Professional Documents
Culture Documents
Jones prescribes albuterol sulfate (Proventil) reactions (such as increased systolic blood pressure,
for a patient with newly diagnosed asthma. coldness in the extremities, and anginal pain).
When teaching the patient about this drug, the Ephedrine is used for its bronchodilator effects with
nurse should explain that it may cause: acute and chronic asthma and occasionally for its
a. Nasal congestion CNS stimulant actions for narcolepsy. It can be
b. Nervousness administered to children age 2 and older.
c. Lethargy
5. A female patient suffers adult respiratory distress
d. Hyperkalemia
syndrome as a consequence of shock.
Albuterol may cause nervousness. The inhaled form
The patients condition deteriorates rapidly, and
of the drug may cause dryness and irritation of the
endotracheal intubation and mechanical ventilation
nose and throat, not nasal congestion; insomnia, not
are initiated. When the high-pressure alarm on the
lethargy; and hypokalemia (with high doses), not
mechanical ventilator, alarm sounds, the nurse starts
hyperkalemia. Otther adverse effects of albuterol
to check for the cause. Which condition triggers the
include tremor, dizziness, headache, tachycardia,
high-pressure alarm?
palpitations, hypertension, heartburn, nausea,
vomiting and muscle cramps. a. Kinking of the ventilator tubing
b. A disconnected ventilator tube
2. Miriam, a college student with acute rhinitis sees
c. An endotracheal cuff leak
the campus nurse because of excessive nasal
d. A change in the oxygen concentration
drainage. The nurse asks the patient about the
without resetting the oxygen level alarm
color of the drainage. In acute rhinitis, nasal
drainage normally is: Conditions that trigger the high-pressure alarm
a. Yellow include kinking of the ventilator tubing,
b. Green bronchospasm or pulmonary embolus, mucus
c. Clear plugging, water in the tube, coughing or biting on
d. Gray endotracheal tube, and the patients being out of
breathing rhythm with the ventilator. A
Normally, nasal drainage in acute rhinitis is clear.
disconnected ventilator tube or an endotracheal cuff
Yellow or green drainage indicates spread of the
leak would trigger the low-pressure alarm. Changing
infection to the sinuses. Gray drainage may indicate
the oxygen concentration without resetting the
a secondary infection.
oxygen level alarm would trigger the oxygen alarm.
3. A male adult patient hospitalized for treatment
6. A male adult patient on mechanical ventilation is
of a pulmonary embolism develops respiratory
receiving pancuronium bromide (Pavulon), 0.01
alkalosis. Which clinical findings commonly
mg/kg I.V. as needed. Which assessment finding
accompany respiratory alkalosis?
indicates that the patient needs another
a. Nausea or vomiting
pancuronium dose?
b. Abdominal pain or diarrhea
c. Hallucinations or tinnitus a. Leg movement
d. Lightheadedness or paresthesia b. Finger movement
c. Lip movement
The patient with respiratory alkalosis may complain
d. Fighting the ventilator
of lightheadedness or paresthesia (numbness and
tingling in the arms and legs). Nausea, vomiting, Pancuronium, a nondepolarizing blocking agent, is
abdominal pain, and diarrhea may accompany used for muscle relaxation and paralysis. It assists
respiratory acidosis. Hallucinations and tinnitus rare mechanical ventilation by promoting encdotracheal
are associated with respiratory alkalosis or any other intubation and paralyzing the patient so that the
acid-base imbalance. mechanical ventilator can do its work. Fighting the
ventilator is a sign that the patient needs another
4. Before administering ephedrine, Nurse Tony
pancuronium dose. The nurse should administer 0.01
assesses the patients history. Because of
to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement
ephedrines central nervous system (CNS) effects, it
of the legs, or lips has no effect on the ventilator and
is not recommended for:
therefore is not used to determine the need for
a. Patients with an acute asthma attack another dose.
b. Patients with narcolepsy
7. On auscultation, which finding suggests a right
c. Patients under age 6
pneumothorax?
