Chapter 50 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 50

Question 1

Type: MCSA

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?

1. The ability to cough

2. Filtration and humidification of inspired air

3. The sneeze reflex initiated by irritants in the nasal passages

4. Decrease in oxygen-carrying capacity of the trachea

Correct Answer: 2

Rationale 1: The client is able to cough.

Rationale 2: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed.

Rationale 3: The client can sneeze.

Rationale 4: There is no decrease in the oxygen-carrying capacity of the trachea.

Global Rationale: Page Reference: 1405

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Describe the mechanisms for respiratory regulation.

Question 2

Type: MCSA

When planning care, for which client would the nurse include close observation for a decreased or absent cough reflex?

1. The client with a nasal fracture

2. The client with impairment of vagus nerve conduction

3. The client with a sinus infection

4. The client with reduction in respiratory membrane conduction

Correct Answer: 2

Rationale 1: Nasal fracture does not depress the cough reflex.

Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections.

Rationale 3: A sinus infection will not depress the cough reflex.

Rationale 4: The respiratory membrane is the alveolar/capillary membrane and is not implicated in decreased or absent cough reflex.

Global Rationale: Page Reference: 1380

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 05 Identify factors influencing respiratory function.

Question 3

Type: MCSA

The client complains of difficulty breathing. Which of the following assessment findings would the nurse commonly associate with that complaint?

1. Use of accessory muscles

2. Increased respiratory depth

3. Increased respiratory rate

4. Decreased respiratory depth

5. Decreased respiratory rate

Correct Answer: 1,2,3,4

Rationale 1: Rate, depth, and use of accessory muscles often are assessment findings indicating difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Rate is generally increased.

Rationale 2: Rate, depth, and use of accessory muscles often are assessment findings indicating difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Rate is generally increased.

Rationale 3: Rate, depth, and use of accessory muscles often are assessment findings indicating difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Rate is generally increased.

Rationale 4: Rate, depth, and use of accessory muscles often are assessment findings indicating difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Rate is generally increased.

Rationale 5: Rate, depth, and use of accessory muscles often are assessment findings indicating difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Rate is generally increased.

Global Rationale: Page Reference: 1386

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe nursing assessments for oxygenation status.

Question 4

Type: MCSA

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?

1. Increased hematocrit

2. Decreased BUN

3. Increased blood sugar

4. Increased sedimentation rate

Correct Answer: 1

Rationale 1: Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the bodys attempt to increase oxygen-carrying capacity by increasing erythrocyte production.

Rationale 2: BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity.

Rationale 3: The blood glucose level is not used to measure oxygenation.

Rationale 4: The sedimentation rate is not a direct measure of oxygenation.

Global Rationale: Page Reference: 1382

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 Identify four major types of conditions that can alter respiratory
function.

Question 5

Type: MCSA

A client, diagnosed with chronic obstructive lung disease receiving oxygen at 1.5 liters per minute via nasal cannula, is complaining of shortness of breath. What action should the nurse take?

1. Increase the oxygen to 3 liters per minute via nasal cannula.

2. Lower the head of the clients bed to semi-Fowlers position.

3. Have the client breathe through pursed lips.

4. Encourage the client to breathe more rapidly.

Correct Answer: 3

Rationale 1: In the client with chronic obstructive lung disease, the drive to breathe is often dependent upon low oxygen concentration. Increasing oxygen delivery by increasing the oxygen from 1.5 Lpm to 3 Lpm may be dangerous to this client.

Rationale 2: Lowering the head of the bed makes it more difficult to breathe. This client should have the head of the bed elevated to Fowlers position or should be assisted to lean over the overbed table to increase chest excursion.

Rationale 3: The client should be taught to breathe out against pursed lips to increase the time it takes to exhale and to help keep airways open.

Rationale 4: Chronic obstructive lung disease makes it difficult for the client to breathe out, so increasing rate of respirations will not be helpful.

Global Rationale: Page Reference: 1390

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing measures to promote respiratory function
and oxygenation.

Question 6

Type: MCSA

After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse?

1. Prepare to resuscitate the client.

2. Have the client concentrate on slowing down respirations.

3. Place the client in Trendelenburgs position and ask him to cough forcefully.

4. Administer 25 mg of meperidine (Demerol) according to the prn pain order.

Correct Answer: 2

Rationale 1: There is no indication that this client needs resuscitation.

