A nurse is caring for a client who has frequent upper respiratory infections. Which
structure is most helpful in protecting against infection?
You selected: Tonsils
Correct
Explanation: Tonsils and adenoids do not contribute to respiration but protect
against infection. Palatine tonsils are composed of lymphoid
tissue. Cilia are fine hairs that move particles and liquid,
preventing irritation and contamination of the airway. Sinuses are
nasal cavity structures. Turbinates warm and add moisture to the
inspired air. (less)
Question 2: While conducting the physical examination during assessment of
(see full question) the respiratory system, which of the following conditions does a
nurse assess by inspecting and palpating the trachea?
Correct response: Deviation from the midline
Explanation: During the physical examination, the nurse must inspect and
gently palpate the trachea to assess for placement and deviation
from the midline. The nurse examines the posterior pharynx and
tonsils with a tongue blade and light, and notes any evidence of
swelling, inflammation, or exudate, as well as changes in color of
the mucous membranes. The nurse also examines the anterior,
posterior, and lateral chest walls for any evidence of muscle
weakness. (less)
Question 3: The nurse enters the room of a client who is being monitored
(see full question) with pulse oximetry. Which of the following factors may alter the
oximetry results?
You selected: Diagnosis of peripheral vascular disease
Correct
Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen
saturation of hemoglobin. A probe is placed on the fingertip,
forehead, earlobe, or bridge of nose. Inaccuracy of results may
be from anemia, bright lights, shivering, nail polish, or peripheral
vascular disease. (less)
Question 4: The nurse working in the radiology clinic is assisting with a
(see full question) pulmonary angiography. The nurse knows that when monitoring
clients after a pulmonary angiography, what should the physician
be notified about?
You selected: Absent distal pulses
Correct
Explanation: When monitoring clients after a pulmonary angiography, nurses
, must notify the physician about diminished or absent distal
pulses, cool skin temperature in the affected limb, and poor
capillary refill. When the contrast medium is infused, the client
will sense a warm, flushed feeling. (less)
Question 5: Which of the following is a late sign of hypoxia?
(see full question)
Correct response: Cyanosis
Explanation: Cyanosis is a late sign of hypoxia. Hypoxia may cause
restlessness and an initial rise in blood pressure that is followed
by hypotension and somnolence.
A client experiences a head injury in a motor vehicle accident. The client’s level of
consciousness is declining, and respirations have become slow and shallow. When
monitoring a client’s respiratory status, which area of the brain would the nurse realize
is responsible for the rate and depth?
You selected: The pons
Correct
Explanation: The pons in the brainstem controls rate and depth of
respirations. When injury occurs or increased intracranial
pressure results, respirations are slowed. The frontal lobe
completes executive functions and cognition. The central sulcus
is a fold in the cerebral cortex called the central fissure. The
Wernicke’s area is the area linked to speech. (less)
Question 2: While conducting the physical examination during assessment of
(see full question) the respiratory system, the nurse assesses which of the
following by inspecting and palpating the trachea?
You selected: Deviation from the midline
Correct
Explanation: During the physical examination, the nurse must inspect and
gently palpate the trachea to assess for placement and deviation
from the midline. The nurse examines the posterior pharynx and
tonsils with a tongue blade and light and notes any evidence of
swelling, inflammation, or exudate. The nurse examines the
posterior pharynx and tonsils with a tongue blade and light to
note changes in color of the mucous membranes. The nurse also
examines the anterior, posterior, and lateral chest walls for any
evidence of muscle weakness. (less)
, Question 3: Which of the following is a deformity of the chest that occurs as a
(see full question) result of over inflation of the lungs?
You selected: Barrel chest
Correct
Explanation: A barrel chest occurs as a result of over inflation of the lungs.
There is an increase in the anteroposterior diameter of the
thorax. Funnel chest occurs when there is a depression in the
lower portion of the sternum, which may result in murmurs.
Pigeon chest occurs as a result of displacement of the sternum
resulting in an increase in the anteroposterior diameter.
Kyphoscoliosis is characterized by elevation of the scapula and
a corresponding S-shaped spine. This deformity limits lung
expansion within the thorax. (less)
Question 4: A nurse is concerned that a client may develop postoperative
(see full question) atelectasis. Which nursing diagnosis would be most appropriate
if this complication occurs?
You selected: Impaired gas exchange
Correct
Explanation: Airflow is decreased with atelectasis, which is a bronchial
obstruction from collapsed lung tissue. If there is an obstruction,
there is limited or no gas exchange in this area. Impaired gas
exchange is thus the most likely nursing diagnosis with
atelectasis. (less)
Question 5: When assessing a client, which adaptation indicates the
(see full question) presence of respiratory distress?
You selected: Orthopnea
Correct
Explanation: Orthopnea is the inability to breathe easily except when upright.
This positioning can mean while in bed and propped with a pillow
or sitting in a chair. If a client cannot breathe easily while lying
down, there is an element of respiratory distress. (less)
Question 6: The nurse answers the call light of a male patient. The patient is
(see full question) complaining of an irritating tickling sensation in the throat, a salty
taste, and a burning sensation in the chest. Upon further
assessment, the nurse notes a tissue with bright red, frothy
blood at the bedside. The nurse can assume the source of the
blood is likely from which of the following?
