Detailed Answer Key Medsurge Respiratory
Latest 2025
1.A |nurse |is |admitting |a |client |who |has |active |tuberculosis |to |a |room |on |a |medical-surgical |unit. |Which |of |the |following
|room |assignments |should |the |nurse |make |for |the |client?
A. A |room |with |air |exhaust |directly |to |the |outdoor |environment
Rationale:A |room |with |air |exhaust |directly |to |the |outside |environment |eliminates |contamination |of |other
|client-care |areas. |This |type |of |ventilation |system |is |referred |to |as |an |airborne |infection |isolation
|room.
B. A |room |with |another |nonsurgical |client
Rationale:A |two-bed |room |with |another |nonsurgical |client |exposes |the |other |client |to |tuberculosis. |A |client
|who |has |tuberculosis |should |have |a |private |room.
C. A |room |in |the |ICU
Rationale:A |client |who |has |active |tuberculosis |and |no |other |comorbidities |is |not |critically |ill.
D. A |room |that |is |within |view |of |the |nurses' |station
Rationale:The |client's |room |should |be |well |ventilated |and |private, |but |it |is |not |necessary |for |it |to |be |close |to
|the |nurses' |station.
2.A |nurse |is |conducting |a |primary |survey |of |a |client |who |has |sustained |life-threatening |injuries |due |to |a |motor-vehicle
|crash. |Identify |the |sequence |of |actions |the |nurse |should |take. |(Move |the |actions |into |the |box |on |the |right, |placing
|them |in |the |selected |order |of |performance. |Use |all |the |steps.) |C. |Open |the |airway |using |a |jaw-thrust |maneuver.
D. |Determine |effectiveness |of |ventilator |efforts.
B. |Establish |IV |access.
A. |Perform |a |Glasgow |Coma |Scale |assessment.
E. |Remove |clothing |for |a |thorough |assessment.
3.A |nurse |is |caring |for |a |client |who |has |emphysema. |Which |of |the |following |findings |should |the |nurse |expect |to |assess
|in |this |client? |(Select |all |that |apply.)
A. Dyspnea
B. Bradycardia
, C. Barrel |chest
D. Clubbing |of |the |fingers
E. Deep |respirations
Rationale:
Dyspnea |is |correct. |Emphysema |is |a |lung |disease |involving |damage |to |the |alveoli |in |which |they
|become |weakened |and |collapse. |Dyspnea |is |seen |in |clients |with |emphysema |as |the |lungs |try |to
|increase |the |amount |of |oxygen |available |to |the |tissues.</br></br>Bradycardia |is |incorrect. |With
|emphysema, |the |heart |rate |will |increase |as |the |heart |tries |to |compensate |for |less |oxygen |to |the
|tissues. |</br></br>Barrel |chest |is |correct. |Clients |with |emphysema |lose |lung |elasticity; |the
|diaphragm |becomes |permanently |flattened |by | hyperinflation |of |the |lungs; |the |muscles |of |the |rib
|cage |become |rigid; |and |the |ribs |flare |outward. |This |produces |the |barrel |chest |typical |of
|emphysema |clients.</br></br>Clubbing |of |the |fingers |is |correct. |Clubbing |results |from |chronic
|low | arterial-oxygen |levels. |The |tips |of |the |fingers |enlarge |and |the |nails |become |extremely
|curved |from |front |to |back.</br></br>Deep |respirations |is |incorrect. |Clients |with |emphysema |lose
|lung |elasticity |and |have |muscle |fatigue; |consequently, |respirations |become |increasingly |shallow.
4.A |nurse |is |caring |for |a |client |who |has |returned |from |the |surgical |suite |following |surgery |for |a |fractured |mandible. |The
|client |had |intermaxillary |fixation |to |repair |and |stabilize |the |fracture. |Which |of |the |following |actions |is |the |priority |for
|the |nurse |to |take?
A. Prevent |aspiration.
Rationale:When |using |the |airway, |breathing, |circulation |approach |to |client |care, |the |nurse |should
|determine |that |the |priority |goal |is |to |prevent |the |client |from |aspirating. |Because |the |client's |jaws |are |wired
|together, |aspiration |of |emesis |is |a |possibility. |Therefore, |the |client |should |be |given |medication |for |nausea, |and
|wire |cutters |should |be |kept |at |the |bedside |in |case |of |vomiting. |B. |Ensure |adequate |nutrition.
