MEDSURG Chapter 49 Care of the Patient with a Respiratory Disorder cooper

1. What is the purpose of the cilia?

a. Warm and moisturize inhaled air

b. Sweep debris toward nasal cavity

c. Stimulate cough reflex

d. Produce mucus

ANS: B

The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Secretions KEY: Nursing Process Step: Planning

2. What happens when there is a decrease in the oxygen level in the blood?

a. Pituitary stimulates the respiratory system to increase respiratory rate

b. The alveoli diffuse more oxygen into the blood

c. Chemoreceptors in the carotid body and aortic body stimulate the respiratory

centers to modify respiratory rates

d. The parietal pleura increases the negative pressure

ANS: C

The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1611 OBJ: 1 TOP: Respiratory rate modification

KEY: Nursing Process Step: Assessment

3. A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention?

a. Complete care quickly

b. Provide a pad and pencil or magic slate

c. Refrain from conversations with the patient to reduce stress level

d. Offer books or jigsaw puzzles for entertainment

ANS: B

Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1534 OBJ: 10 TOP: Laryngectomy

KEY: Nursing Process Step: Implementation

4. A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding?

a. Obtain a blood pressure

b. Record the approximate amount of blood lost

c. Inquire about a headache

d. Record the last episode of epistaxis

ANS: A

Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1618

OBJ: 9 TOP: Epistaxis KEY: Nursing Process Step: Implementation

5. The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of:

a. friction rub.

b. sibilant wheezes.

c. crackles.

d. sonorous wheezes.

ANS: B

The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes, which are high-pitched whistling sounds.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1612 OBJ: 16 TOP: Asthma KEY: Nursing Process Step: Assessment

6. How will the kidneys behave in respiratory acidosis?

a. Retain bicarbonate to increase the pH

b. Excrete more urine to reduce potassium

c. Concentrate the urine to conserve circulating fluid in the blood stream

d. Lower the pH by excretion of bicarbonate

ANS: A

In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Table 48-2 OBJ: 11 TOP: Respiratory acidosis

KEY: Nursing Process Step: Assessment

7. An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. What is the infected fluid that the physician removes called?

a. Emboli

b. Emphysema

c. Sputum

d. Empyema

ANS: D

If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1642 OBJ: 11 TOP: Empyema KEY: Nursing Process Step: Assessment

8. Which instruction by the nurse is inappropriate for teaching the proper technique for collection of a sputum specimen?

a. Bring the sputum up from the lungs

b. Rinse mouth with water before expectorating in specimen cup

c. Collect specimens before meals

d. Send specimen to the lab without delay

ANS: C

Collecting specimens before meals will avoid possible emesis from coughing after eating.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1615, Box 48-2 OBJ: 12 TOP: Diagnostic procedures

KEY: Nursing Process Step: Implementation

9. When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger:

a. on the same side as the blood pressure cuff.

b. while exercising the arm to stimulate circulation.

c. that is a normal temperature.

d. on the same side as an arterial catheter.

ANS: C

The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Safety Alert OBJ: 9 TOP: Pulse oximeter

KEY: Nursing Process Step: Assessment

10. A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a "barrel chest." What does this pathology result from?

a. An increase in the lateromedial area from hypertrophy of mucous glands in the

bronchi

b. An increased anteroposterior diameter caused by overinflation of the alveoli

c. A decrease in anteroposterior diameter caused by chronic dilation of the bronchi

d. A widening of the sternocostal area secondary to chronic constriction of smooth

muscles in the airways leading to bronchospasms

ANS: B

The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation).

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1658, Figure 48-16

OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Assessment

11. A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this?

a. Only 82% of the red blood cells are able to use oxygen.

b. There is only 82% of oxygen bound to the hemoglobin compared with the amount

available.

c. Eighteen percent of oxygen is not dissolved in the blood.

d. The muscular respiratory effort is only 18% effective.