Rationale 2: This client is hyperventilating and should be assisted to slow down respirations. Techniques to slow respirations include counting respirations or having the client match respirations with the nurse who then slows down the respiratory rate.

Rationale 3: There is no need to place the client in Trendelenburgs position for coughing.

Rationale 4: Demerol may slow breathing, but is not necessary at this time.

Global Rationale: Page Reference: 1389

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing measures to promote respiratory function
and oxygenation.

Question 7

Type: MCSA

The client is experiencing severe shortness of breath, but is not cyanotic. What lab value would the nurse review in an attempt to understand this phenomenon?

1. Blood sugar

2. Hemoglobin and hematocrit

3. Cardiac enzymes

4. Serum electrolytes

Correct Answer: 2

Rationale 1: Blood sugar is not used to evaluate respiratory function.

Rationale 2: In order to exhibit cyanosis, the clients blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit.

Rationale 3: Cardiac enzymes are not used to evaluate respiratory function.

Rationale 4: Serum electrolytes are not used to evaluation respiratory function.

Global Rationale: Page Reference: 1382-1383

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Identify four major types of conditions that can alter respiratory
function.

Question 8

Type: MCSA

The client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?

1. Cheyne-Stokes

2. Biots

3. Cluster

4. Kussmauls

Correct Answer: 4

Rationale 1: Cheyne-Stokes respirations are commonly a result of congestive heart failure, increased intracranial pressure, or drug overdose.

Rationale 2: Biots respirations are often the result of central nervous system disorders.

Rationale 3: Cluster respirations are often the result of central nervous system disorders.

Rationale 4: Kussmauls respirations are a type of hyperventilation that accompanies metabolic acidosis. They represent the bodys attempt to compensate for the acidosis by blowing off carbon dioxide.

Global Rationale: Page Reference: 1385

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe nursing assessments for oxygenation status.

Question 9

Type: MCSA

Upon assessment, the nurse notes that the client is dyspneic, has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?

1. Ineffective Breathing Pattern

2. Anxiety

3. Ineffective Airway Clearance

4. Impaired Gas Exchange

Correct Answer: 3

Rationale 1: There are no data to support Ineffective Breathing Pattern.

Rationale 2: There are no data that support Anxiety as a diagnosis.

Rationale 3: The data given for this client best support the nursing diagnosis of Ineffective Airway Clearance. The most supportive finding for this diagnosis is bibasilar crackles.

Rationale 4: There are no data that support Impaired Gas Exchange.

Global Rationale: Page Reference: 1387

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 06 Identify four major types of conditions that can alter respiratory
function.

Question 10

Type: MCSA

The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction?

1. Sputum contains bacteria that should be expectorated.

2. Swallowing sputum is dangerous to the system.

3. The nurse should view the sputum for quality and quantity.

4. The client is likely to aspirate the sputum while attempting to swallow it.

Correct Answer: 3

Rationale 1: Sputum does contain bacteria, but they are killed by the acid environment of the gastrointestinal tract.

Rationale 2: There is no danger to swallowing sputum.

Rationale 3: There is no good rationale for having the client expectorate the sputum except for the nurse to view it for quality and quantity.

Rationale 4: The client is no more likely to aspirate sputum than any other fluid.

Global Rationale: Page Reference: 1390

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing measures to promote respiratory function
and oxygenation.

Question 11

Type: MCSA

The nurse is planning a time schedule for a clients twice-daily postural drainage. Which time schedule would be best?

1. 0800 and 1100

2. 1200 and 1800

3. 0700 and 2000

4. 0900 and 2100

Correct Answer: 3

Rationale 1: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Since this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span.

Rationale 2: Since this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span.

Rationale 3: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 0700 and 2000.

Rationale 4: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Since this client is getting the treatments only twice each day, the sessions should be separated as far as possible to allow for benefits across a longer time span. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 0700 and 2000.

Global Rationale: Page Reference: 1394

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Describe nursing measures to promote respiratory function and oxygenation.
09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 12

Type: MCSA

The client is receiving oxygen by nonrebreather mask, but the bag is not deflating on inspiration. What action should be taken by the nurse?

