Chapter 13: The Respiratory System My Nursing Test Banks

Chapter 13: The Respiratory System

MULTIPLE CHOICE

1. The nurse explains that the purpose of mucus is to:

a.

warm the air entering the lungs.

b.

trap particles and bacteria.

c.

protect the cilia.

d.

clean the sinus cavity.

ANS: B

Mucus traps particles and bacteria that may be in the inspired air.

DIF: Cognitive Level: Knowledge REF: 257 OBJ: 1 (theory)

TOP: Mucus KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. After positioning the patient in high Fowlers, the nurse should:

a.

attempt to help the patient slow her respirations.

b.

coach in pursed-lip breathing.

c.

give oxygen at 5 L/min by nasal cannula.

d.

reposition patient in orthopneic position.

ANS: B

Coaching in pursed-lip breathing will open the respiratory tree with negative pressure. Oxygen given at such a high concentration will cause an emphysemic patient to stop breathing. High Fowlers position is beneficial and easy to position with minimal equipment.

DIF: Cognitive Level: Analysis REF: 272 OBJ: 2 (clinical)

TOP: Oxygen Administration to Emphysemic Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

3. The nurse explains that the mechanism that triggers rate and depth of respiration is based on:

a.

ease of respiration.

b.

alveolar pressure.

c.

patency of bronchi.

d.

blood pH.

ANS: D

Chemoreceptors in the brainstem and carotid arteries measure hydrogen concentration, as well as CO2 and O2, to trigger respiration rate to correct the excessive CO2.

DIF: Cognitive Level: Comprehension REF: 259 OBJ: 2 (theory)

TOP: Ventilation and Blood pH KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse uses a visual aid to show the mechanics of inhaling which correctly illustrates:

a.

the diaphragm moves down.

b.

the negative pressure of the lung converts to positive pressure.

c.

muscles contract, pulling the rib cage down.

d.

bronchi enlarge.

ANS: A

On inspiration, the diaphragm moves down, increasing the area of negative pressure, muscles pull the rib cage up, and the positive-pressure room air flows into the negative-pressure lungs.

DIF: Cognitive Level: Comprehension REF: 259 OBJ: 2 (theory)

TOP: Mechanics of Inspiration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse explains that the substance that decreases the surface tension of the alveolar walls is:

a.

plasma.

b.

surfactant.

c.

cilia.

d.

mucus.

ANS: B

Surfactant is the substance that reduces the surface tension of the walls of the alveoli, making gas exchange more effective.

DIF: Cognitive Level: Comprehension REF: 259 OBJ: 1 (theory)

TOP: Surfactant KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. Using animation, the nurse demonstrates how most of the inspired oxygen is carried to the tissues by the:

a.

plasma.

b.

lymphatic system.

c.

red blood cells.

d.

white blood cells.

ANS: C

The red blood cells carry 97% of the oxygen to the cells, attached to hemoglobin.

DIF: Cognitive Level: Comprehension REF: 260 OBJ: 1 (theory)

TOP: Oxygen Transport KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse points out to the student nurse that one of the patients she is caring for has an obstructive respiratory disorder. The student is correct in identifying the patient diagnosed with __________ as having an obstructive disorder.

a.

atelectasis

b.

lung cancer

c.

Guillain-Barr syndrome

d.

chronic bronchitis

ANS: D

Obstructive lung disease is related to the reduced ability to move air in and out of the lungs. Asthma, emphysema, and chronic bronchitis are classified as obstructive disorders. Atelectasis, lung cancer, and Guillain-Barr syndrome are restrictive disorders.

DIF: Cognitive Level: Application REF: 261 OBJ: 1 (theory)

TOP: Obstructive Lung Disease KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. When reviewing risk factors, the nurse correctly identifies which patient as having the greatest risk of throat cancer?

a.

The patient who drinks 4 cups of coffee per day.

b.

The patient who smokes 1 pack of cigarettes per week.

c.