ANS: B

An SaO2 indicates that only 82% of the available oxygen is bound to the hemoglobin.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1616 OBJ: 8 TOP: SaO2 KEY: Nursing Process Step: Assessment

12. What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis?

a. Place the patient in drainage and secretion precautions

b. Place the patient in acid-fast bacillus (AFB) Isolation Precautions

c. Maintain the patient in enteric isolation

d. Place the patient in any Isolation Precautions

ANS: B

If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation Precautions should be requested immediately.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1636 OBJ: 13 TOP: Tuberculosis

KEY: Nursing Process Step: Implementation

13. How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised?

a. Report redness and swelling of extremities

b. Accept that the therapy is long term

c. Monitor renal function every several months

d. Rise slowly to avoid dizziness

ANS: B

INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-2 OBJ: 13 TOP: INH KEY: Nursing Process Step: Planning

14. The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related to an imbalance between the oxygen supply and demand?

a. Direct patient in vigorous independent ROM.

b. Allow to exercise until respirations are over 20 breaths/min over baseline.

c. Plan care to provide optimum rest.

d. Provide frequent cool showers.

ANS: C

Nursing interventions will be directed at attempting to decrease the patient's anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1649, Nursing Care Plan OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD)

KEY: Nursing Process Step: Planning

15. A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse's initial intervention?

a. Report signs to the charge nurse.

b. Elevate head of bed and administer oxygen.

c. Prevent patient from excessive coughing.

d. Increase IV flow rate.

ANS: B

When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the physician should be notified, but only after the patient is stabilized and oxygenated.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1654, 1655 OBJ: 15 TOP: Pulmonary embolism

KEY: Nursing Process Step: Implementation

16. What is true about activities such as walking for the patient with emphysema?

a. Repair dilated alveoli

b. Increase capacity to use oxygen

c. Lessen the oxygen needs

d. Lessen metabolic oxygen needs

ANS: B

Aerobic exercises such as walking will increase the body's ability to use oxygen through sustained rhythmic contractions of large muscles.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1559

OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Implementation

17. The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate?

a. The patient will present with edema of the lower extremities and extended neck

veins due to hypertension of the pulmonary circulation.

b. The patient will present with a dry hacking cough and chest pain due to

constriction of the pulmonary vein.

c. The patient will present with hypertension and a headache related to pulmonary

hypertension.

d. The patient will present with unlabored respiration and cyanosis around the mouth.

ANS: A

COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1658 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD)

KEY: Nursing Process Step: Implementation

18. What is a major advantage of video assisted thoracoscopic surgery (VATS)?

a. The surgeon can record entire surgical procedure on a video.

b. The surgeon can remove tumors of the lung through a small keyhole incision.

c. The surgeon can x-ray and excise tumor in the same procedure.

d. The surgeon can avoid the use of a closed chest drainage system after surgery.

ANS: B

The video assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1650

OBJ: 19 TOP: VATS KEY: Nursing Process Step: Implementation

19. How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound?

a. Sonorous wheeze

b. Friction rub

c. Coarse crackles

d. Crackles

ANS: B

A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1612, Table 48-1 OBJ: 6 TOP: Adventitious sounds

KEY: Nursing Process Step: Assessment

20. What is inspiratory capacity?

a. The amount of air in the lung after a maximal inhalation

b. The amount of air moved with each normal inhalation and expiration

c. The amount of air that can be inhaled in one breath from the resting expiratory

level

d. The amount of air that can be forcefully exhaled after maximum inhalation

ANS: C

Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting expiratory level.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ: 7 TOP: Inspiratory capacity

KEY: Nursing Process Step: Implementation

21. The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what condition?

a. Pulmonary embolus

b. Spontaneous pneumothorax

c. Early signs of unilateral pneumonia

d. An attack of asthma

ANS: B

Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1648, Figure 48-13 OBJ: 11 TOP: Postoperative complications

KEY: Nursing Process Step: Assessment

22. Which important precaution should the nurse include when instructing an emphysema patient on the use of home oxygen?

a. Use oxygen only when extremely short of breath

b. Keep the home oxygen regulator set on 6 L

c. Use home oxygen at night while sleeping

d. Limit to 1 to 2 L oxygen flow

ANS: D

Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body's own respiratory regulatory centers and can cause respiratory failure.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1659 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD)