Rationale:The |client |should |be |NPO |initially |after |surgery |until |the |gag |reflex |has |returned. |Once |the |client
|is |able |to |eat, |the |client |may |advance |to |a |calorie-appropriate, |high-protein |liquid |diet. |However,
|this |is |not |the |priority |at |this |time.
C. |Promote |oral |hygiene
Rationale:The |client |will |have |an |incision |inside |the |mouth. |While |it |is |important |that |the |client |receive
| frequent |mouth |cleaning, |this |is |not |the |priority |at |this |time. |D. |Relieve |the |client's |pain.
Rationale:While |the |client |may |be |in |pain |and |will |need |to |be |medicated, |this |is |not |the |priority |at |this |time.
5.A |nurse |is |caring |for |a |client |who |has |a |new |diagnosis |of |myasthenia |gravis. |For |which |of |the |following
|manifestations |should |the |nurse |monitor?
A. Confusion
Rationale:Myasthenia |gravis |does |not |affect |cognition, |level |of |consciousness, |or |orientation.
, B. Weakness
Rationale:Generalized |weakness |of |the |diaphragmatic |and |intercostal |muscles |may |produce |respiratory
|distress |or |predispose |the |client |to |respiratory |infections.
C. Increased |intracranial |pressure
Rationale:
Myasthenia |gravis |does |not |affect |pressure |within |the |brain.
D. Increased |urinary |output
Rationale:Myasthenia |gravis |does |not |cause |increased |urine |output.
6.A |nurse |is |assessing |a |client |who |has |a |long |history |of |smoking |and |is |suspected |of |having |laryngeal |cancer. |The
| nurse |should |anticipate |that |the |client |will |report |that |her |earliest |manifestation |was |A. |dysphagia.
Rationale:Dysphagia, |difficulty |swallowing, |is |a |later |manifestation |of |cancer |of |the |larynx. |It |occurs |as |the
| tumor |grows |in |size |and |impedes |the |esophagus. | B. |hoarseness.
Rationale:Laryngeal |cancer, |a |malignant |tumor |of |the |larynx, |is |most |often |caused |by |long |exposure |to
| tobacco |and |alcohol. |Hoarseness |that |does |not |resolve |for |several |weeks |is |the |earliest |manifestation |of |cancer
| of |the |larynx |because |the |tumor |impedes |the |action |of |the |vocal |cords |during |speech. |The |voice |may |sound
| harsh |and |lower |in |pitch |than |normal. |C. |dyspnea.
Rationale:Dyspnea, |shortness |of |breath, |is |a |later |manifestation |of |laryngeal |cancer. |It |occurs |as |the |tumor
| grows |in |size |and |impedes |the |airway |opening. |D. |weight |loss.
Rationale:Weight |loss |is |a |later |manifestation |of |laryngeal |cancer, |usually |indicative |of |metastasis.
7.A |nurse |in |the |emergency |department |is |caring |for |a |client |who |has |extensive |partial |and |full-thickness |burns |of |the
|head, |neck, |and |chest. |While |planning |the |client's |care, |the |nurse |should |identify |which |of |the |following |risks |as |the
|priority |for |assessment |and |intervention?
A. Airway |obstruction
Rationale:When |using |the |airway, |breathing, |circulation |approach |to |client |care, |the |nurse |determines |that
|the |priority |risk |is |airway |obstruction. |Burns |of |the |head, |neck, |and |chest |often |involve |damage
| to |the |pulmonary |tree |due |to |heat |as |well |as |smoke |and |soot |inhalation. |This |can |result |in |severe
respiratory |difficulty. |Nursing |measures |to |maintain |a |patent |airway |should |take |priority |in |this
|client's |care.
B. Infection
Rationale:Prevention |of |infection |is |essential |throughout |hospitalization |and |treatment; |however, |another
|risk |is |the |priority.
, C. Fluid |imbalance
Rationale:Adequate |fluid |replacement |is |essential |throughout |the |acute |phase |of |burn |treatment; |however,
|another |risk |is |the |priority.
D. Paralytic |ileus
Rationale:Paralytic |ileus |can |develop |during |the |acute |phase |of |burn |care |and |might |require |nasogastric
|decompression; |however, |another |risk |is |the |priority.
8.A |nurse |is |caring |for |a |client |who |has |chronic |obstructive |pulmonary |disease |(COPD). |The |client |tells |the |nurse, |"I
|can |feel |the |congestion |in |my |lungs, |and |I |certainly |cough |a |lot, |but |I |can't |seem |to |bring |anything |up." |Which |of |the
|following |actions |should |the |nurse |take |to |help |this |client |with |tenacious |bronchial |secretions?
