger airways. Stridor is high-pitched crowing sound on inspiration and is due to an
upper airway obstruction, such as edema, adhesions or tracheal hypertrophy.

4. ANSWER: C
Deep breathing, coughing, and pursed lip exhalations are all techniques that the nurse can teach the client to improve
ventilation. Adequate fluid intake is essential for keeping sputum liquefied; however, very hot and very cold drinks
should be avoided because they may cause bronchospasm. Clients with COPD also need to be taught to avoid
exposure to infections, early signs of infection, and the need to seek medical intervention promptly should symptoms
occur. Options B and D are not indicated in the client’s therapy

5. ANSWER: B
Rationale: Resonance is the normal lung percussion sound. Flatness can be heard over the thigh. With client who has
large pleural effusion, flatness can be heard during percussion. Hyperresonance is indicative of emphysema or
pneumothorax. With bronchitis, a resonance might be heard.
6. ANSWER: A
Tracheostomy tube should not be thread anywhere. It should be secured around the client’s neck where both ends
meet on one side of the neck. This provides a double thickness security to avoid dislodgement of the tube by a
forceful cough.

7. ANSWER: A
Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining
into sutured bronchial stump.

8. ANSWER: B
Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion. Option B will not address
the problem in the situation. Nurse should never adjust the suction pressure without any doctor’s order. There is no
alarm system attached to chest tube drainage.

9. ANSWER: A
The nurse should suggest creative methods to increase the intake of fluids (A), such as having disposable fruit juices
readily available. Clients with COPD should have at least three liters of fluids a day. These clients often reduce fluid
intake because of shortness of breath. (B) is not indicated. These symptoms are not indicative of an allergy (C). Many
elderly depend on their pets for socialization and self-esteem. Humidified oxygen will not relieve these symptoms and
increased oxygen levels will stifle the COPD client's trigger to breathe (D).

10. ANSWER: A
This client has a barrel chest. The anterior-posterior diameter of the chest is larger than the transverse diameter, as is
characteristic of the client with chronic obstructive pulmonary disease, although the client maybe muscular, the barrel
chest is not associated with the client’s age, height, or weight. Use of bronchodilators will not change the shape of the
client’s chest.

11. ANSWER: D
Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is
obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full
physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be
done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know
about the patient’s history of medical problems, the patient is the best informant for these data.

12. ANSWER: B
An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia. Although it is important
to note immediately if the client is experiencing a decreased level of consciousness, increased temperature, or slowed
respiratory rate, none of these are as indicative of a life-threatening a complication as tachycardia.

13. ANSWER: B
Rhinitis, inflammation of the nasal cavities, is the most common upper respiratory disorder. Rhinitis may be either
acute or chronic. Acute viral rhinitis is the common cold. Allergic rhinitis, or hay fever, results from a sensitivity
reaction to allergens such as plant pollens. It tends to occur seasonally. The etiology of vasomotor rhinitis is unknown.
Although its manifestations are similar to those of allergic rhinitis, it is not linked to allergens. Atrophic rhinitis is
characterized by changes in the mucous membrane of the nasal cavities.

14. ANSWER: D
Chronic use of nasal sprays may lead to rhinitis medicamentosa, a rebound phenomenon of drug-induced nasal
irritation and inflammation. The nasal spray is being used correctly. The worsening nasal congestion is not considered
a side effect. No other signs indicate that the client has a bacterial sinus infection.

15. ANSWER: B
A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which
increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize
incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done
after the morphine is given.

16. ANSWER: A
Common pharmacologic triggers include aspirin and other NSAIDs, sulfites (which are used as preservatives in wine,
beer, fresh fruits, and salad), and beta-blockers.

17. ANSWER: C
This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication
every day for best effect. This is not the medication the client will use during an acute asthma attack because it does
not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be
one of his daily medications.

18. ANSWER: A
Economic status may be affected by COPD through changes in income and health insurance coverage. If the client is
the head of the household, severe COPD may require role changes that have a negative impact on self-image. If the
client is experiencing difficulty in quitting smoking, his self-image will probably not be altered as much as it would be
related to income. The client may be experiencing difficulty with his marital relationship, but it probably will not be
causing changes in his self-image. Although the client may have had to change his hobbies to accommodate the
disease, it probably will not have affected his self-image adversely.

19. ANSWER: C
Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor
for the return of these reflexes before allowing the patient to take oral fluids or food. Vital signs are monitored
immediately after the procedure but should not need to be obtained every 15 minutes for 2 hours. The patient does
not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler’s position.

20. ANSWER: A
A barrel chest results from lung hyperinflation and is a common finding in patients with COPD. Consolidation, fluid,
and air in the pleural space all would indicate that intervention is needed.

21. ANSWER: A
Client with chronic respiratory problems, such as asthma and COPD, impair the client’s gas exchange and increase the
client’s risk associated with inhalation anesthetic agents. It is because of these factors that the client is more likely to
develop atelectasis and pneumonia.

22. ANSWER: B
From 1 to 9 mcg/mL is not at a therapeutic level. A therapeutic level of theophylline is between 10 and 20 mcg/mL.
Greater than 20 mcg/mL is a toxic level of theophylline.

23. ANSWER: A
This patient needs to be evaluated immediately and receive prompt treatment to reduce the airway obstruction and
reverse inflammation.