KEY: Nursing Process Step: Implementation

23. The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful?

a. In 24 hours, but must take cold liquids for the rest of the day

b. If there is no blood in his sputum

c. In 8 hours after a period of nothing by mouth

d. When the gag reflex returns

ANS: D

Following a bronchoscopy, the patient can eat as soon as the gag reflex returns, usually in about 2 hours.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1614 OBJ: 7 TOP: Bronchoscopy

KEY: Nursing Process Step: Implementation

24. The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment?

a. Document the tidaling

b. Elevate the head of the bed and notify charge nurse of malfunction of drainage

system

c. Add more sterile water to the water seal chamber

d. Turn patient to the affected side

ANS: A

Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1646, Box 48-6 OBJ: 14 TOP: Closed chest drainage

KEY: Nursing Process Step: Assessment

25. How does pursed lip breathing assist patients with asthma during an attack?

a. It distracts the patient with breathing technique to reduce anxiety.

b. It gets rid of CO2 faster.

c. It opens bronchioles by backflow air pressure.

d. It increases PACO2..

ANS: C

The resistance or the expiration through the pursed lips causes a backflow of air and helps to open the bronchioles.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1664

OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation

26. How do leukotriene modifiers reduce the symptoms of asthma?

a. By drying up mucus

b. By causing bronchodilation and anti-inflammation effects

c. By suppressing cough

d. By liquefying mucus

ANS: B

Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-3 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Planning

27. How should a patient be positioned after a thoracentesis is completed and the dressing applied?

a. High Fowler

b. Semi-Fowler

c. Side lying on unaffected side

d. Prone

ANS: C

After a thoracentesis the patient is placed in a side-lying position on the unaffected side.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ: 11 TOP: Pleural Effusion

KEY: Nursing Process Step: Implementation

28. What should the nurse do to keep the chest tubes from becoming occluded?

a. Irrigate tubes as needed

b. Prevent dependent loops

c. Loop the tube over the bed rail

d. "Milk" the tube frequently

ANS: B

To keep the tubes patent, the tubes should be kept straight without dependent loops. These tubes are not irrigated and should not be milked frequently.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1645 OBJ: 1 | 14 TOP: Closed chest drainage

KEY: Nursing Process Step: Planning

29. Which patient assessment indicates the most severe respiratory distress?

a. Nasal flaring, symmetrical chest wall expansion, SaO2 88%

b. Abdominal breathing, SaO2 97%

c. Substernal retraction, SaO2 84%

d. Substernal retraction, SaO2 90%

ANS: C

Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ: 5 TOP: Pneumothorax

KEY: Nursing Process Step: Assessment

30. Which preoperative teaching should a nurse include for a person scheduled for a partial laryngectomy? (Select all that apply.)

a. Tracheal suction will be frequent

b. The presence of a temporary tracheotomy

c. That isolation will be required for 24 hours

d. The surgery involves removal of a diseased vocal cord

e. Some speech will be retained

f. The sense of smell and taste will be lost

ANS: A, B, D, E

A partial laryngectomy involves the removal of the diseased cord and possible thyroid cartilage. There will be a temporary tracheostomy that will be closed once edema is under control. Tracheal suctioning will be done frequently. There will be some vocal ability retained. Isolation is not required. Sense of smell and taste are lost with a total laryngectomy.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1623 OBJ: 10 TOP: Patient teaching

KEY: Nursing Process Step: Assessment

31. Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.)

a. Positioning in orthopneic position

b. Suctioning

c. Assisting to cough

d. Providing hydration

e. Starting IV fluids

f. Starting mucolytic agents

ANS: A, B, C, D

Independent nursing intervention to help a patient to expectorate would include positioning, assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic agent requires a physician's order and is not an independent nursing action..

PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ: 12 TOP: Assisting expectoration

KEY: Nursing Process Step: Planning

32. Identify the purposes of chest drainage. (Select all that apply.)

a. Drains air, blood, and fluid from pleural space

b. Restores positive pressure in chest cavity

c. Restores negative intrapleural pressure

d. Allows lung to collapse and rest

e. Allows route for medication administration

ANS: A, C

A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavity's normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1644 OBJ: 14 TOP: Closed chest drainage

KEY: Nursing Process Step: Planning

33. What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.)

a. Moist mucous membranes

b. Kyphosis

c. Decrease in pulmonary blood flow

d. Stasis pooling of secretions

e. Reduced number of cilia

ANS: B, C, D, E

Age-related changes that affect the respiratory system are dryer mucous membranes, which reduce ability to humidify inspired air, kyphosis, which restricts the expansion of the lung, stasis pooling of respiratory secretions, and reduced number of cilia, which make infection of the upper and lower airway more likely.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1641, Lifespan OBJ: 9 TOP: Pneumonia KEY: Nursing Process Step: Planning

34. The nurse explains to the person with pneumonia in the left lung that being positioned in the "good lung down" offers the advantage of (select all that apply):

a. PaO2 rising in the good lung.

b. blood flow to "bad lung" being increased.

c. the dependent lung being better perfused.

d. dyspnea disappearing.

e. decreased hypoxia.

ANS: A, C, E

The "good lung down" position increases the PaO2 in the good lung and also allows for better perfusion, consequently decreasing hypoxia, although dyspnea may still be evident.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1642

OBJ: 11 TOP: Pneumonia KEY: Nursing Process Step: Implementation

35. The are the structures of the lung in which gas exchange occurs.

ANS:

alveoli

The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Lower respiratory tract

KEY: Nursing Process Step: Assessment

36. The nurse prepares a patient for the procedure of a(n) , which will remove the fluid from around the lung to improve respiration and obtain a specimen.

ANS:

thoracentesis

Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1615 OBJ: 7 TOP: Thoracentesis

KEY: Nursing Process Step: Implementation

37. The nurse explains that the opening between the vocal cords is the .

ANS:

glottis

The glottis is the opening between the vocal cords.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1608

OBJ: 2 TOP: Glottis KEY: Nursing Process Step: Implementation

38. The nurse recognizes that the reading in an arterial gas report indicates the amount of oxygen dissolved in the plasma.

ANS:

PaO2

The PaO2 reading indicates the amount of oxygen dissolved in the plasma.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1616 OBJ: 8 TOP: Blood gases KEY: Nursing Process Step: Assessment

39. The nurse explains that the diagnostic test that can scan the chest and the abdomen in less than 30 seconds is the .

ANS:

spiral CT scan helical CT scan

The spiral or helical CT scan can scan the chest and the abdomen in less than 30 seconds. This test is faster and more accurate.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ: 7 TOP: Spiral or helical CT scan

KEY: Nursing Process Step: Implementation

40. The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. Place the events of reoxygenation in order. (Separate letters by a comma and space as follows: A, B, C, D)

a. Pulmonary artery takes blood to capillary system of the alveoli

b. Blood enters the left atria via the pulmonary vein

c. Blood enter the left ventricle

d. Unoxygenated blood enters the right ventricle

e. Blood enters the aorta

f. CO2 diffused and oxygen infused into the blood in alveoli

g. Unoxygenated blood enters the right atrium

ANS:

G, D, A, F, B, C, E

The unoxygenated blood enters the right atria via the vena cava, then to the right ventricle and out the pulmonary artery into the capillary bed of the alveoli, CO2 and O2 are exchanged in the alveoli, the CO2 being exhaled and the oxygenated blood continues to the right atria via the pulmonary vein, then to the left ventricle and out the aorta to the body.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1613 OBJ: 3 TOP: Reoxygenation of blood

KEY: Nursing Process Step: Implementation

41. The nurse describes the pathophysiologic process of an asthma attack. Place the events in their proper sequence. (Separate letters by a comma and space as follows: A, B, C, D)

a. Inflammatory process in the mast cells of the lungs

b. Increase in edema and mucus production in the bronchioles

c. Release of histamine

d. Narrowing of the airways

e. Exposure to allergen

ANS:

E, A, C, B, D

The allergen activates the mast cells in the lungs, which release histamine, causing an increase in edema and mucus production that narrows the airways and causes the classic signs of asthma.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1663, Figure 48-14 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation