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WorksheetsMedical-Surgical Nursing (Care for the Client with Upper Respiratory Disorder)
Total questions: 100
Worksheet time: 1hrs 21mins
A client asks the nurse about the purpose of incentive spirometry. Which information should the nurse include in the explanation?
increases lung volume
B.
Prevents lung collapse
Decreases oxygen demand
Clears mucus secretions
A client is prescribed an oral steroid drug to improve breathing. Which instruction should the nurse provide to the client?
"You will probably be taking this medication long-term."
Be sure to follow the step-wise reduction of the medication."
"Stop the medication when your symptoms subside."
"If you feel side effects, cut the dosage in half."
The nurse preceptor is monitoring the actions of a new graduate nurse caring for a client with a tracheostomy. Which action by the new graduate requires follow-up from the preceptor?
Suctioning the tracheostomy, then the mouth
Assessing oxygen saturation
Suctioning secretions with a clean technique
Assessing for irritation around the stoma
A client has crackles and reports increasing shortness of breath. Which action should the nurse take first?
Administer a bronchodilator.
Place the client in high Fowler position.
Assess the respiratory rate.
Apply oxygen to the client.
The nurse is caring for a client with a chest tube. Which intervention should the nurse implement? (Select all that apply.)
Ensure oxygen is available.
Report hyperresonance with percussion.
Prescribe pain medications as needed.
Monitor for air leaks.
assess for pain
The nurse is planning care for a client who is receiving oxygen. Which intervention should the nurse include?
Assess the client for anxiety.
Ensure the client is comfortable with the manner of administration.
Suction upper airways each shift.
D.
Increase the oxygen flow if the client requests.
The nurse assessing a client suspects a right pneumothorax. Which finding supports the nurse's suspicion?
Right tracheal shift
Decreased expansion on the left side of the chest
O2 saturation of 94%
Asymmetry of the chest expansion
Which manifestation should the nurse recognize as a sign of chronic respiratory disease in a client?
Inspiration to expiration (I:E) ratio of 1:2
Crackles noted in bilateral lungs
Clubbing of the nails
Sudden shortness of breath
The nurse assessing a newborn suspects respiratory distress. Which finding supports the suspicion?
Intercostal retractions
Respiratory rate of 44
Acrocyanosis at birth
Abdominal breathing
Which method is the most acurate for measuring a client's respiratory rate?
Measure the respiratory rate for 6 seconds and multiply by 10.
Measure the respiratory rate for 30 seconds and multiply by 2.
Measure the respiratory rate for 1 minute.
Measure the respiratory rate for 15 seconds and multiply by 4.
The nurse is participating in a community health clinic. Which client should the nurse identify as being at risk for compromised oxygenation? (Select all that apply.)
A 64-year-old woman with osteoporosis and limited mobility
A 46-year-old woman with a history of anxiety attacks
A 70-year-old woman who eats a well-balanced diet and exercises daily
A 28-year-old man who smokes with a 10 pack per year history
A 56-year-old man who has been working at a textile factory
Which term should the nurse know describes the primary purpose of the ribs?
deflation
protection
exhalation
inspiration
The nurse taught a class about the role of the pleural membranes. Which statement by a participant indicates that learning occurred?
"The pleural membranes contain the heart."
"The pleural membranes warm and moisten air."
"The pleural membranes permit gas exchange."
"The pleural membranes help to keep the lungs inflated."
A client diagnosed with bronchitis asks the nurse about the function of the bronchi. Which should the nurse include in the response?
Contain the heart, trachea, esophagus, and the great vessels
Help to keep the lungs inflated
Capture and help sweep the debris toward the mouth for removal when coughing
Warm and moisten air as it moves through the respiratory tract to the alveoli
Which condition will cause a patient to secrete erythropoietin?
Low blood pressure
Hypercarbia
Inflammation
Hypoxia
A staff member wants to know where the greatest proportion of iron is located. How should the nurse respond? The greatest proportion of total body iron is located in the:
Erythrocytes
Spleen pulp
Bone marrow
Liver tissue
A 60-year-old female with emphysema is having difficulty expiring a given volume of air. When giving report, the nurse will relay that the patient is most likely experiencing _____ pulmonary disease.