The patient who drinks several carbonated drinks per day.

d.

The patient who drinks 4 vodka tonics per day.

ANS: D

The combination of alcohol and cigarettes increases the risk for throat cancer. However, the patient consuming 4 vodka drinks per day is at a higher risk than the patient smoking 1 pack of cigarettes per week. Coffee and carbonated drink consumption has not been found to increase the risk of throat cancer.

DIF: Cognitive Level: Analysis REF: 262 | Elder Care Points

OBJ: 2 (theory) TOP: Alcohol-Related Throat Cancer

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

9. The nurse cautions each person prior to giving the influenza immunization that they should not take it if they are allergic to:

a.

strawberries.

b.

ragweed.

c.

penicillin.

d.

eggs.

ANS: D

The influenza vaccine is cultured in chicken embryos, making anyone allergic to eggs probably allergic to the immunization.

DIF: Cognitive Level: Application REF: 261 OBJ: 2 (theory)

TOP: Influenza Immunization Allergy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

10. After auscultating a coarse low-pitched sonorous rattling in the left lower lobe, the nurse is concerned that the patient may be developing:

a.

an accumulation of secretions in the larger air passages.

b.

narrowing in the lower lobe of the lung.

c.

irritation in the pleurae.

d.

crackles in the left lower lobe.

ANS: A

Low-pitched sonorous wheezing sounds are caused by secretions accumulating in the larger airways. Narrowing of air passages will result in high-pitched wheezes. Irritation of pleurae will cause a pleural friction rub to be heard. Crackles are produced by air passing through moisture in the smaller airways.

DIF: Cognitive Level: Application REF: 263-264 OBJ: 4 (theory)

TOP: Breath Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

11. When the nurse places the diaphragm of the stethoscope over one of the main bronchi, the expected normal breath sound heard is:

a.

bronchovesicular.

b.

bronchial.

c.

rhonchi.

d.

vesicular.

ANS: A

Bronchovesicular sounds are moderate hollow sounds that are equal on inspiration and expiration.

DIF: Cognitive Level: Comprehension REF: 264 OBJ: 4 (theory)

TOP: Breath Sounds KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

12. The nurse performing tracheal suctioning of the patient with a respiratory disorder should suction no longer than _____ seconds.

a.

2 to 5

b.

5 to 10

c.

10 to 15

d.

15 to 20

ANS: C

The suctioning, which is done during extraction of the suction tip, should not last more than 10 to 15 seconds as it deprives the patient of oxygen.

DIF: Cognitive Level: Comprehension REF: 272 OBJ: 5 (theory)

TOP: Suctioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. The nurse is aware that the patient is in respiratory failure when the blood gas findings are a PaO2 of _____ mm Hg and a PaCO2 of _____ mm Hg.

a.

46; 52

b.

50; 45

c.

52; 42

d.

55; 58

ANS: A

Respiratory failure is defined by blood gases that have a PaO2 level below 50 mm Hg and a PaCO2 level equal to or higher than 50 mm Hg.

DIF: Cognitive Level: Analysis REF: 273 OBJ: 5 (clinical)

TOP: Blood Gases KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse assesses a patients respirations who was recently admitted with a traumatic head injury. The nurse expects to find which type of breathing during the assessment?

a.

Apneustic respiration

b.

Cheyne-Stokes

c.

Kussmauls

d.

Biots

ANS: D

Biots respirations are characterized by irregular periods of apnea followed by four to five breaths of identical depth. This pattern is associated with increased intracranial pressure, which is common with a traumatic head injury. Apneustic respirations are indicative of damage to the respiratory centers in the brain. Cheyne-Stokes respirations are often seen in patients in a coma resulting from a disorder affecting the central nervous system. Kussmauls respiration is an abnormal breathing pattern often seen in patients with diabetic acidosis and coma.

DIF: Cognitive Level: Application REF: 273 OBJ: 4 (theory)

TOP: Biots Respiration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. After having the postoperative patient deep-breathe and cough, the nurse should offer:

a.

a warm drink.

b.

mouth care.

c.

oxygen by mask.

d.

an iced drink.

