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
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
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
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
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
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
7. A worried patient asks the nurse to explain the advantage of a fluoroscopy. What is the
nurse’s 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
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.
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.
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
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
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
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
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
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
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
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.
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
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 patient’s head during and for 10 minutes after feeding.
d.
Position the patient on the left side after the feeding.
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
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)
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
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
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
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
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.
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
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.
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 _____.
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.
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.