1. Turn the client to the left side.

2. Increase the percentage of oxygen being delivered.

3. Check for an airtight seal between the clients face and the mask.

4. Increase the liter flow of oxygen being delivered.

Correct Answer: 4

Rationale 1: There is no need to turn the client to either side.

Rationale 2: All oxygen is delivered at 100%, so there is no method to increase the percentage of oxygen being delivered.

Rationale 3: The seal between the clients face and the mask should be snug, but will not be airtight.

Rationale 4: If the bag attached to the nonrebreather mask is not deflating on inspiration, the nurse should increase the liter flow of the oxygen being delivered.

Global Rationale: Page Reference: 1398

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 13

Type: MCSA

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?

1. Tape the airway in place.

2. Suction the client.

3. Turn the clients head to the side.

4. Insert a nasal trumpet.

Correct Answer: 3

Rationale 1: The airway should not be taped in place as it would then act as an airway obstruction if dislodged.

Rationale 2: While suctioning the client is possible with the airway in place, the client should be suctioned only when it is necessary.

Rationale 3: The nurse should turn the clients head to the side to allow drainage of oral secretions.

Rationale 4: Insertion of a nasal trumpet or nasopharyngeal airway is not necessary when the oropharyngeal airway is in place.

Global Rationale: Page Reference: 1404

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 14

Type: MCSA

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?

1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.

2. Remove the tracheostomy ties and replace them with an elastic bandage.

3. Remove the tracheostomy inner cannula.

4. Tape the tracheostomy obturator to the head of the bed.

Correct Answer: 4

Rationale 1: The cuff should not be deflated if the client is being mechanically ventilated.

Rationale 2: The tracheostomy ties are only removed when they are soiled and need to be changed.

Rationale 3: The tracheostomy inner cannula is only removed for cleaning.

Rationale 4: The obturator should be taped to the head of the bed so that it will be readily available if the client tracheostomy tube should become dislodged.

Global Rationale: Page Reference: 1405

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Describe nursing measures to promote respiratory function and oxygenation.
09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 15

Type: MCSA

The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement?

1. Turn the suction level up to 60 cm prior to inserting the catheter.

2. Increase the oxygen flow to the client by 20% prior to suctioning.

3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction.

4. Instruct the client to cough forcefully from the abdomen prior to suction.

Correct Answer: 3

Rationale 1: Turning up the suction level will not hyperinflate the clients lungs.

Rationale 2: Increasing the oxygen flow rate will not hyperinflate the clients lungs.

Rationale 3: The nurse should provide 2 to 3 breaths at 1.5 times the clients normal tidal volume prior to and after insertion of the suction catheter.

Rationale 4: Coughing will not hyperinflate the clients lungs.

Global Rationale: Page Reference: 1410, 1412

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.

Question 16

Type: MCSA

The nurse who is assessing a clients chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?

1. Discontinue the chest tube suction.

2. Collaborate with the clients physician.

3. Mark the area involved and remove the tube.

4. Reinforce the chest tube dressing.

Correct Answer: 2

Rationale 1: Chest tube suction should not be discontinued.

Rationale 2: The nurse should collaborate with the clients physician regarding this finding.

Rationale 3: The tube should not be removed.

Rationale 4: Simply reinforcing the chest tube dressing will not prevent further air loss and does not allow for physician input.

Global Rationale: Page Reference: 1418-1419

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Describe nursing assessments for oxygenation status.
09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 17

Type: MCSA

The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure?

1. An occlusive dressing

2. A 4 4 gauze

3. An adhesive gauze pad dressing

4. A nonadherent gauze dressing

Correct Answer: 1

Rationale 1: Since this chest tube was put in without a purse-string suture, there is nothing to pull the tissue together once the tube is removed. In order to prevent leakage of air into the chest cavity, an occlusive dressing must be used.

Rationale 2: This is not an occlusive dressing.

Rationale 3: This is not an occlusive dressing.

Rationale 4: This is not an occlusive dressing.

Global Rationale: Page Reference: 1419

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 18

Type: MCSA

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement, made by the client, would indicate that this client needs further instruction?