You selected: The lungs
Correct
structure is most helpful in protecting against infection?
You selected: Tonsils
Correct
Explanation: Tonsils and adenoids do not contribute to respiration but protect
against infection. Palatine tonsils are composed of lymphoid
tissue. Cilia are fine hairs that move particles and liquid,
preventing irritation and contamination of the airway. Sinuses are
nasal cavity structures. Turbinates warm and add moisture to the
inspired air. (less)
Question 2: While conducting the physical examination during assessment of
(see full question) the respiratory system, which of the following conditions does a
nurse assess by inspecting and palpating the trachea?
Correct response: Deviation from the midline
Explanation: During the physical examination, the nurse must inspect and
gently palpate the trachea to assess for placement and deviation
from the midline. The nurse examines the posterior pharynx and
tonsils with a tongue blade and light, and notes any evidence of
swelling, inflammation, or exudate, as well as changes in color of
the mucous membranes. The nurse also examines the anterior,
posterior, and lateral chest walls for any evidence of muscle
weakness. (less)
Question 3: The nurse enters the room of a client who is being monitored
(see full question) with pulse oximetry. Which of the following factors may alter the
oximetry results?
You selected: Diagnosis of peripheral vascular disease
Correct
Explanation: Pulse oximetry is a noninvasive method of monitoring oxygen
saturation of hemoglobin. A probe is placed on the fingertip,
forehead, earlobe, or bridge of nose. Inaccuracy of results may
be from anemia, bright lights, shivering, nail polish, or peripheral
vascular disease. (less)
Question 4: The nurse working in the radiology clinic is assisting with a
(see full question) pulmonary angiography. The nurse knows that when monitoring
clients after a pulmonary angiography, what should the physician
be notified about?
You selected: Absent distal pulses
Correct
Explanation: When monitoring clients after a pulmonary angiography, nurses
, must notify the physician about diminished or absent distal
pulses, cool skin temperature in the affected limb, and poor
capillary refill. When the contrast medium is infused, the client
will sense a warm, flushed feeling. (less)
Question 5: Which of the following is a late sign of hypoxia?
(see full question)
Correct response: Cyanosis
Explanation: Cyanosis is a late sign of hypoxia. Hypoxia may cause
restlessness and an initial rise in blood pressure that is followed
by hypotension and somnolence.
A client experiences a head injury in a motor vehicle accident. The client’s level of
consciousness is declining, and respirations have become slow and shallow. When
monitoring a client’s respiratory status, which area of the brain would the nurse realize
is responsible for the rate and depth?
You selected: The pons
Correct
Explanation: The pons in the brainstem controls rate and depth of
respirations. When injury occurs or increased intracranial
pressure results, respirations are slowed. The frontal lobe
completes executive functions and cognition. The central sulcus
is a fold in the cerebral cortex called the central fissure. The
Wernicke’s area is the area linked to speech. (less)
Question 2: While conducting the physical examination during assessment of
(see full question) the respiratory system, the nurse assesses which of the
following by inspecting and palpating the trachea?
You selected: Deviation from the midline
Correct
Explanation: During the physical examination, the nurse must inspect and
gently palpate the trachea to assess for placement and deviation
from the midline. The nurse examines the posterior pharynx and
tonsils with a tongue blade and light and notes any evidence of
swelling, inflammation, or exudate. The nurse examines the
posterior pharynx and tonsils with a tongue blade and light to
note changes in color of the mucous membranes. The nurse also
examines the anterior, posterior, and lateral chest walls for any
evidence of muscle weakness. (less)
, Question 3: Which of the following is a deformity of the chest that occurs as a
(see full question) result of over inflation of the lungs?
You selected: Barrel chest
Correct
Explanation: A barrel chest occurs as a result of over inflation of the lungs.
There is an increase in the anteroposterior diameter of the
thorax. Funnel chest occurs when there is a depression in the
lower portion of the sternum, which may result in murmurs.
Pigeon chest occurs as a result of displacement of the sternum
resulting in an increase in the anteroposterior diameter.
Kyphoscoliosis is characterized by elevation of the scapula and
a corresponding S-shaped spine. This deformity limits lung
expansion within the thorax. (less)
Question 4: A nurse is concerned that a client may develop postoperative
(see full question) atelectasis. Which nursing diagnosis would be most appropriate
if this complication occurs?
You selected: Impaired gas exchange
Correct
Explanation: Airflow is decreased with atelectasis, which is a bronchial
obstruction from collapsed lung tissue. If there is an obstruction,
there is limited or no gas exchange in this area. Impaired gas
exchange is thus the most likely nursing diagnosis with
atelectasis. (less)
Question 5: When assessing a client, which adaptation indicates the
(see full question) presence of respiratory distress?
You selected: Orthopnea
Correct
Explanation: Orthopnea is the inability to breathe easily except when upright.
This positioning can mean while in bed and propped with a pillow
or sitting in a chair. If a client cannot breathe easily while lying
down, there is an element of respiratory distress. (less)
Question 6: The nurse answers the call light of a male patient. The patient is
(see full question) complaining of an irritating tickling sensation in the throat, a salty
taste, and a burning sensation in the chest. Upon further
assessment, the nurse notes a tissue with bright red, frothy
blood at the bedside. The nurse can assume the source of the
blood is likely from which of the following?
You selected: The lungs
Correct