ANS: B

Mouth care should be offered after deep breathing and coughing to clear the mouth of unpleasant taste.

DIF: Cognitive Level: Comprehension REF: 274 OBJ: 5 (theory)

TOP: Mouth Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

16. A patient is admitted to the medical unit with an acute illness accompanied by a fever for the last 3 days. What will likely be the patients respiratory response?

a.

Hypercarbia

b.

Respiratory alkalosis

c.

Kussmauls respirations

d.

Respiratory acidosis

ANS: B

Respiratory alkalosis, or hypocapnia, results from the patients respiratory rate being elevated for a prolonged period due to the persistent fever. The patient blows off too much CO2 as a result. Hypercarbia and respiratory acidosis are the same and result from disorders that cause hypoventilation. Kussmauls respirations are an abnormal breathing pattern.

DIF: Cognitive Level: Application REF: 273 OBJ: 2 (theory)

TOP: Hypocapnia KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The nurse is caring for a patient with COPD who has been in the hospital for several days. The patient complains of shortness of breath and asks the nurse to turn up his oxygen to compensate for his labored breathing. What is the best nursing response?

a.

Turn up the patients oxygen flow by 1 liter.

b.

Call the physician for an order to turn up the oxygen.

c.

Assess the patient in an attempt to identify the cause of the shortness of breath.

d.

Ask the patient what he usually keeps his oxygen set on at home.

ANS: C

The nurse should assess the patient for possible causes of the shortness of breath before calling the physician. The nurse may be able to implement nursing interventions, or may need to contact the physician for orders based on the assessment findings. Since the COPD patients respiratory drive is lowering levels of PO2, turning up the oxygen may take away his incentive to breathe. Asking the patient about his home oxygen is not helpful at this point.

DIF: Cognitive Level: Analysis REF: 259 OBJ: 2 (clinical)

TOP: Respiration Control KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

18. The nurse clarifies that when interstitial edema occurs in the lung tissue, ventilation is inhibited by: (Select all that apply.)

a.

thickened alveolar membranes.

b.

pus formation.

c.

alveoli filling with fluid.

d.

surfactant evaporation.

e.

failure of gas to diffuse across membrane.

ANS: A, C, E

Interstitial edema will cause problems that affect the alveoli: thickened walls and filling with fluid that obstructs gas exchange across the thickened walls. Pus formation is associated with infection. Surfactant decreases surface tension on the alveolar wall, allowing it to expand more easily with inspiration and preventing alveolar collapse on expiration.

DIF: Cognitive Level: Application REF: 259 OBJ: 2 (theory)

TOP: Interstitial Edema KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. The nurse reminds a group of retirees that age may alter the respiratory systems by: (Select all that apply.)

a.

weakened cough.

b.

kyphosis.

c.

increased ciliary movement.

d.

decrease in body fluid.

e.

muscle weakness.

ANS: A, B, D, E

Age often decreases ciliary movement. All other options are age-related changes that affect the respiratory system.

DIF: Cognitive Level: Application REF: 260 OBJ: 2 (theory)

TOP: Age-Related Changes That Affect Ventilation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The U.S. Public Health Service recommends influenza immunization for: (Select all that apply.)

a.

physicians.

b.

compromised infants.

c.

older adults.

d.

chronically ill people.

e.

nurses.

ANS: A, C, D, E

Compromised infants should not be immunized. Health care workers, older adults, and chronically ill individuals are at risk for contracting influenza and should be immunized.

DIF: Cognitive Level: Comprehension REF: 261 OBJ: 3 (theory)

TOP: Influenza Immunization KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

21. The nurse notes physical signs of labored breathing, which include: (Select all that apply.)

a.

grunting on expiration.

b.

elevating shoulders and ribs on inspiration.

c.

tensing neck and shoulder muscles.

d.

substernal retraction.

e.

productive cough.

