Chapter 12: The Respiratory System deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE 1. What is the purpose of mucus? a. To warm the air entering the lungs. b. To trap particles and bacteria. c. To protect the cilia. d. To clean the sinus cavity. ANS: B Mucus traps particles and bacteria that may be in the inspired air. PTS: 1 DIF: Cognitive Level: Knowledge REF: 252 OBJ:1 (theory) TOP: Mucus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. 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. ANS: B Coaching in pursed-lip breathing will open the respiratory tree with negative pressure. Oxygen given at such a high concentration will cause an emphysemic patient to stop breathing. Collecting a sputum specimen and ensuring patent IV access are appropriate interventions that should be performed after the patient’s dyspnea is addressed. PTS: 1 DIF: Cognitive Level: Analysis REF: 268 OBJ: 7 (clinical) TOP: Oxygen Administration to Emphysemic Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse explains that the mechanism that triggers rate and depth of respiration is based on which factor? a. Ease of respiration. b. Alveolar pressure. c. Patency of bronchi. d. Blood pH. ANS: D Chemoreceptors in the brainstem and carotid arteries measure hydrogen concentration, as well as CO2 and O2, to trigger respiration rateto correct the excessive CO2. PTS:1 DIF: Cognitive Level: Comprehension REF: 254 OBJ:2 (theory) TOP: Ventilation and Blood pH KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. 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.