1. I will replace my cotton blankets with polyester ones.

2. My son will not be able to smoke when I am around.

3. I will have my electrical appliance checked for grounding.

4. I will buy a fire extinguisher for my bedroom.

Correct Answer: 1

Rationale 1: Polyester blankets and fabrics tend to produce static electricity, which can cause sparks and can cause oxygen-saturated fabrics to burn more readily.

Rationale 2: The client understands the hazards associated with home oxygen therapy.

Rationale 3: This statement reflects understanding of home oxygen therapy.

Rationale 4: This statement reflects understanding of home oxygen therapy.

Global Rationale: Page Reference: 1396

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 19

Type: MCSA

The client who has a nasotracheal tube in place has been restless and pulling at the tube. How would the nurse assess if the tube is still in place?

1. Count the clients respirations.

2. Assess the depth of the clients respirations.

3. Auscultate for bilateral breath sounds.

4. Deflate the cuff and listen for minimal leak.

Correct Answer: 3

Rationale 1: Counting the respirations does not assess tube placement.

Rationale 2: This will not determine tube placement.

Rationale 3: The end of the endotracheal tube should sit just above the bifurcation of the trachea into the two mainstem bronchi. If the tube is in correct position, the nurse should be able to hear equal bilateral breath sounds.

Rationale 4: Deflating the cuff and listening for minimal leak is a way to prevent damage to the trachea, not a way to assess placement.

Global Rationale: Page Reference: 1404

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 20

Type: MCSA

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurses next action?

1. Fill the humidifier with normal saline.

2. Pad the tubing where it contacts the clients ears.

3. Set the oxygen delivery to 5 liters.

4. Secure the cannula with ties around the clients head.

Correct Answer: 2

Rationale 1: The humidifier should be filled with water prior to initiating therapy.

Rationale 2: It is necessary to pad the cannula where it contacts the clients ears as pressure irritation may occur.

Rationale 3: Since this client has chronic obstructive pulmonary disease, the oxygen should be set at a lower delivery rate (generally no more than 1.5 to 2 Lpm).

Rationale 4: The cannula does not require ties to secure.

Global Rationale: Page Reference: 1401

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.
11 Verbalize the steps used in:
a. Administering oxygen by cannula, face mask, or face tent.

Question 21

Type: MCSA

The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties?

1. Remove the old ties, clean the area well, and then put on new ties.

2. Attach the new tape and tie with a square knot behind the clients neck.

3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties.

4. Remove the outer cannula, replace the soiled ties, and reinsert.

Correct Answer: 3

Rationale 1: Removing the ties without an assistant could allow the tracheostomy tube to become dislodged. \

Rationale 2: The knot for securing the tracheostomy tube should be tied at the side of the neck to prevent an area of pressure development.

Rationale 3: Since these ties are very soiled, it is likely that they must be removed before new ties are attached. The safest way to perform this intervention is to have an assistant hold the tracheostomy tube flange in place while the nurse removes the old ties and replaces them.

Rationale 4: The outer cannula is not removed in a new tracheostomy.

Global Rationale: Page Reference: 1414

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
d. Providing tracheostomy care.

Question 22

Type: MCSA

The nurse is planning the care of a client who has need for frequent suctioning. Which of the following should the nurse delegate to the UAP?

1. Both oral and tracheal suctioning

2. Only oral suctioning

3. Only tracheal suctioning

4. Neither oral nor tracheal suctioning

Correct Answer: 2

Rationale 1: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP. Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP.

Rationale 2: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP.

Rationale 3: Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP.

Rationale 4: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP. Tracheal suctioning is a sterile procedure that requires client assessment and should not be delegated to the UAP.

Global Rationale: Page Reference: 1407

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12 Recognize when it is appropriate to delegate aspects of
oxygen therapy, suctioning, and tracheostomy care

Question 23

Type: MCSA

During tracheal suctioning, the nurse notes that the client heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take?

1. Immediately discontinue suctioning.

2. Prepare to resuscitate the client.

3. Continue to suction until the airway is clear.

4. Complete the suction episode as quickly as possible.

Correct Answer: 4

Rationale 1: There is no need to immediately discontinue suctioning.

Rationale 2: There is no need to prepare to resuscitate the client.

Rationale 3: The client will likely not tolerate continuing the suction episode until the airway is clear.