A. Maintaining |a |semi-Fowler's |position |as |often |as |possible
Rationale:Although |a |semi-Fowler's |position |can |help |the |client |breathe |more |easily, |it |will |not |alter |the
|consistency |of |secretions.
B. Administering |oxygen |via |nasal |cannula |at |2 |L/min
Rationale:Administration |of |oxygen |helps |correct |hypoxemia, |but |it |will |not |alter |the |consistency |of
|secretions.
C. Helping |the |client |select |a |low-salt |diet
Rationale:Although |a |low-salt |diet |can |help |limit |peripheral |edema, |it |will |not |alter |the |consistency |of
|secretions.
D. Encouraging |the |client |to |drink |2 |to |3 |L |of |water |daily
Rationale:COPD |is |a |term |for |two |diseases |of |the |respiratory |system: |chronic |bronchitis |and |emphysema.
Maintaining |hydration |through |the |consumption |of |adequate |fluids |will |help |liquefy |thick
|secretions |and |facilitate |their |expectoration.
9.A |nurse |is |observing |the |closed |chest |drainage |system |of |a |client |who |is |24 |hr |post |thoracotomy. |The |nurse |notes
|slow, |steady |bubbling |in |the |suction |control |chamber. |Which |of |the |following |actions |should |the |nurse |take? |A.
|Check |the |tubing |connections |for |leaks.
Rationale:This |action |is |used |to |determine |why |a |water |seal |chamber |has |continuous |bubbling, |not |slow,
|steady |bubbling.
B. Check |the |suction |control |outlet |on |the |wall.
Rationale:This |action |is |used |to |determine |why |a |suction |control |chamber |that |is |hooked |to |wall |suction
| has |little |or |no |bubbling. |C. |Clamp |the |chest |tube.
Rationale:The |nurse |should |briefly |clamp |the |chest |tube |to |check |for |air |leaks |or |to |change |the |drainage
| system. |This |is |not |an |appropriate |action |for |the |nurse |to |take |at |this |time. | D. |Continue |to |monitor |the |client's
| respiratory |status.
Latest 2025
1.A |nurse |is |admitting |a |client |who |has |active |tuberculosis |to |a |room |on |a |medical-surgical |unit. |Which |of |the |following
|room |assignments |should |the |nurse |make |for |the |client?
A. A |room |with |air |exhaust |directly |to |the |outdoor |environment
Rationale:A |room |with |air |exhaust |directly |to |the |outside |environment |eliminates |contamination |of |other
|client-care |areas. |This |type |of |ventilation |system |is |referred |to |as |an |airborne |infection |isolation
|room.
B. A |room |with |another |nonsurgical |client
Rationale:A |two-bed |room |with |another |nonsurgical |client |exposes |the |other |client |to |tuberculosis. |A |client
|who |has |tuberculosis |should |have |a |private |room.
C. A |room |in |the |ICU
Rationale:A |client |who |has |active |tuberculosis |and |no |other |comorbidities |is |not |critically |ill.
D. A |room |that |is |within |view |of |the |nurses' |station
Rationale:The |client's |room |should |be |well |ventilated |and |private, |but |it |is |not |necessary |for |it |to |be |close |to
|the |nurses' |station.
2.A |nurse |is |conducting |a |primary |survey |of |a |client |who |has |sustained |life-threatening |injuries |due |to |a |motor-vehicle
|crash. |Identify |the |sequence |of |actions |the |nurse |should |take. |(Move |the |actions |into |the |box |on |the |right, |placing
|them |in |the |selected |order |of |performance. |Use |all |the |steps.) |C. |Open |the |airway |using |a |jaw-thrust |maneuver.
D. |Determine |effectiveness |of |ventilator |efforts.
B. |Establish |IV |access.
A. |Perform |a |Glasgow |Coma |Scale |assessment.
E. |Remove |clothing |for |a |thorough |assessment.
3.A |nurse |is |caring |for |a |client |who |has |emphysema. |Which |of |the |following |findings |should |the |nurse |expect |to |assess
|in |this |client? |(Select |all |that |apply.)
