NURSING PROGRAM

Respiratory Part 1 ANSWER KEY

1. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall.
Which finding indicates the presence of a pneumothorax in this client?
A. A low respiratory rate
B. Diminished breath sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury
B
Rationale: Focus on the subject, a blunt chest injury. A larger pneumothorax may cause tachypnea,
cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur
on the affected side. Subcutaneous emphysema (SCE, SE) occurs when gas or air travels under the
skin. Subcutaneous refers to the tissue beneath the skin, and emphysema refers to trapped air.

2. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary
disease. Which findings would the nurse expect to note on assessment of this client? Select all that
apply.
A. A low arterial PCo2 level
B. A hyper- inflated chest noted on the chest x-ray
C. Decreased oxygen saturation with mild exercise
D. A widened diaphragm noted on the chest x-ray
E. Pulmonary function tests that demonstrate increased vital capacity
BC
Rationale: Focus on the subject, manifestations of COPD. Think about the pathophysiology
associated with this disorder. Remember that hypercapnia, a hyperinflated chest, a flat diaphragm,
oxygen desaturation on exercise, and decreased vital capacity are manifestations.
Hyperinflated lungs can be caused by blockages in the air passages or by air sacs that are less elastic,
Chronic airflow limitation imposes a load on respiratory muscles as does lung hyperinflation,
flattening the diaphragm and reducing its ability to generate tension.

3. The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking
the client about the purpose of this type of breathing. The nurse determines that the client understands if
the client states that the primary purpose of pursed-lip breathing is to promote which outcome?
A. Promote oxygen intake
B. Strengthen the diaphragm
C. Strengthen the intercostal muscles
D. Promote carbon dioxide elimination
D
RATIONALE: Note the strategic word, primary, and the subject, client understanding of pursed-lip
breathing, Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung
disease

4. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated
for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.
A. Activities should be resumed gradually.
B. Avoid contact with other individuals, except family members, for at least 6 months.
C. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.

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 D. Respiratory isolation is not necessary because family members already have been exposed.
E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
F. When 1 sputum culture is negative; the client is no longer considered infectious and usually
can return to former employment.
ACDE
RATIONALE: Focus on the subject, home care instructions for tuberculosis. Knowledge regarding
the pathophysiology, transmission, and treatment of tuberculosis is needed to answer this question.

5. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding if noted in the client,
should be reported immediately to the health care provider?
A. Dry cough
B. Hematuria
C. Bronchospasm
D. Blood-streaked sputum
C
Eliminate option 2 first because it is unrelated to the procedure. Next, eliminate option 1 because a
dry cough may be expected. Noting that a biopsy has been performed will assist in eliminating option
4, because blood-streaked sputum would be expected. Note that the correct option relates to the
airway.

6. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the
suctioning time to a maximum of which time period?
A. 5 seconds
B. 10 seconds
C. 30 seconds
D. 60 seconds
B
RATIONALE: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker
cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must
preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

7. The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse
notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?
A. Continue to suction.
B. Notify the health care provider immediately.
C. Stop the procedure and re oxygenate the client.
D. Ensure that the suction is limited to 15 seconds.
What is informed consent?
C
Test-Taking Strategy: Focus on the subject, a decreased heart rate, and recall that suctioning can
cause cardiac irregularities. Also, use of the ABCs—airway–breathing–circulation— should direct
you to the correct option.
8. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should
expect to note which finding?
A. Slow, deep respirations
B. Rapid, deep respirations
C. Paradoxical respirations
D. Pain, especially with inspiration
D
Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain
and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow
respirations, splinting or guarding the chest protectively to minimize chest movement, and possible
bruising at the fracture site.

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9. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most
distinctive sign of flail chest?
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation
C
Cyanosis and hypotension occur with many different disorders, so eliminate options 1 and 2 first.
From the remaining options, choose paradoxical chest movement over dyspnea on exhalation by
remembering that a flail chest has broken rib segments that move independently of the rest of the rib
cage.

10. A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent
intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and
notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse
immediately assesses for other signs of which condition?
A. Right pneumothorax
B. Pulmonary embolism
C. Displaced endotracheal tube
D. Acute respiratory distress syndrome
A
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration,
asymmetrical chest expansion, and diminished or absent breath sounds on
the affected side.

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 11. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory
distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress
syndrome?
A. Bilateral wheezing
B. Inspiratory crackles
C. Intercostal retractions
D. Increased respiratory rate
D
Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased
respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body.
This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis.
Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
(ARDS) is a severe lung condition. It occurs when fluid fills up the air sacs in lungs. Too much fluid
in your lungs can lower the amount of oxygen or increase the amount of carbon dioxide in your
bloodstream

12. The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory
treatments) to a client having expectoration problems because of chronic thick, tenacious mucus
production in the lower airway. The nurse explains that after the client is positioned for postural
drainage the nurse will perform which action to help loosen secretions?
A. Palpation and clubbing
B. Percussion and vibration
C. Hype oxygenation and suctioning
D. Administer a bronchodilator and monitor peak flow
B
Rationale: Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller
lower airways. Postural drainage positions the client so that gravity can help mucus move from
smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not
actions that will loosen secretions.

13. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should
wear which items when performing this care?
A. Surgical mask and gloves
B. Particulate respirator, gown, and gloves
C. Particulate respirator and protective eyewear
D. Surgical mask, gown, and protective eyewear
B
Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually
fitted particulate respirator.
The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the
possibility exists that the clothing could become contaminated, such as when giving a bed bath.

14. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which
is most commonly reported?
A. Hot, flushed feeling
B. Sudden chills and fever
C. Chest pain that occurs suddenly
D. Dyspnea when deep breaths are taken
C
Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in
onset. The next most commonly reported symptom is dyspnea, which is accompanied by an
increased respiratory rate.

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 15. The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should
assess whether the client wears which item during periods of exposure to silica particles?
A. Mask
B. Gown
C. Gloves
D. Eye protection
A
Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust.
The client should wear a mask to limit inhalation of this substance, which can cause
restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary.

16. The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes
that the client understands the information if the client indicates to report which early sign of
exacerbation?
A. Fever
B. Fatigue
C. Weight loss
D. Shortness of breath
D
Rationale: Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later
manifestations include night sweats, fever, weight loss, and skin nodules.

17. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to
deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for
the client?
A. Face tent
B. Venturi mask
C. Aerosol mask
D. Tracheostomy collar
B
Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen
delivery system for the client
with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a
precise oxygen concentration.
The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but
most often are used to administer high humidity.

18. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will
enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse
instruct the client to assume?
A. Sitting up in bed
B. Side-lying in bed
C. Sitting in a recliner chair
D. Sitting up and leaning on an over bed table

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D
Rationale: Positions that will assist the client with emphysema with breathing include sitting up and
leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning
against the wall
Emphysema is a condition that involves damage to the walls of the air sacs (alveoli) of the lung. The
main cause of emphysema is long-term exposure to airborne irritants, including: Tobacco. Symptoms
of emphysema may include coughing, wheezing, shortness of breath, chest tightness, and an increased
production of mucus

19. The community health nurse is conducting an educational session with community members regarding
the signs and symptoms associated with tuberculosis. The nurse informs the participants that
tuberculosis is considered as a diagnosis if which signs and symptoms are present. Select all that apply.
A. Dyspnea
B. Headache
C. Night sweats
D. A bloody, productive cough
E. A cough with the expectoration of mucoid sputum
ACDE
Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss,
anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client’s
previous exposure to tuberculosis should also be assessed and correlated with the clinical
manifestations.

20. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to
determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should
take what initial action?
A. Administer oxygen
B. Check the client’s vital signs
C. Ventilate the client manually
D. Start cardiopulmonary resuscitation
C
Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem,
the client is disconnected from the ventilator and manual resuscitation is used
to support respirations until the problem can be corrected. No reason is given to begin
cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen
is helpful, it will not provide ventilation to the client.

21. A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions
in the order they should be accomplished (1-5).
____ Check peak and trough levels of the antibiotic.
____ Insert an IV catheter to establish venous access.
____ Collect a sputum sample for culture and sensitivity.
____ Administer prescribed antibiotic intravenous piggyback.
____ Obtain data about the client’s history and physical status.
Answer: 5, 2, 3, 4, 1.

22. Levofloxacin (Levaquin) 750 mg IVPB is prescribed for a client with pneumonia. The dose is
available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop
factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse?

Answer: 25 gtt/minute.

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23. A nurse identifies that a client’s hemoglobin level is decreasing and is concerned about tissue
hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from
hemoglobin?
A. pH
B. PO2
C. PCO2
D. HCO3
C
The lower the PO2 and the higher the PCO2, the more rapidly oxygen dissociates from the
oxyhemoglobin molecule.

24. During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-
chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is
not fluctuating. What initial action should the nurse take?
A. Take the client’s vital signs.
B. Inform the health care provider.
C. Turn the client to the unaffected side.
D. Check the tube to ensure that it is not kinked.
D
Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of
fluctuation because of lung re-expansion is unlikely 36 hours after a traumatic open chest injury.

25. A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a
spontaneous pneumothorax. The client asks, “How could this have happened?” What likely cause of the
spontaneous pneumothorax should the nurse’s response take into consideration?
A. Pleural friction rub
B. Tracheoesophageal fistula
C. Rupture of a subpleural bleb
D. Puncture wound of the chest wall
C
The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface.
Blebs are similar to blisters, but are filled with air.

26. A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this
client?
A. Localized tissue necrosis
B. Carbon dioxide retention
C. Increased respiratory rate
D. Saturated hemoglobin molecule
B
Loss of alveolar surface area causes retention of carbon dioxide, which, after exhausting the
available bicarbonate ions functioning as buffers, will cause a lower pH (respiratory acidosis).

27. A nurse is caring for a variety of clients. For which client is it most essential for the nurse to
implement measures to prevent pulmonary embolism?
A. 59-year-old who had a knee replacement
B. 60-year-old who has bacterial pneumonia
C. 68-year-old who had emergency dental surgery
D. 76-year-old who has a history of thrombocytopenia

A
Clients who have had joint replacement have decreased mobility; they are at risk for developing
thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the
circulation.

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28. A client who has acquired immunodeficiency syndrome develops bacterial pneumonia. On admission
to the emergency department, the client’s PaO2 is 80 mm Hg. When the arterial blood gases are drawn
again, the level is determined to be 65 mm Hg. What should the nurse do first?
A. Increase the oxygen flow rate.
B. Notify the health care provider.
C. Decrease the tension of oxygen in the plasma.
D. Have the arterial blood gases redone to verify accuracy.

B. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.

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