Rationale 4: An increase in heart rate from 80 to 100 is not an unusual finding during suctioning, but does indicate increased stress on the client. The nurse should complete the suctioning episode as quickly as possible.

Global Rationale: Page Reference: 1411

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
c. Suctioning a tracheostomy or endotracheal tube.

Question 24

Type: MCSA

The client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client the nurse should:

1. Hyperventilate the client using settings on the mechanical ventilator.

2. Hyperventilate the client using a manual resuscitator.

3. Avoid hyperventilation, but instill normal saline into the endotracheal tube.

4. Avoid hyperventilation and increase the oxygen to 100% for several breaths.

Correct Answer: 4

Rationale 1: Hyperventilating the client will likely serve to force secretions back into the respiratory tract.

Rationale 2: Hyperventilating the client will likely serve to force secretions back into the respiratory tract.

Rationale 3: There is no need to instill normal saline into the tube of a client with copious frothy secretions.

Rationale 4: The nurse should avoid hyperventilation and should increase the oxygen to 100% for several breaths prior to initiating suction.

Global Rationale: Page Reference: 1410-1411

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11 Verbalize the steps used in:
c. Suctioning a tracheostomy or endotracheal tube.

Question 25

Type: MCSA

The client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?

1. The medications cannot be used on the same day.

2. The steroid inhaler should be used when immediate effects are necessary.

3. The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler.

4. Both medications have the possible side effect of increased heart rate.

Correct Answer: 4

Rationale 1: The medications can be used on the same day.

Rationale 2: It is imperative for the client to understand that the steroid inhaler is not a rescue inhaler and should not be used for immediate relief.

Rationale 3: While the client should be taught to use both inhalers as infrequently as possible, the client should be taught to use the inhaler when necessary. When the inhalers are used together, the bronchodilator is used first, followed by the steroid.

Rationale 4: Both of these medications have the possible side effect of increased heart rate.

Global Rationale: Page Reference: 1391-1392

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 26

Type: MCMA

The client complains of difficulty breathing. What will the nurse most likely assess in this client?

Standard Text: Select all that apply.

1. Use of accessory muscles.

2. Increased respiratory depth.

3. Increased respiratory rate.

4. Decreased respiratory depth.

5. Decreased respiratory rate.

Correct Answer: 1,2,3,4

Rationale 1: Use of accessory muscles is an assessment finding associated with difficulty breathing.

Rationale 2: Increased respiratory depth is an assessment finding associated with difficulty breathing.

Rationale 3: Increased respiratory rate is an assessment finding associated with difficulty breathing.

Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Respiratory rate is generally increased.

Rationale 5: Respiratory rate is generally increased.

Global Rationale: Page Reference: 1386

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe nursing assessments for oxygenation status.

Question 27

Type: MCSA

A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to:

1. Improve oxygenation.

2. Remove irritants from the nasal passages.

3. Remove irritants from the trachea or bronchi.

4. Close the glottis.

Correct Answer: 3

Rationale 1: Coughing does not improve oxygenation.

Rationale 2: Sneezing removes irritants from the nasal passages.

Rationale 3: The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus that traps pathogens and microscopic particulate matter. These foreign particles are then swept upward toward the larynx and throat by cilia. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi.

Rationale 4: Swallowing closes the glottis.

Global Rationale: Page Reference: 1380

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Explain the role and function of the respiratory system in transporting oxygen and carbon dioxide to and from body tissues.

Question 28

Type: MCSA

A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in:

1. Ventilation.

2. Alveolar gas exchange.

3. Transportation of oxygen and carbon dioxide.

4. Systemic diffusion.

Correct Answer: 1

Rationale 1: Atelectasis affects lung compliance, which is a condition that needs to be present for adequate ventilation.

Rationale 2: Alveolar gas exchange is the diffusion of oxygen from the alveoli and into the pulmonary blood vessels, and occurs after ventilation.

Rationale 3: Transportation of oxygen and carbon dioxide occurs in the blood.

Rationale 4: Systemic diffusion of oxygen and carbon dioxide occurs between the capillaries and the tissues and cells.

Global Rationale: Page Reference: 1382

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Identify four major types of conditions that can alter respiratory function.

Question 29

Type: MCSA

A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the clients degree of effective gas exchange?

1. Blood glucose.

2. Serum potassium.

3. Serum sodium.

4. Arterial blood gas.

Correct Answer: 4

Rationale 1: The blood glucose level is not used to determine a clients degree of effective gas exchange.

Rationale 2: The serum potassium level is not used to determine a clients degree of effective gas exchange.

Rationale 3: The serum sodium level is not used to determine a clients degree of effective gas exchange.

Rationale 4: Blood for partial pressures or blood gases are usually obtained from arterial blood.

Global Rationale: Page Reference: 1386

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe nursing assessments for oxygenation status.

Question 30

Type: MCMA

The nurse is determining a clients ability to transport oxygen from the lungs to body tissues. What factors will influence this ability?

Standard Text: Select all that apply.

1. Cardiac output.

2. Exercise.

3. Diet.

4. Erythrocyte count.

5. Hematocrit.

Correct Answer: 1,2,4,5

Rationale 1: Cardiac output is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 2: Exercise is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 3: Diet is not a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 4: Erythrocyte count is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Rationale 5: Hematocrit level is a factor that affects the rate of oxygen transport from the lungs to the tissues.

Global Rationale: Page Reference: 1383

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify factors influencing respiratory function.

Question 31

Type: MCSA

A clients blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client?

1. Decreased respiration rate.

2. Increased respiration rate.

3. Increased blood pressure.

4. Decreased bowel sounds.

Correct Answer: 2

Rationale 1: An increase in carbon dioxide level will increase, not decrease, respirations.

Rationale 2: Of the three blood gaseshydrogen, oxygen, and carbon dioxidethat can trigger chemoreceptors, increased carbon dioxide concentration normally has the strongest effect on stimulating respiration.

Rationale 3: An increase in carbon dioxide level might not increase the clients blood pressure.

Rationale 4: An increase in carbon dioxide level has no effect on the clients bowel sounds.

Global Rationale: Page Reference: 1385

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe nursing assessments for oxygenation status.

Question 32

Type: MCSA

A clients blood gas results reveal a low oxygen level. The nurse realizes that which area of the body will respond to this level and influence respirations?

1. Alveoli.

2. Trachea.

3. Bronchioles.

4. Carotid bodies.

Correct Answer: 4

Rationale 1: The alveoli do not respond to a low oxygen level.

Rationale 2: The trachea does not respond to a low oxygen level.

Rationale 3: The bronchioles do not respond to a low oxygen level.

Rationale 4: Special neural receptors sensitive to decreases in O2 concentration are located outside the central nervous system in the carotid bodies, just above the bifurcation of the common carotid arteries, and aortic bodies located above and below the aortic arch. Decreases in arterial oxygen concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory center to increase ventilation.

Global Rationale: Page Reference: 1383

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Describe the processes of breathing (ventilation) and gas exchange (respiration).

Question 33

Type: MCSA

An older client is prescribed diazepam (Valium). What will the nurse assess in this client?

1. Respirations.

2. Urine output.

3. Muscle tone.

4. Appetite.

Correct Answer: 1

Rationale 1: Medications such as diazepam (Valium) can decrease the rate and depth of respirations. Older clients are at high risk of respiratory depression. The nurse must carefully monitor respiratory status in this client.

Rationale 2: Diazepam (Valium) does not affect urine output.

Rationale 3: Diazepam (Valium) does not affect muscle tone.

Rationale 4: Diazepam (Valium) does not affect appetite.

Global Rationale: Page Reference: 1384

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.

Question 34

Type: MCMA

While assessing an older client, the nurse will keep in mind what effects that aging has on respiratory function?

Standard Text: Select all that apply.

1. Decreased cough reflex.

2. Stiffening of blood vessels.

3. Alteration in protein synthesis.

4. Dry mucous membranes.

5. Increased risk of aspiration.

Correct Answer: 1,4,5

Rationale 1: The cough reflex decreases during aging.

Rationale 2: Stiffening of blood vessels is an effect of aging on the cardiovascular system.

Rationale 3: Alteration in protein synthesis is an effect of aging on the metabolic system.

Rationale 4: Mucous membranes are drier with aging.

Rationale 5: Increased risk of aspiration occurs in aging because of gastroesophageal reflux disease.

Global Rationale: Page Reference: 1384

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify factors influencing respiratory function.

Question 35

Type: MCSA

A client is diagnosed with congestive heart failure. The nurse will assess the client for which condition that can alter this clients respiratory function?

1. Condition that affects the airway.

2. Condition that affects transport.

3. Conditions that affect the movement of air.

4. Conditions that affect diffusion.

Correct Answer: 2

Rationale 1: Conditions that affect the airway are those that partially or totally occlude the respiratory passages.

Rationale 2: Once oxygen moves into the lungs and diffuses into the capillaries, the cardiovascular system transports the oxygen to all body tissues, and transports CO2 from the cells back to the lungs, where it can be exhaled from the body. Conditions that decrease cardiac output, such as congestive heart failure or hypovolemia, affect tissue oxygenation and also the bodys ability to compensate for hypoxemia.

Rationale 3: Conditions that affect the movement of air would alter the clients breathing pattern.

Rationale 4: Impaired diffusion can affect levels of gases in the blood, particularly oxygen, which does not diffuse as readily as does carbon dioxide. Hypoxemia, or reduced oxygen levels in the blood, can be caused by conditions that impair diffusion at the alveolarcapillary level such as pulmonary edema or atelectasis, or by low hemoglobin levels.

Global Rationale: Page Reference: 1386

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify factors influencing respiratory function.

Question 36

Type: MCMA

The nurse is conducting a health history for a client with a respiratory disorder. What will be included in this assessment?

Standard Text: Select all that apply.

1. Lifestyle.

2. Presence of cough.

3. Sputum production.

4. Pain.

5. Diet.

Correct Answer: 1,2,3,4

Rationale 1: A comprehensive nursing history relevant to oxygenation status should include data about lifestyle.

Rationale 2: A comprehensive nursing history relevant to oxygenation status should include data about the presence of a cough.

Rationale 3: A comprehensive nursing history relevant to oxygenation status should include data about sputum production.

Rationale 4: A comprehensive nursing history relevant to oxygenation status should include data about pain.

Rationale 5: A comprehensive nursing history relevant to oxygenation status does not include data about diet.

Global Rationale: Page Reference: 1387

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe nursing assessments for oxygenation status.

Question 37

Type: MCMA

What will the nurse instruct a client to do to promote a healthy respiratory status?

Standard Text: Select all that apply.

1. Use pursed-lip breathing.

2. Exercise regularly.

3. Do not smoke.

4. Breathe through the nose.

5. Breathe through the mouth.

Correct Answer: 2,3,4

Rationale 1: Client teaching to promote healthy breathing does not include the use of pursed-lip breathing. This technique is for a client with a lung disorder such as chronic obstructive lung disease or emphysema.

Rationale 2: Client teaching to promote healthy breathing includes regular exercise.

Rationale 3: Client teaching to promote healthy breathing includes not smoking.

Rationale 4: Client teaching to promote healthy breathing includes breathing through the nose.

Rationale 5: Client teaching to promote healthy breathing does not include breathing through the mouth.

Global Rationale: Page Reference: 1389

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing measures to promote respiratory function
and oxygenation.

Question 38

Type: MCSA

Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective?

1. A humidifier takes moisture out of the air.

2. A humidifier tightens secretions.

3. A humidifier prevents my lungs from getting too dry.

4. A humidifier replaces the use of oxygen.

Correct Answer: 3

Rationale 1: A humidifier adds moisture to the air.

Rationale 2: A humidifier loosens secretions.

Rationale 3: The purposes of humidifiers are to prevent mucous membranes from drying and becoming irritated and to loosen secretions for easier expectoration.

Rationale 4: A humidifier does not replace the use of oxygen but is used with oxygen.

Global Rationale: Page Reference: 1390

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10 State outcome criteria for evaluating client responses to measures that promote adequate oxygenation.

Question 39

Type: MCSA

The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client?

1. Respiratory rate 24 and labored.

2. Audible wheeze upon auscultation.

3. High-pitched cough present.

4. Presence of a productive cough.

Correct Answer: 4

Rationale 1: Expectorants do not affect the respiratory rate.

Rationale 2: Expectorants should improve lung sounds.

Rationale 3: Expectorants should cause a more productive cough.

Rationale 4: Expectorants break up mucus, making it more liquid and easier to cough out.

Global Rationale: Page Reference: 1391

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10 State outcome criteria for evaluating client responses to measures that promote adequate oxygenation.

Question 40

Type: MCSA

When conducting nasotracheal suctioning of a client, what will the nurse do?

1. Apply suction for 510 seconds.

2. Plan to suction for 10 minutes.

3. Apply suction while inserting the catheter.

4. Apply suction for 2030 seconds.

Correct Answer: 1

Rationale 1: When conducting nasotracheal suctioning, the nurse should apply suction for 510 seconds.

Rationale 2: Suctioning should be done for no longer than 5 minutes.

Rationale 3: Suction should never be applied while inserting the catheter.

Rationale 4: Suction should only be applied for 510 seconds.

Global Rationale: Page Reference: 1408

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.

Question 41

Type: MCSA

The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity?

1. How to apply suction during the insertion of the catheter.

2. Not to apply suction during the insertion of the catheter.

3. How to maintain sterile technique.

4. How to listen for lung sounds.

Correct Answer: 2

Rationale 1: The nurse would instruct not to apply suction during the insertion of the catheter.

Rationale 2: Oral suctioning using a Yankauer suction tube can be delegated to UAP, since this is not a sterile procedure. The nurse needs to review the procedure and important points, such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane.

Rationale 3: Oral suctioning uses clean, not sterile, technique.

Rationale 4: The nurse should not delegate the auscultation of lung sounds to UAP.

Global Rationale: Page Reference: 1407

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11 Verbalize the steps used in:
b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.
12 Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care.

Question 42

Type: MCMA

The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure?

Standard Text: Select all that apply.

1. Amount, consistency, color, and odor of sputum.

2. Amount of sterile solution used to flush the catheter.

3. Lung sounds before the procedure.

4. Lung sounds after the procedure.

5. Oxygen saturation after the procedure.

Correct Answer: 1,3,4,5

Rationale 1: The nurse should document the amount, consistency, color, and odor of suctioned sputum.

Rationale 2: The nurse does not need to document the amount of sterile solution used to flush the catheter.

Rationale 3: The nurse should document the clients lung sounds before the procedure.

Rationale 4: The nurse should document the clients lung sounds after the procedure.

Rationale 5: The nurse should document the clients oxygen saturation after the procedure.

Global Rationale: Page Reference: 1409

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning.
13 Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care.

Question 43

Type: MCMA

The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a clients medical record. What should this documentation include?

Standard Text: Select all that apply.

1. Lung sounds before and after suctioning.

2. Characteristics of suctioned sputum.

3. Integrity of the skin around the stoma.

4. Type of tracheostomy ties used.

5. Flow rate of oxygen.

Correct Answer: 1,2,3,4,5

Rationale 1: The nurse should document lung sounds before and after suctioning.

Rationale 2: The nurse should document characteristics of suctioned sputum.

Rationale 3: The nurse should document the integrity of the skin around the stoma.

Rationale 4: The nurse should document the type of tracheostomy ties used.

Rationale 5: The flow rate of the oxygen is not a part of documentation after tracheostomy suctioning or tracheostomy care.

Global Rationale: Page Reference: 1413

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
c. Suctioning a tracheostomy or endotracheal tube.
d. Providing tracheostomy care.
13 Demonstrate appropriate documentation and reporting of
oxygen therapy, suctioning, and tracheostomy care.

Question 44

Type: MCSA

The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon this history, the nurses greatest concern is that this client might develop which of the following?

1. Chronic renal failure

2. A gastric ulcer

3. Hypoxemia

4. A cerebral vascular accident

Correct Answer: 3

Rationale 1: Injury to the heart muscle might affect renal function, it is not the nurses greatest concern.

Rationale 2: While an injury to the heart muscle can cause stress to the client and lead to a gastric ulcer, this is not the nurses greatest concern.

Rationale 3: While injury to the heart muscle might affect any or all of the body systems, at this point the nurse is most concerned that the client will develop hypoxemia. The status of the respiratory system is closely linked to and dependent upon the cardiovascular system.

Rationale 4: Injury to the heart muscle may or may not cause a cerebral vascular accident. This is not the area of greatest concern to the nurse at this time.

Global Rationale: Page Reference: 1386

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 03 Describe three major alterations in cardiovascular function.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

Leave a Reply