Restrictive
Obstructive
Atelectatic
Pleuritic
A 30-year-old male is involved in a motor vehicle accident and sustains trauma to the lungs and chest wall. He experiences respiratory failure. Which of the following lab values would the nurse expect?
Electrolyte imbalances
Elevated PaCO2
Low hematocrit
Elevated pH
A nurse is reviewing the results of an ABG and finds reduced oxygenation of arterial blood. What term should the nurse use to describe this condition?
Ischemia
Hypoxia
Hypoxemia
Hypocapnia
A 20-year-old male is in acute pain. An arterial blood gas reveals decreased carbon dioxide (CO2) levels. Which of the following does the nurse suspect is the most likely cause?
Hyperventilation
Hypoventilation
Apnea
Cyanosis
A patient wants to know how carbon dioxide is transported in the body. How should the nurse respond? Carbon dioxide (CO2) is mainly transported in the blood:
Attached to oxygen (O2)
Dissolved in red blood cells
Combined with albumin
In the form of bicarbonate
A patient asks how oxygen is transported in the body. What is the nurse’s best response? Most of the oxygen (O2) is transported:
Dissolved in the plasma
Bound to hemoglobin
In the form of carbon dioxide (CO2)
As a free-floating molecule
An aide asks a nurse how surfactant works. How should the nurse respond? Surfactant facilitates alveolar distention and ventilation by:
Decreasing thoracic compliance
Attracting water to the alveolar surface
Decreasing surface tension in alveoli
Increasing diffusion in alveoli
During inspiration, muscular contraction of the diaphragm causes air to move into the lung. The mechanisms that drive air movement during inspiration are a(n):
Decrease in intra-alveolar pressure and shortening of the rib cage
Decrease in the size of the thorax and alveolar expansion
Increase in the size of the thorax and a decrease in intrapleural pressure
Increase in atmospheric pressure and intrapleural pressure
If an individual with respiratory difficulty were retaining too much carbon dioxide, which of the following compensatory responses would the nurse expect to be initiated?
Decrease in ventilation rate
Increase in respiratory rate
Increase in tidal volume
Vasodilation of the pulmonary arterioles
While reviewing the results of the pulmonary functions test, the nurse is aware that the maximum amount of gas that can be displaced (expired) from the lung is called:
Vital capacity (VC)
Total lung capacity
Functional capacity
Residual volume
The nurse is describing the movement of blood into and out of the capillary beds of the lungs to the body organs and tissues. What term should the nurse use to describe this process?
perfusion
ventilation
diffusion
circulation
Prolonged immobility is implicated in the development of which of the following disorders?
Bronchitis and bronchiectasis
Sarcoidosis and idiopathic pulmonary fibrosis
Atelectasis and pulmonary embolism
Pulmonary hypertension and cor pulmonale
Which of the following individuals is experiencing a disorder of ventilation that has a restrictive rather than obstructive etiology?
A 30-year-old African American man who has been diagnosed with sarcoidosis
An infant whose routine screening is suggestive of cystic fibrosis
An elderly, lifelong smoker who has been admitted to hospital with emphysema
A 16-year-old girl who must limit her activity to prevent asthmatic attacks
Which of the following manifestations typically accompanies an asthmatic attack?
Decreased residual volume
Decreased pulmonary arterial pressure
Prolonged inspiration
Hyperinflation of the lungs
Most respiratory disorders in infants produce a decrease in:
lung compliance.
airway resistance.
oxygen demand.
respiratory rate.
A patient has just been admitted to the postsurgical unit following a below-the-knee amputation. Which of the following measures should her care team prioritize to prevent atelectasis during the patient’s immediate recovery?
Bedrest and supplementary oxygen by nasal cannula
Administration of bronchodilators by nebulizer
Deep-breathing exercises and early mobilization
Adequate hydration and a high-humidity environment
Cystic fibrosis (CF), the major cause of severe chronic respiratory disease in children, is characterized by:
constipation.
salt depletion.
watery mucus.
high cholesterol.
Acute onset bronchial asthma causes wheezing and breathlessness as a result of
airway inflammation.
alveolar collapse.
compression atelectasis.
pulmonary hypertension.
A patient with a diagnosis of community-acquired pneumonia is producing copious secretions that are physically obstructing her airway. Which of the following pathophysiologic processes will result from this condition?