d. Elderly patients
a. Bilateral inspiratory and expiratory crackles
Ephedrine is not recommended for elderly patients,
b. Absence of breaths sound in the right thorax
who are particularly susceptible to CNS reactions
c. Inspiratory wheezes in the right thorax
(such as confusion and anxiety) and to cardiovascular
d. Bilateral pleural friction rub The trachea will shift according to the pressure
gradients within the thoracic cavity. In tension
In pneumothorax, the alveoli are deflated and no air
pneumothorax and hemothorax, accumulation of air
exchange occurs in the lungs. Therefore, breath
or fluid causes a shift away from the injured side. If
sounds in the affected lung field are absent. None of
there is no significant air or fluid accumulation, the
the other options are associated with
trachea will not shift. Tracheal deviation toward the
pneumothorax. Bilateral crackles may result from
contralateral side in simple pneumothorax is seen
pulmonary congestion, inspiratory wheezes may
when the thoracic contents shift in response to the
signal asthma, and a pleural friction rub may indicate
release of normal thoracic pressure gradients on the
pleural inflammation.
injured side.
8. Rhea, confused and short breath, is brought to the
11. After undergoing a left pneumonectomy, a
emergency department by a family member. The
female patient has a chest tube in place for drainage.
medical history reveals chronic bronchitis and
When caring for this patient, the nurse must:
hypertension. To learn more about the current
respiratory problem, the doctor orders a chest x-ray a. Monitor fluctuations in the water-seal
and arterial blood gas (ABG) analysis. When chamber
reviewing the ABG report, the nurses sees many b. Clamp the chest tube once every shift
abbreviations. What does a lowercase a in ABG c. Encourage coughing and deep breathing
value present? d. Milk the chest tube every 2 hours
a. Activity intolerance related to fatigue A patient with a laryngectomy cannot speak, yet still
b. Anxiety related to actual threat to health needs to communicate. Therefore, the nurse should
status plan to develop an alternative communication
c. Risk for infection related to retained method. After a laryngectomy, edema interferes
secretions with the ability to swallow and necessitates tube
d. Impaired gas exchange related to airflow (enteral) feedings. To prevent injury to the tracheal
obstruction mucosa, the nurse should deflate the tracheostomy
cuff or use the minimal leak technique. To decrease
A patient airway and an adequate breathing pattern
edema, the nurse should place the patient in semi-
are the top priority for any patient, making impaired
Fowlers position.
gas exchange related to airflow obstruction the
most important nursing diagnosis. The other options 13. A male patient has a sucking stab wound to the
also may apply to this patient but less important. chest. Which action should the nurse take first?
10. Nurse Ruth assessing a patient for tracheal a. Drawing blood for a hematocrit and
displacement should know that the trachea will hemoglobin level
deviate toward the: b. Applying a dressing over the wound and
taping it on three sides
a. Contralateral side in a simple pneumothorax
c. Preparing a chest tube insertion tray
b. Affected side in a hemothorax
d. Preparing to start an I.V. line
c. Affected side in a tension pneumothorax
d. Contralateral side in hemothorax The nurse immediately should apply a dressing over
the stab wound and tape it on three sides to allow air
to escape and to prevent tension pneumothorax Controlled coughing helps maintain a patent airway
(which is more life-threatening than an open chest by helping to mobilize and remove secretions. A
wound). Only after covering and taping the wound moderate fluid intake (usually 2 L or more daily) and
should the nurse draw blood for laboratory tests, moderate activity help liquefy and mobilize
assist with chest tube insertion, and start an I.V. line. secretions. Bed rest and sedatives may limit the
patients ability to maintain a patent airway, causing
14. For a patient with advance chronic obstructive
a high risk for infection from pooled secretions.
pulmonary disease (COPD), which nursing action
best promotes adequate gas exchange? 17. Nurse Lei caring for a client with a pneumothorax
and who has had a chest tube inserted notes
a. Encouraging the patient to drink three
continues gentle bubbling in the suction control
glasses of fluid daily
chamber. What action is appropriate?