24. ANSWER: C
If both bronchodilators and steroids are ordered by inhaler, the client should be instructed to use bronchodilator first
then the steroid inhaler. If the bronchioles are dilated first, more tissue is exposed for the steroid drugs to act upon.

25. ANSWER: C
Pulmonary edema in a client with heart failure is the accumulation of fluid in the alveoli characterized by increased
rales, tachypnea, tachycardia, pink frothy sputum, decreased SO2 and PO2. The client presents with acute
restlessness and anxiety. Urine output is generally decreased in heart failure clients; increased urinary output is
usually caused by diuretic therapy

26. ANSWER: B
The maximum amount of oxygen administered via nasal cannula is 6 L/min; 15 L/min is the amount used for a
nonrebreather mask. The nonrebreather mask’s reservoir bag should be inflated; a nasal cannula does not have a
bag. Oral hygiene should be performed every two to three hours. A nasal cannula and oxygen tubing should be kept
clean and changed if contaminated.

27. ANSWER: C
The FEV1 does not increase; it decreases. The FVC does decrease, and the patient can exhibit increased anterior-
posterior chest diameter and pursed lip breathing.

28. ANS: C
Rationale: When a client becomes angry and resents advice from a younger health care provider to give up a lifelong habit,
the nurse should apologize and assure the client that no disrespect was intended. The other options would antagonize the
client rather than reduce anger.
 29. Answer: (B);
The patient should be encouraged to drink 2 liters per day to help to liquefy secretions. The patients should have
only low flow oxygen (1-2L/min) to prevent respiratory depression. Respiratory drive is dependent upon high CO 2
and low O2 levels. Higher O2 levels can result in loss of respiratory drive.

30. Answer: A
Rationale: A client with emphysema who requires oxygen should receive a maximum of 3 L/minute. A flow rate of 6L/minute
(option B) would be excessive. The client shouldn’t adjust the oxygen flow rate (option C.) Changing the tubing at
each shift (option D) is unnecessary.

31. Answer: B
A client who is upset with the treatment regimen should be given the opportunity to express feelings. The other options don’t
provide this opportunity.

32. ANSWER: D.
Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. They
don’t take a breath when their levels of carbon dioxide are higher than normal, as to those with healthy respiratory
physiology. If too much oxygen is given, the client has little stimulus to take another breath. In the meantime, his carbon
dioxide levels continue to climb, and the client will pass out, leading to a respiratory arrest.

33. Answer: (C)

The nurse should anticipate that the patient will have a heparin drip to prevent extension of the existing clot.

34. Answer: (B);

The vena cava filter, which is placed intravascular, will remain in placed indefinitely. The patient will not charge the device at
home. The patient should be encouraged to be as active as possible and to limit immobility. The patient will be an
anticoagulant therapy following discharge and should notify the doctor in any signs of deep venous thrombosis develop

35. Answer: (A)

The majority of pulmonary emboli originate in the deep leg veins

36. Answer: (B)

The major hemodynamic consequence of massive pulmonary embolus is pulmonary hypertension, which ultimately leads to
right heart failure.

37. Answer: (D)

The most effective means of preventing development of pulmonary embolism is preventing development of deep in
thrombosis.

38. Rationale: D. (pg. 333) As the diaphragm descends during inspiration, thoracic pressure is reduced because thoracic
volume is increased. The pressure of the atmospheric air is higher in comparison, so air will rush into the alveoli.

39. Rationale: A. (pg. 333) The tidal volume is the amount of air inhaled and exhaled while breathing normally.

40. Rationale: C. (pg. 333) The lower Po2 and the higher the Pco2, the more rapidly O2 from the oxyhemoglobin molecule.

41. Rationale: C. (pg.333) The negative pressure from suctioning removes O2 as well as secretions; such should be applied
only after the catheter is inserted, and it is being withdrawn.

42. Rationale: A. (pg. 334) Furosemide (Lasix) acts on the loop of Henle by increasing the excretion of chloride and sodium.
43. Rationale: B. The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it
also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the
diaphragm to help with exhalation, reducing residual volume.

44. Rationale: A. (pg. 334) Retention of CO2 after exhausting the available bicarbonate ions functioning as buffers, will
cause a lower pH (respiratory acidosis)

45. Rationale: C. (pg. 334) Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of
fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury.

46. Rationale: C. (pg. 335) As a person with a tear in the lung inhales, air moves through that opening into the intrapleural
space. This creates a positive pressure and causes partial or complete collapse of the lung.

47. Rationale: B. (pg. 333) Because atelectasis involves collapsing of alveoli distal to the bronchioles, breath sounds would
be diminished in the lower lobes.

48. ANS: B
Clients with mild and infrequent asthma symptoms are treated with regular daily administration of anti inflammatory inhaler
and short-acting beta-agonist inhaler for quick relief in acute episodes. Bronchodilators and corticosteroids as oral or
inhaled medication are used for client with more severe and frequent episodes of asthma.

49. ANS: C
Rationale: A primary physiological alteration occurring with ARDS is shunting of blood around nonventilated alveoli. Alveoli
collapse in ARDS, and ventilaton decreases, Blood perfusing to these area cannot undergo adequate gas exchange.

50. ANS: A
Rationale: RSV is the cause of bronchiolitis in most cause; RSV can live for several hours for nonporous surfaces and can
be transferred by the hands.