Compensatory vasoconstriction
Ventilation without perfusion
Dead air space
Perfusion without ventilation
A Total laryngectomy results in?
Permanent loss of the voice and a change in the airway.
Retains some voice
Client is able to eat post operatively
With a hemilaryngectomy.......
No change may occur in voice quality occurs
Airway and swallowing remain intact
Airway and swallowing do not remain intact
Is a Supraglottic laryngectomy a voice-sparing operation?
Yes
No
I don't know
What are some nursing interventions that an RN would implement to Monitoring for or Prevent Aspiration?
Administer antiemetic medications
Have functioning suction set-up
Confirm placement of feeding tube and check residuals per protocol
Keep the HOB at 30-45 degrees
Bleeding is a postoperative complication. What are signs and symptoms of bleeding would the RN assess and monitor for?
Active bleeding from the surgical site, drains, and trachea.
Increased heart rate, decreased blood pressure
Cold, clammy, pale skin
Tachypnea
What would the RN include when Monitoring for Respiratory Distress/Hypoxia?
Restlessness
Confusion
Tachypnea
Use of accessory muscles
Pulse oximetry
In preparing the client to go home, the nurse assesses the patient’s level of knowledge about self-care management. What are some nursing interventions you would utilize to ensure the client is ready to go home?
Explain tubes, dressings, and drains, monitor drainage
Verbalize avoidance of strenuous exercise
Educate client on proper nutrition and fluid intake to prevent malnutrition and dehydration
Ensure client and family recognize s/s of infection
Educate on the importance of wearing or carrying medical identification—such as a bracelet or card
When caring for a postoperative laryngectomy patient what are some nursing interventions that Promote Adequate Nutrition & Hydration especially if client is NPO.
Provide IV fluids
Provide thick liquids, closely monitor and have suction readily available
Monitor weight & Vital signs
Monitor electrolytes
Administer enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition.
After a total laryngectomy what nursing interventions would you implement when caring for this client?
Maintain HOB in Semi or High Fowlers position
Provide adequate Humidification
Cautious use of analgesic medications
Use pulse oximeter to monitor 02 status
Encourage coughing and deep breathing
You are explaining to a nursing student what a Total Laryngectomy is. What would you include in your explanation?
A complete removal of the larynx
This procedure is performed for advanced laryngeal cancer
Results in permanent loss of the voice
Need to breathe through a stoma created in the lower neck
10. A student is nervous for a big exam and is breathing rapidly, what do you expect out
of the followings
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
9- Which of the following laboratory results below indicates compensated metabolic alkalosis?
a) Low p CO2, normal bicarbonate and, high pH
b) Low p CO2, low bicarbonate, low pH
c) High p CO2, normal bicarbonate and, low p H
d) High pCO2, high bicarbonate and High pH
8.- Which of the following is most appropriate for a female suffering from Insulin
dependent diabetes mellitus with a pH of 7.2, HCO3-17 mmol/L and pCO2-20 mm HG
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis
7.Which of the following laboratory results below indicates uncompensated metabolic
alkalosis?
a) Low p CO2, normal bicarbonate and, high pH
b) Low p CO2, low bicarbonate, low pH
c) High p CO2, normal bicarbonate and, low p H
d) Normal pCO2, high bicarbonate and High Ph
6.The main compensatory mechanism in respiratory alkalosis is
a) Retention of bicarbonate
b) Decrease in renal acid excretion
c) Increase in Red Blood Cells.
d) Buffer system.
5.The primary change in respiratory acidosis is
a) Increase in bicarbonate concentration.
b) Increase in pCO2.
c) Decrease in respiratory rate.
d) Hypoxia.
4.Hemoglobin has more powerful buffering action compared to plasma proteins because of:
a) Carboxylic groups.
b) Amino groups.
c) Imidazole groups of histidine residues.
d) Formation of carbaminohemoglobin.
3.The greatest buffering capacity at physiological pH would be provided by a protein rich in which of the following amino acids?
a) Lysine
b) Histidine
c) Aspartic acid
d) Leucine
2.In correcting alkalosis, bicarbonate buffering action is not efficient because:
a) pH value is low.
b) It is a weak buffer.
c) Base/Acid ratio is 20/1
d) Bicarbonate quantity is not enough.
