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PULMONARY MASTERY GUIDE
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. - ANSWER-B
Rationale: 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. - ANSWER-
B
Rationale: 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. - ANSWER-D
Rationale: 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. - ANSWER-A
Rationale: 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. - ANSWER-B
Rationale: Surfactant is the substance that reduces
the surface tension of the walls of the alveoli,
making gas exchange more effective.