b. Keeping the patient in semi-fowlers position
c. Using a high-flow venturi mask to deliver a. Do nothing, because this is an expected
oxygen as prescribe finding
d. Administering a sedative, as prescribe b. Immediately clamp the chest tube and notify
the physician
The patient with COPD retains carbon dioxide, which
c. Check for an air leak because the bubbling
inhibits stimulation of breathing by the medullary
should be intermittent
center in the brain. As a result, low oxygen levels in
d. Increase the suction pressure so that the
the blood stimulate respiration, and administering
bubbling becomes vigorous
unspecified, unmonitored amounts of oxygen may
depress ventilation. To promote adequate gas Continuous gentle bubbling should be noted in the
exchange, the nurse should use a Venturi mask to suction control chamber. Option b is incorrect. Chest
deliver a specified, controlled amount of oxygen tubes should only be clamped to check for an air leak
consistently and accurately. Drinking three glasses of or when changing drainage devices (according to
fluid daily would not affect gas exchange or be agency policy). Option c is incorrect. Bubbling should
sufficient to liquefy secretions, which are common in be continuous and not intermittent. Option d is
COPD. Patients with COPD and respiratory distress incorrect because bubbling should be gentle.
should be places in high-Fowlers position and should Increasing the suction pressure only increases the
not receive sedatives or other drugs that may further rate of evaporation of water in the drainage system.
depress the respiratory center.
18. Nurse Maureen has assisted a physician with the
15. A male patients X-ray result reveals bilateral insertion of a chest tube. The nurse monitors the
white-outs, indicating adult respiratory distress client and notes fluctuation of the fluid level in the
syndrome (ARDS). This syndrome results from: water seal chamber after the tube is inserted. Based
on this assessment, which action would be
a. Cardiogenic pulmonary edema
appropriate?
b. Respiratory alkalosis
c. Increased pulmonary capillary permeability a. Inform the physician
d. Renal failure b. Continue to monitor the client
c. Reinforce the occlusive dressing
ARDS results from increased pulmonary capillary
d. Encourage the client to deep-breathe
permeability, which leads to noncardiogenic
pulmonary edema. In cardiogenic pulmonary edema, The presence of fluctuation of the fluid level in the
pulmonary congestion occurs secondary to heart water seal chamber indicates a patent drainage
failure. In the initial stage of ARDS, respiratory system. With normal breathing, the water level rises
alkalosis may arise secondary to hyperventilation; with inspiration and falls with expiration. Fluctuation
however, it does not cause ARDS. Renal failure does stops if the tube is obstructed, if a dependent loop
not cause ARDS, either. exists, if the suction is not working properly, or if the
lung has reexpanded. Options A, C, and D are
16. For a female patient with chronic obstructive
incorrect.
pulmonary disease, which nursing intervention
would help maintain a patent airway? 19. Nurse Reynolds caring for a client with a chest
tube turns the client to the side, and the chest tube
a. Restricting fluid intake to 1,000 ml per day
accidentally disconnects. The initial nursing action is
b. Enforcing absolute bed rest
to:
c. Teaching the patient how to perform
controlled coughing a. Call the physician
d. Administering prescribe sedatives regularly b. Place the tube in bottle of sterile water
and in large amounts c. Immediately replace the chest tube system
d. Place a sterile dressing over the
disconnection site
If the chest drainage system is disconnected, the end not signs that require immediate notification of the
of the tube is placed in a bottle of sterile water held physician.
below the level of the chest. The system is replaced
23. An emergency room nurse is assessing a male
if it breaks or cracks or if the collection chamber is
client who has sustained a blunt injury to the chest
full. Placing a sterile dressing over the disconnection
wall. Which of these signs would indicate the
site will not prevent complications resulting from the
presence of a pneumothorax in this client?
disconnection. The physician may need to be
notified, but this is not the initial action. a. A low respiratory rate
b. Diminished breath sounds
20. A nurse is assisting a physician with the removal
c. The presence of a barrel chest
of a chest tube. The nurse should instruct the client
d. A sucking sound at the site of injury
to:
This client has sustained a blunt or a closed chest
a. Exhale slowly
injury. Basic symptoms of a closed pneumothorax
b. Stay very still
are shortness of breath and chest pain. A larger
c. Inhale and exhale quickly
pneumothorax may cause tachypnea, cyanosis,
d. Perform the Valsalva maneuver
diminished breath sounds, and subcutaneous
When the chest tube is removed, the client is asked emphysema. Hyperresonance also may occur on the
to perform the Valsalva maneuver (take a deep affected side. A sucking sound at the site of injury
breath, exhale, and bear down). The tube is quickly would be noted with an open chest injury.
withdrawn, and an airtight dressing is taped in place.