1.- The pH of the body fluids is stabilized by buffer systems. Which of the following compounds is the most effective buffer system at physiological pH?
a) Bicarbonate buffer
b) Phosphate buffer
c) Protein buffer
d) Haemoglobin buffer
Emphysema
specific area that is drained by a stream
negatively charged electrons
Lung disease in which the avioli lose elasticity
chemical reaction in which heat energy is absorbed
How do you position patient with epistaxis?
Lithotomy position
Sit upright with head tilted forward
Sit upright with head tilted backward
Side lying position with neck support
9X8
72
81
76
84
This remains the most common treatment for rhinitis and are administered for sneezing, pruritus and rhinorrhea.
Antibiotics
Antivirals
Antihistamines
Antimetabolites
The most common cause of laryngitis is:
Bacterial
Viral
Superficial
Fungal
The nurse is caring for a patient who had total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?
When a patient has less than 30 ml for 2 consecutive days
When the patient states that there is discomfort and requests removal
When the drainage tube comes out
In 1 week when the patient no longer has serous drainage.
A patient has herpes simplex infection that developed adter having the common cold. What medication does the nurse anticipate will be administered for this infection?
Antibiotic
Antiviral
Antihistamine
Antibacterial ointment
The most common major suppurative complication of sore throat.
Peritonsillar abscess
Infection
Bleeding
Loss of voice
The most serious complication of tonsillectomy is _______
loss of voice
hemorrhage
pain scale of 9 out of 10
infection
The oxygen flow rate for nasal cannula should not exceed _____ L/min
4
6
8
10
A patient will require a ______ mask, which is the most reliable and accurate method of delivery, when precise concentration of oxygen is required.
T-Piece
Re-breather mask
Venturi Mask
Nasal Cannula
A ________ is used when a patient requires low medium concentration of oxygen for which precise accuracy is not essential.
Venturi Mask
Rebreather mask
Nasal Cannula
T-piece
It is important when a patient is on oxygen to post a " ______" to prevent an untoward incident.
No playing
No smoking
No talking
No eating
Decrease in the oxygen supply in the tissues is called?
Hypoxia
Hypoxemia
Anemic hypoxia
Circulatory hypoxia
Decreased oxygen level in the blood is called?
Hypoxia
Hypoxemia
Hypoxemic Hypoxia
Anemic hypoxia
The two centers of the brain that are responsible for the neurologic control of ventilation are the Pneumotaxic center and _______?
Apneustic center
Ballistic Center
Opportunistic
Dyspneic center
What is the Purpose of Cilia?
Traps the mucus in the respiratory tract
Moves the mucus back up to the Larynx
Catches the bacteria in the respiratory tract
I don't care
A patient with sinus congestion reports discomfort when the nurse is palpating the SUPRA-ORBITAL ridges. The nurse is aware that the patient is referring to which SINUS?
Frontal
Ethmoidal
Maxillary
Sphenoidal
The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a VERY LATE symptom of hypoxia?
Barrel Chest
Funnel Chest
Kyphoscoliosis
Pigeon Chest
A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. WHAT IS A SAFE BUT LOW OXYGEN SATURATION LEVEL FOR A PATIENT?
40 mm Hg
75 mm Hg
90 mm Hg
95 mm Hg
The nurse is performing chest auscultation for a patient with ASTHMA. How does the nurse describe the high pitched, sibilant, musical sound that are heard?
Rales
Crackles
Wheezes
Rhonchi
Younger children are usually affected with Epiglottitis and older children are affected with Croup
True
False
Croup can be managed at home
True
False
Croup is mostly caused by viral infection
True
False
Select all that apply. Epiglottitis is managed by the following:
Intubation
Tracheostomy
Antibiotics
Oral Suctioning
Treatment of epiglottitis requires immediate and prophylactic intubation
True
False
Management of epiglottitis requires careful assessment of the inflammation using careful oral inspection
True
False
Epiglottitis is always considered as a medical emergency
True
False
Which is not a common manifestation of Croup?
Stridor
Barking cough
Retractions
High grade fever
Which of the following is/are true about Croup? Select all that apply.
Primarily caused by viral infection
Always considered as a medical emergency
Can be managed at home
Managed with bronchodilators
Select all that apply. Manifestations of Tracheomalacia include:
Intercostal retraction
Feeding problem
Clubbing of fingers
Stridor
