Chapter 23 Nursing School Test Banks
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is
reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what
1. complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
C) Aspiration
D) Pulmonary embolism
Ans: B
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of
developing atelectasis.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses
assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions.
2. What should the nurse encourage the patient to do?
A) Increase oral fluids unless contraindicated.
B) Call the nurse for oral suctioning, as needed.
C) Lie in a low Fowlers or supine position.
D) Increase activity.
Ans: A
Feedback:
The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the
3. community. How should the nurse administer this test?
A) Administer intradermal injections into the childrens inner forearms.
B) Administer intramuscular injections into each childs vastus lateralis.
C) Administer a subcutaneous injection into each childs umbilical area.
D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid.
Ans: A
Feedback:
The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm
4. The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patien
, has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis?
A) The patient is experiencing painless hemoptysis.
B) The patients arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing.
C) The patients oxygen saturation level is below 88%, but he denies shortness of breath.
D) The patients pain intensifies when he coughs or takes a deep breath.
Ans: D
Feedback:
The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing,
or sneezing worsens the pain.
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the
5. primary rationale behind this nursing action?
A) Smoking decreases the amount of mucus production.
B) Smoke particles compete for binding sites on hemoglobin.
C) Smoking causes atrophy of the alveoli.
D) Smoking damages the ciliary cleansing mechanism.
Ans: D
Feedback:
In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage
(scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract.
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What
6. intervention should the nurse first anticipate?
A) Preparing to assist with intubating the patient
B) Setting up oxygen at 5 L/minute by nasal cannula
C) Performing deep suctioning
D) Setting up a nebulizer to administer corticosteroids
Ans: A
Feedback:
A patient who has ARDS (acute resp distress syndrome, fluid accumulates in lungs making it difficult to breath)
usually requires intubation and mechanical ventilation.
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting
with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The
patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has develope
7. Further assessment findings supporting the presence of a pneumothorax include what?
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is
reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what
1. complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
C) Aspiration
D) Pulmonary embolism
Ans: B
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of
developing atelectasis.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses
assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions.
2. What should the nurse encourage the patient to do?
A) Increase oral fluids unless contraindicated.
B) Call the nurse for oral suctioning, as needed.
C) Lie in a low Fowlers or supine position.
D) Increase activity.
Ans: A
Feedback:
The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the
3. community. How should the nurse administer this test?
A) Administer intradermal injections into the childrens inner forearms.
B) Administer intramuscular injections into each childs vastus lateralis.
C) Administer a subcutaneous injection into each childs umbilical area.
D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid.
Ans: A
Feedback:
The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm
4. The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patien
, has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis?
A) The patient is experiencing painless hemoptysis.
B) The patients arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing.
C) The patients oxygen saturation level is below 88%, but he denies shortness of breath.
D) The patients pain intensifies when he coughs or takes a deep breath.
Ans: D
Feedback:
The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing,
or sneezing worsens the pain.
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the
5. primary rationale behind this nursing action?
A) Smoking decreases the amount of mucus production.
B) Smoke particles compete for binding sites on hemoglobin.
C) Smoking causes atrophy of the alveoli.
D) Smoking damages the ciliary cleansing mechanism.
Ans: D
Feedback:
In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage
(scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract.
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What
6. intervention should the nurse first anticipate?
A) Preparing to assist with intubating the patient
B) Setting up oxygen at 5 L/minute by nasal cannula
C) Performing deep suctioning
D) Setting up a nebulizer to administer corticosteroids
Ans: A
Feedback:
A patient who has ARDS (acute resp distress syndrome, fluid accumulates in lungs making it difficult to breath)
usually requires intubation and mechanical ventilation.
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting
with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The
patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has develope
7. Further assessment findings supporting the presence of a pneumothorax include what?
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
