Respiratory Disorders NCLEX questions

Respiratory Disorders NCLEX questions ScienceMedicineNursing Setfiretoit Save Respiratory NCLEX Questions 131 terms rwillia2Preview Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Cardiac Disorders NCLEX 50 terms NarsTsakPreview NP1 Ex 382 term des A male patient has a sucking stab wound to the chest. Which action should the nurse take first?ADrawing blood for a hematocrit and hemoglobin level BApplying a dressing over the wound and taping it on three sides CPreparing a chest tube insertion tray DPreparing to start an I.V. line B A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?AActivity intolerance related to fatigue BAnxiety related to actual threat to health status CRisk for infection related to retained secretions DImpaired gas exchange related to airflow obstruction D A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?A Nausea or vomiting BAbdominal pain or diarrhea CHallucinations or tinnitus DLightheadedness or paresthesia

• The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea,

vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.

Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not

recommended for:

A Patients with an acute asthma attack B Patients with narcolepsy C Patients under age 6 D Elderly patients

• Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to

cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm?A Kinking of the ventilator tubing B A disconnected ventilator tube C An endotracheal cuff leak D A change in the oxygen concentration without resetting the oxygen level alarm

• Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus

plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would tigger the oxygen alarm.A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?A Leg movement B Finger movement C Lip movement D Fighting the ventilator D.Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.On auscultation, which finding suggests a right pneumothorax?A Bilateral inspiratory and expiratory crackles B Absence of breaths sound in the right thorax C Inspiratory wheezes in the right thorax D Bilateral pleural friction rub

• In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are

absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis.When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase "a" in ABG value present?A Acid-base balance B Arterial Blood C Arterial oxygen saturation D Alveol B.A lowercase "a" in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase "A" represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli.Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A Contralateral side in a simple pneumothorax B Affected side in a hemothorax C Affected side in a tension pneumothorax D Contralateral side in hemothorax

• The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation

of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: A Monitor fluctuations in the water-seal chamber B Clamp the chest tube once every shift C Encourage coughing and deep breathing D Milk the chest tube every 2 hours

• When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent

pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?A Encouraging the patient to drink three glasses of fluid daily B Keeping the patient in semi-fowler's position C Using a high-flow venturi mask to deliver oxygen as prescribe D Administering a sedative, as prescribe

• The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low

oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A Cardiogenic pulmonary edema B Respiratory alkalosis C Increased pulmonary capillary permeability D Renal failure

• ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary

edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate?A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous

• Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to

check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?A Inform the physician B Continue to monitor the client C Reinforce the occlusive dressing D Encourage the client to deep-breathe

• The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water

level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing

action is to:

A Call the physician B Place the tube in bottle of sterile water C Immediately replace the chest tube system D Place a sterile dressing over the disconnection site

• If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The

system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.