Question 1

The nurse is administering a purified protein derivative (PPD) test to a nursing student. Which of the following statements concerning PPD testing is true?

Accepted Answer

A positive reaction to a PPD test indicates that the individual has been exposed to the TB bacterium. It does not necessarily mean the person has active TB, which requires further testing to determine. A negative reaction does not always exclude TB, especially in the early stages or in cases of compromised immune response. The PPD test is typically read 48 to 72 hours after administration, not within 12 to 24 hours.

Question 2

A nurse is suctioning a client via an open system tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

Accepted Answer

When suctioning a client via an open system tracheostomy tube, it is recommended to limit the suctioning time to a maximum of 15 seconds to prevent hypoxia and other potential complications.

Question 3

The nurse is preparing to administer medication to the client with an exacerbation of asthma. Which of the following medications would improve the respiratory function of the client?

Accepted Answer

Bronchodilators are specifically designed to relax the bronchial muscles and widen the airways, directly addressing the constriction and inflammation that characterize an asthma exacerbation, thus improving respiratory function.

Question 4

The nurse is providing care for a client admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this client?

Accepted Answer

The client's muscular dystrophy leads to inadequate muscle strength for ventilation, making "Impaired Spontaneous Ventilation" the most appropriate diagnosis.

Question 5

The nurse is planning care for an older adult client newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of Ineffective Airway Clearance. Which of the following is the nurse's priority intervention?

Accepted Answer

Positioning the client to optimize maximum ventilation is the priority intervention for a patient with ineffective airway clearance due to pneumonia. Proper positioning can help improve lung expansion and facilitate the drainage of secretions, which is critical in the management of pneumonia.

Question 6

A nurse is preparing to obtain a sputum specimen from an adult client. Which of the following nursing actions will facilitate obtaining the specimen?

Accepted Answer

Having the client take deep breaths helps to mobilize secretions from the lungs, making it easier to obtain a sputum specimen.

Question 7

The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

Accepted Answer

Antitussive/expectorant medications aim to reduce dry, unproductive coughs while making any necessary coughing more productive by thinning and loosening mucus, which is reflected in choice C.

Question 8

The nurse is admitting to the medical-surgical unit an older adult with a diagnosis of pulmonary hypertension and right-sided heart failure. The client is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

Accepted Answer

A quick physical examination of breathing, circulation, and oxygenation is the first action the nurse should take. This will help to assess the client's condition and determine the need for immediate interventions.

Question 9

A client is unable to breathe independently and is now on mechanical ventilation. Which of the following is a correct nursing intervention for maintenance?

Accepted Answer

Providing a client who is unable to breathe independently and on mechanical ventilation with a paper and pencil or letter board is a correct nursing intervention. This is because the client may not be able to speak, and these tools can help them communicate their needs and concerns.

Question 10

The nurse is preparing to obtain sputum specimens from several clients. Which of the following clients could the nurse collect a sputum specimen without using a suction catheter?

Accepted Answer

The client admitted with chronic bronchitis is likely to be able to cough effectively to produce a sputum specimen without the need for a suction catheter. Clients with a newly placed tracheostomy, an endotracheal tube, or late-stage amyotrophic lateral sclerosis would typically require assistance with suctioning to obtain a sputum specimen due to impaired cough or airway access.

Question 11

The nurse is providing teachings on smoking cessation to an older client with emphysema. The client states, "My doctor wants me to quit smoking. It's too late now, though; I already have lung problems." Which of the following would be the best response to his statement?

Accepted Answer

Stopping smoking can lead to significant health improvements, even for those with existing lung damage. The body has an ability to repair itself to some extent, and ceasing smoking can slow the progression of lung diseases like emphysema.

Question 12

The nurse is providing care to a pregnant woman in preterm labor. The client is 32 weeks pregnant. Initially, the client states, "I've gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now." After teaching the client about fetal development, the nurse will know her teaching is effective if the client makes which of the following statements?

Accepted Answer

The correct answer is C because babies born preterm, particularly before 34 weeks of gestation, are at a higher risk for respiratory distress syndrome (RDS) due to the immaturity of their lungs. This condition can indeed be life-threatening, and understanding this risk indicates effective teaching on the part of the nurse.

Question 13

The nurse is providing care to the adult client with mechanically ventilated client who has a tracheostomy. The client has a pulse oximetry reading at 85%, heart rate at 113 beats/min, and respiratory rate at 30 breaths/min. The client has become restless and has labored gurgling respirations. The nurse auscultates bilateral crackles and rhonchi. What is the most appropriate nursing action at this time?

Accepted Answer

The most appropriate nursing action is to provide sterile endotracheal suctioning. The client's symptoms, including restlessness, labored gurgling respirations, and the presence of bilateral crackles and rhonchi, suggest that there is a significant amount of secretions in the airway. Suctioning will help to clear these secretions, potentially improving oxygenation as indicated by the low pulse oximetry reading.

Question 14

Which of the following best describes the function of type 1 alveolar cells?

Accepted Answer

Type 1 alveolar cells, also known as pneumocytes, are primarily involved in the process of gas exchange in the lungs. They form the thin alveolar wall that allows for the efficient exchange of oxygen and carbon dioxide between the air in the lungs and the blood in the surrounding capillaries.

Question 15

The nurse is caring for a client diagnosed with pneumonia, teaching him or her how to cough and deep-breathe. The client asks, "Why is drinking fluids so important?" What is the nurse's best response?

Accepted Answer

Fluids help to thin out secretions in the lungs, making it easier for individuals to cough them up, which is particularly important in conditions like pneumonia where mucus production is increased.

Question 16

The client was admitted to the intensive care unit (ICU) for respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28; partial pressure of oxygen (PaO₂)= 85; partial pressure of carbon dioxide (PaCO₂)= 60. What changes to care does the nurse anticipate?

Accepted Answer

The arterial blood gas (ABG) results indicate respiratory acidosis (pH = 7.28, PaCO2 = 60), suggesting that the client is retaining too much CO2. Increasing the number of breaths per minute on the ventilator will help to eliminate more CO2, correcting the acidosis.

Question 17

The nurse is caring for a 6-month-old infant diagnosed with respiratory syncytial virus (RSV) infection. What consideration will most influence the nurse's plan of care?

Accepted Answer

Infants' airways are narrower than those of older children and adults, making them more susceptible to obstruction, especially with conditions like RSV that cause inflammation and increased mucus production. This anatomical difference significantly influences care plans for infants with respiratory conditions.

Question 18

While a client is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?

Accepted Answer

The immediate action should be to place the disconnected end of the chest tube nearest the client into a bottle of sterile water to maintain the water seal and prevent air from entering the pleural space, which can lead to a pneumothorax. This is a temporary measure until the system can be safely reconnected or replaced.

Question 19

When using sterile technique to perform care of a new tracheostomy, which of the following is correct?

Accepted Answer

Placing the client in a semi-Fowler's position, if possible, is correct when performing care of a new tracheostomy using sterile technique. This position helps to reduce the risk of aspiration and facilitates easier access to the tracheostomy site.

Question 20

The nurse is providing care for a young adult client with an intracranial hemorrhage secondary to a closed head injury. During the assessment, the nurse notices that the client's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

Accepted Answer

The described respiratory pattern matches Cheyne-Stokes respirations, which are characterized by a cyclical pattern of increasing and decreasing breathing depth, followed by a period of apnea. This pattern is often seen in conditions affecting the brain, such as intracranial hemorrhage.

Quiz 36: Oxygenation