A. Dyspnea
B. Bradycardia
, C. Barrel |chest
D. Clubbing |of |the |fingers
E. Deep |respirations
Rationale:
Dyspnea |is |correct. |Emphysema |is |a |lung |disease |involving |damage |to |the |alveoli |in |which |they
|become |weakened |and |collapse. |Dyspnea |is |seen |in |clients |with |emphysema |as |the |lungs |try |to
|increase |the |amount |of |oxygen |available |to |the |tissues.</br></br>Bradycardia |is |incorrect. |With
|emphysema, |the |heart |rate |will |increase |as |the |heart |tries |to |compensate |for |less |oxygen |to |the
|tissues. |</br></br>Barrel |chest |is |correct. |Clients |with |emphysema |lose |lung |elasticity; |the
|diaphragm |becomes |permanently |flattened |by | hyperinflation |of |the |lungs; |the |muscles |of |the |rib
|cage |become |rigid; |and |the |ribs |flare |outward. |This |produces |the |barrel |chest |typical |of
|emphysema |clients.</br></br>Clubbing |of |the |fingers |is |correct. |Clubbing |results |from |chronic
|low | arterial-oxygen |levels. |The |tips |of |the |fingers |enlarge |and |the |nails |become |extremely
|curved |from |front |to |back.</br></br>Deep |respirations |is |incorrect. |Clients |with |emphysema |lose
|lung |elasticity |and |have |muscle |fatigue; |consequently, |respirations |become |increasingly |shallow.
4.A |nurse |is |caring |for |a |client |who |has |returned |from |the |surgical |suite |following |surgery |for |a |fractured |mandible. |The
|client |had |intermaxillary |fixation |to |repair |and |stabilize |the |fracture. |Which |of |the |following |actions |is |the |priority |for
|the |nurse |to |take?
A. Prevent |aspiration.
Rationale:When |using |the |airway, |breathing, |circulation |approach |to |client |care, |the |nurse |should
|determine |that |the |priority |goal |is |to |prevent |the |client |from |aspirating. |Because |the |client's |jaws |are |wired
|together, |aspiration |of |emesis |is |a |possibility. |Therefore, |the |client |should |be |given |medication |for |nausea, |and
|wire |cutters |should |be |kept |at |the |bedside |in |case |of |vomiting. |B. |Ensure |adequate |nutrition.
Rationale:The |client |should |be |NPO |initially |after |surgery |until |the |gag |reflex |has |returned. |Once |the |client
|is |able |to |eat, |the |client |may |advance |to |a |calorie-appropriate, |high-protein |liquid |diet. |However,
|this |is |not |the |priority |at |this |time.
C. |Promote |oral |hygiene
Rationale:The |client |will |have |an |incision |inside |the |mouth. |While |it |is |important |that |the |client |receive
| frequent |mouth |cleaning, |this |is |not |the |priority |at |this |time. |D. |Relieve |the |client's |pain.
Rationale:While |the |client |may |be |in |pain |and |will |need |to |be |medicated, |this |is |not |the |priority |at |this |time.
5.A |nurse |is |caring |for |a |client |who |has |a |new |diagnosis |of |myasthenia |gravis. |For |which |of |the |following
|manifestations |should |the |nurse |monitor?
A. Confusion
Rationale:Myasthenia |gravis |does |not |affect |cognition, |level |of |consciousness, |or |orientation.
, B. Weakness
Rationale:Generalized |weakness |of |the |diaphragmatic |and |intercostal |muscles |may |produce |respiratory
|distress |or |predispose |the |client |to |respiratory |infections.
C. Increased |intracranial |pressure
Rationale:
Myasthenia |gravis |does |not |affect |pressure |within |the |brain.
D. Increased |urinary |output
Rationale:Myasthenia |gravis |does |not |cause |increased |urine |output.
6.A |nurse |is |assessing |a |client |who |has |a |long |history |of |smoking |and |is |suspected |of |having |laryngeal |cancer. |The
| nurse |should |anticipate |that |the |client |will |report |that |her |earliest |manifestation |was |A. |dysphagia.
Rationale:Dysphagia, |difficulty |swallowing, |is |a |later |manifestation |of |cancer |of |the |larynx. |It |occurs |as |the
| tumor |grows |in |size |and |impedes |the |esophagus. | B. |hoarseness.
Rationale:Laryngeal |cancer, |a |malignant |tumor |of |the |larynx, |is |most |often |caused |by |long |exposure |to
| tobacco |and |alcohol. |Hoarseness |that |does |not |resolve |for |several |weeks |is |the |earliest |manifestation |of |cancer
| of |the |larynx |because |the |tumor |impedes |the |action |of |the |vocal |cords |during |speech. |The |voice |may |sound
| harsh |and |lower |in |pitch |than |normal. |C. |dyspnea.