ANS: A, B, C, D

Productive cough is not a sign of labored breathing. All other options are often seen with laboring respirations.

DIF: Cognitive Level: Application REF: 262-263 OBJ: 4 (theory)

TOP: Signs of Labored Breathing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. The nurse explains that anorexia in the patient with a respiratory disorder may be attributed to: (Select all that apply.)

a.

increased sense of taste.

b.

bad taste in mouth.

c.

fear that eating will exacerbate coughing.

d.

fatigue.

e.

altered sense of smell.

ANS: B, C, D, E

The sense of taste is usually altered in the patient with a respiratory disorder. All of the other factors contribute to lack of appetite in the patient with a respiratory disorder.

DIF: Cognitive Level: Comprehension REF: 274 OBJ: 2 (theory)

TOP: Anorexia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

23. The nurse uses a visual aid to show the hinged door that helps prevent aspiration. This hinged door is the __________.

ANS:

epiglottis

The epiglottis is the hinged door that closes upon swallowing and opens when breathing.

DIF: Cognitive Level: Knowledge REF: 257 OBJ: 1 (theory)

TOP: Epiglottis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. Rapid opening and closing of the glottis combined with movement of the mouth, lips, and tongue is what makes _____________.

ANS:

speech

The rapid opening and closing of the glottis combined with the movement of the mouth, lips, and tongue is what makes speech.

DIF: Cognitive Level: Comprehension REF: 258 OBJ: 1 (theory)

TOP: Speech KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. The nurse describes the ability of the lungs to respond to change in the volume and pressure of inhaled air by expanding as lung __________.

ANS:

compliance

The lungs normal expansion in response to inhaled air is known as lung expansion. Lung compliance first increases and then decreases with age as the lungs become stiffer and the chest wall becomes more rigid.

DIF: Cognitive Level: Comprehension REF: 259 OBJ: 1 (theory)

TOP: Lung Compliance KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MATCHING

Trace the route of a molecule of oxygen inhaled from room air to the point of gas exchange.

a.

Larynx

b.

Left and right bronchi

c.

Trachea

d.

Oxygen is inhaled through the nose

e.

Bronchioles

f.

Alveoli

26. Step 1

27. Step 2

28. Step 3

29. Step 4

30. Step 5

31. Step 6

26. ANS: D DIF: Cognitive Level: Comprehension REF: 258

OBJ: 1 (theory) TOP: Inhalation Process

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. ANS: A DIF: Cognitive Level: Comprehension REF: 258

OBJ: 1 (theory) TOP: Inhalation Process

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

28. ANS: C DIF: Cognitive Level: Comprehension REF: 258

OBJ: 1 (theory) TOP: Inhalation Process

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. ANS: B DIF: Cognitive Level: Comprehension REF: 258

OBJ: 1 (theory) TOP: Inhalation Process

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. ANS: E DIF: Cognitive Level: Comprehension REF: 258

OBJ: 1 (theory) TOP: Inhalation Process

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. ANS: F DIF: Cognitive Level: Comprehension REF: 258

OBJ: 1 (theory) TOP: Inhalation Process

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Place in the appropriate sequence the steps of auscultation of the chest.

a.

Place diaphragm of stethoscope above clavicles.

b.

Listen in midaxillary line to level of diaphragm.

c.

Move stethoscope from side to side down midline of the chest.

d.

Place diaphragm of stethoscope above scapulae.

e.

Move stethoscope side to side on either side of the spine.

32. Step 1

33. Step 2

34. Step 3

35. Step 4

36. Step 5

32. ANS: A DIF: Cognitive Level: Application REF: 264

OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

33. ANS: C DIF: Cognitive Level: Application REF: 264

OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

34. ANS: D DIF: Cognitive Level: Application REF: 264

OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

35. ANS: E DIF: Cognitive Level: Application REF: 264

OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

36. ANS: B DIF: Cognitive Level: Application REF: 264

OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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