ADULT HEALTH 1 -Respiratory med surg
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.
B
Mucus traps particles and bacteria that may be in the inspired air.
A patient with emphysema presents to the emergency room with severe dyspnea; O2 saturation is 74%,
pulse is 120, and respirations are 26 . The nurse positions the patient in high Fowler. What action should
the nurse take next?
a. Collect a sputum specimen.
b. Coach the patient in pursed-lip breathing.
c. Give oxygen at 5 L/min by nasal cannula.
d. Ensure patent intravenous (IV) access.
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. Collecting a sputum
specimen and ensuring patent IV access are appropriate interventions that should be performed after
the patient's dyspnea is addressed.
The nurse explains that the mechanism that triggers rate and depth of respiration is based on which
factor?
a. Ease of respiration.
b. Alveolar pressure.
c. Patency of bronchi.
d. Blood pH.
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.
When creating a visual aid to show the mechanics of inhaling, the nurse correctly illustrates which
scenario?
a. The diaphragm moves downward.
b. The negative pressure of the lung converts to positive pressure.
,c. The muscles contract and pull the rib cage downward.
d. The bronchi enlarge.
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.
The nurse explains that the substance that decreases the surface tension of the alveolar walls is:
a. plasma.
b. surfactant.
c. cilia.
d. mucus.
B
Surfactant is the substance that reduces the surface tension of the walls of the alveoli, making gas
exchange more effective.
Most of the inspired oxygen is carried to the tissues via which component of the body?
a. Plasma
b. Lymphatic system
c. Red blood cells
d. White blood cells
C
The red blood cells carry 97% of the oxygen to the cells, attached to hemoglobin.
The nurse is caring for a patient with an obstructive respiratory disorder. Which of these conditions is an
example of an obstructive lung disorder?
a. Atelectasis
b. Lung cancer
c. Guillain-Barré syndrome
d. Chronic bronchitis
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-Barré syndrome are restrictive disorders.
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.
, 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.
The nurse is preparing to administer the influenza immunization to four patients. Allergy to which
substance should cause the nurse to question giving the immunization?
a. Strawberries
b. Ragweed
c. Penicillin
d. Eggs
D
The influenza vaccine is cultured in chicken embryos, making anyone allergic to eggs probably allergic to
the immunization.
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.
A
Bronchovesicular sounds are moderate hollow sounds that are equal on inspiration and expira-tion.
The nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action
demonstrates appropriate technique?
a. The nurse maintains clean technique.
b. The nurse places the patient in a side-lying position.
c. The nurse suctions the patient for 10 to 15 seconds.
d. The nurse reassures the patient that he will feel no discomfort.
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. Deep tracheal suction requires sterile tech-nique, and the
patient should be positioned with the neck slightly extended to facilitate entrance into the trachea. Even
though the procedure does not last for a long time, suctioning is uncom-fortable for the patient.
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
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.
B
Mucus traps particles and bacteria that may be in the inspired air.
A patient with emphysema presents to the emergency room with severe dyspnea; O2 saturation is 74%,
pulse is 120, and respirations are 26 . The nurse positions the patient in high Fowler. What action should
the nurse take next?
a. Collect a sputum specimen.
b. Coach the patient in pursed-lip breathing.
c. Give oxygen at 5 L/min by nasal cannula.
d. Ensure patent intravenous (IV) access.
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. Collecting a sputum
specimen and ensuring patent IV access are appropriate interventions that should be performed after
the patient's dyspnea is addressed.
The nurse explains that the mechanism that triggers rate and depth of respiration is based on which
factor?
a. Ease of respiration.
b. Alveolar pressure.
c. Patency of bronchi.
d. Blood pH.
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.
When creating a visual aid to show the mechanics of inhaling, the nurse correctly illustrates which
scenario?
a. The diaphragm moves downward.
b. The negative pressure of the lung converts to positive pressure.
,c. The muscles contract and pull the rib cage downward.
d. The bronchi enlarge.
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.
The nurse explains that the substance that decreases the surface tension of the alveolar walls is:
a. plasma.
b. surfactant.
c. cilia.
d. mucus.
B
Surfactant is the substance that reduces the surface tension of the walls of the alveoli, making gas
exchange more effective.
Most of the inspired oxygen is carried to the tissues via which component of the body?
a. Plasma
b. Lymphatic system
c. Red blood cells
d. White blood cells
C
The red blood cells carry 97% of the oxygen to the cells, attached to hemoglobin.
The nurse is caring for a patient with an obstructive respiratory disorder. Which of these conditions is an
example of an obstructive lung disorder?
a. Atelectasis
b. Lung cancer
c. Guillain-Barré syndrome
d. Chronic bronchitis
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-Barré syndrome are restrictive disorders.
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.
, 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.
The nurse is preparing to administer the influenza immunization to four patients. Allergy to which
substance should cause the nurse to question giving the immunization?
a. Strawberries
b. Ragweed
c. Penicillin
d. Eggs
D
The influenza vaccine is cultured in chicken embryos, making anyone allergic to eggs probably allergic to
the immunization.
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.
A
Bronchovesicular sounds are moderate hollow sounds that are equal on inspiration and expira-tion.
The nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action
demonstrates appropriate technique?
a. The nurse maintains clean technique.
b. The nurse places the patient in a side-lying position.
c. The nurse suctions the patient for 10 to 15 seconds.
d. The nurse reassures the patient that he will feel no discomfort.
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. Deep tracheal suction requires sterile tech-nique, and the
patient should be positioned with the neck slightly extended to facilitate entrance into the trachea. Even
though the procedure does not last for a long time, suctioning is uncom-fortable for the patient.
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