Rationale:Dyspnea, |shortness |of |breath, |is |a |later |manifestation |of |laryngeal |cancer. |It |occurs |as |the |tumor
| grows |in |size |and |impedes |the |airway |opening. |D. |weight |loss.
Rationale:Weight |loss |is |a |later |manifestation |of |laryngeal |cancer, |usually |indicative |of |metastasis.
7.A |nurse |in |the |emergency |department |is |caring |for |a |client |who |has |extensive |partial |and |full-thickness |burns |of |the
|head, |neck, |and |chest. |While |planning |the |client's |care, |the |nurse |should |identify |which |of |the |following |risks |as |the
|priority |for |assessment |and |intervention?
A. Airway |obstruction
Rationale:When |using |the |airway, |breathing, |circulation |approach |to |client |care, |the |nurse |determines |that
|the |priority |risk |is |airway |obstruction. |Burns |of |the |head, |neck, |and |chest |often |involve |damage
| to |the |pulmonary |tree |due |to |heat |as |well |as |smoke |and |soot |inhalation. |This |can |result |in |severe
respiratory |difficulty. |Nursing |measures |to |maintain |a |patent |airway |should |take |priority |in |this
|client's |care.
B. Infection
Rationale:Prevention |of |infection |is |essential |throughout |hospitalization |and |treatment; |however, |another
|risk |is |the |priority.
, C. Fluid |imbalance
Rationale:Adequate |fluid |replacement |is |essential |throughout |the |acute |phase |of |burn |treatment; |however,
|another |risk |is |the |priority.
D. Paralytic |ileus
Rationale:Paralytic |ileus |can |develop |during |the |acute |phase |of |burn |care |and |might |require |nasogastric
|decompression; |however, |another |risk |is |the |priority.
8.A |nurse |is |caring |for |a |client |who |has |chronic |obstructive |pulmonary |disease |(COPD). |The |client |tells |the |nurse, |"I
|can |feel |the |congestion |in |my |lungs, |and |I |certainly |cough |a |lot, |but |I |can't |seem |to |bring |anything |up." |Which |of |the
|following |actions |should |the |nurse |take |to |help |this |client |with |tenacious |bronchial |secretions?
A. Maintaining |a |semi-Fowler's |position |as |often |as |possible
Rationale:Although |a |semi-Fowler's |position |can |help |the |client |breathe |more |easily, |it |will |not |alter |the
|consistency |of |secretions.
B. Administering |oxygen |via |nasal |cannula |at |2 |L/min
Rationale:Administration |of |oxygen |helps |correct |hypoxemia, |but |it |will |not |alter |the |consistency |of
|secretions.
C. Helping |the |client |select |a |low-salt |diet
Rationale:Although |a |low-salt |diet |can |help |limit |peripheral |edema, |it |will |not |alter |the |consistency |of
|secretions.
D. Encouraging |the |client |to |drink |2 |to |3 |L |of |water |daily
Rationale:COPD |is |a |term |for |two |diseases |of |the |respiratory |system: |chronic |bronchitis |and |emphysema.
Maintaining |hydration |through |the |consumption |of |adequate |fluids |will |help |liquefy |thick
|secretions |and |facilitate |their |expectoration.
9.A |nurse |is |observing |the |closed |chest |drainage |system |of |a |client |who |is |24 |hr |post |thoracotomy. |The |nurse |notes
|slow, |steady |bubbling |in |the |suction |control |chamber. |Which |of |the |following |actions |should |the |nurse |take? |A.
|Check |the |tubing |connections |for |leaks.
Rationale:This |action |is |used |to |determine |why |a |water |seal |chamber |has |continuous |bubbling, |not |slow,
|steady |bubbling.
B. Check |the |suction |control |outlet |on |the |wall.
Rationale:This |action |is |used |to |determine |why |a |suction |control |chamber |that |is |hooked |to |wall |suction
| has |little |or |no |bubbling. |C. |Clamp |the |chest |tube.
Rationale:The |nurse |should |briefly |clamp |the |chest |tube |to |check |for |air |leaks |or |to |change |the |drainage
| system. |This |is |not |an |appropriate |action |for |the |nurse |to |take |at |this |time. | D. |Continue |to |monitor |the |client's
| respiratory |status.