24. Nurse Reese is caring for a client hospitalized
An alternative instruction is to ask the client to take
with acute exacerbation of chronic obstructive
a deep breath and hold the breath while the tube is
pulmonary disease. Which of the following would the
removed. Options A, B, and C are incorrect client
nurse expect to note on assessment of this client?
instructions.
a. Hypocapnia
21. While changing the tapes on a tracheostomy
b. A hyperinflated chest noted on the chest x-
tube, the male client coughs and tube is dislodged.
ray
The initial nursing action is to:
c. Increased oxygen saturation with exercise
a. Call the physician to reinsert the tube d. A widened diaphragm noted on the chest x-
b. Grasp the retention sutures to spread the ray
opening
Clinical manifestations of chronic obstructive
c. Call the respiratory therapy department to
pulmonary disease (COPD) include hypoxemia,
reinsert the tracheotomy
hypercapnia, dyspnea on exertion and at rest,
d. Cover the tracheostomy site with a sterile
oxygen desaturation with exercise, and the use of
dressing to prevent infection
accessory muscles of respiration. Chest x-rays reveal
If the tube is dislodged accidentally, the initial a hyperinflated chest and a flattened diaphragm if
nursing action is to grasp the retention sutures and the disease is advanced.
spread the opening. If agency policy permits, the
25. An oxygen delivery system is prescribed for a
nurse then attempts immediately to replace the
male client with chronic obstructive pulmonary
tube. Covering the tracheostomy site will block the
disease to deliver a precise oxygen concentration.
airway. Options A and C will delay treatment in this
Which of the following types of oxygen delivery
emergency situation.
systems would the nurse anticipate to be
22. Nurse Oliver is caring for a client immediately prescribed?
after removal of the endotracheal tube. The nurse
a. Face tent
reports which of the following signs immediately if
b. Venturi mask
experienced by the client?
c. Aerosol mask
a. Stridor d. Tracheostomy collar
b. Occasional pink-tinged sputum
The Venturi mask delivers the most accurate oxygen
c. A few basilar lung crackles on the right
concentration. It is the best oxygen delivery system
d. Respiratory rate 24 breaths/min
for the client with chronic airflow limitation because
The nurse reports stridor to the physician it delivers a precise oxygen concentration. The face
immediately. This is a high-pitched, coarse sound tent, aerosol mask, and tracheostomy collar are also
that is heard with the stethoscope over the trachea. high-flow oxygen delivery systems but most often
Stridor indicates airway edema and places the client are used to administer high humidity.
at risk for airway obstruction. Options B, C, and D are
26. Blessy, a community health nurse is conducting
an educational session with community members
regarding tuberculosis. The nurse tells the group that exhalation. Options A, B, and C are not the purposes
one of the first symptoms associated with of this type of breathing.
tuberculosis is:
30. A nurse is caring for a male client with acute
a. Dyspnea respiratory distress syndrome. Which of the
b. Chest pain following would the nurse expect to note in the
c. A bloody, productive cough client?
d. A cough with the expectoration of mucoid
a. Pallor
sputum
b. Low arterial PaO2
One of the first pulmonary symptoms is a slight c. Elevated arterial PaO2
cough with the expectoration of mucoid sputum. d. Decreased respiratory rate
Options A, B, and C are late symptoms and signify
The earliest clinical sign of acute respiratory distress
cavitation and extensive lung involvement.
syndrome is an increased respiratory rate. Breathing
27. A nurse performs an admission assessment on a becomes labored, and the client may exhibit air
female client with a diagnosis of tuberculosis. The hunger, retractions, and cyanosis. Arterial blood gas
nurse reviews the result of which diagnosis test that analysis reveals increasing hypoxemia, with a PaO2
will confirm this diagnosis? lower than 60 mm Hg.