CHAPTER 29:Medical-Surgical Nursing (6th Edition) By Linda S. Williams Paula D. Hopper

Test Bank Understanding Medical-Surgical Nursing 6th Edition Linda S. Williams Paula D. Hopper Chapter 29: Respiratory System Function, Assessment, and Therapeutic Measures Multiple Choice Questions 1. The nurse is reviewing the arterial blood gas results for a patient with a respiratory disorder. What should the nurse recognize as being the most important chemical regulator of respiration? A. The blood level of oxygen B. The blood level of nitrogen C. The blood level of carbon dioxide D. The amount of hemoglobin in red blood cells Answer: C Explanation: Carbon dioxide is the primary chemical regulator of respiration because it directly affects blood pH, triggering the respiratory center to adjust breathing rate and depth. Why Other Options Are Wrong: A is incorrect because oxygen levels only significantly affect respiration in severe hypoxia. B is incorrect because nitrogen is inert and does not regulate respiration. D is incorrect because hemoglobin transports oxygen but does not regulate breathing. 2. The nurse is reviewing the results of a patient's pulmonary function tests. Which result describes the air remaining in lungs after normal expiration? A. Tidal volume B. Expiratory reserve C. Forced vital capacity D. Functional residual capacity Answer: D Explanation: Functional residual capacity is the volume of air remaining in the lungs after a normal exhalation, representing the balance between lung elasticity and chest wall recoil. Why Other Options Are Wrong: A is incorrect because tidal volume is the air moved during normal breathing. B is incorrect because expiratory reserve is the additional air expelled beyond tidal volume. C is incorrect because forced vital capacity is the total air exhaled forcefully after maximal inhalation. 3. The nurse is reviewing the exchange of gases in the blood stream with a patient prescribed oxygen therapy. How should the nurse explain the transport of carbon dioxide in the blood? A. As CO2 in plasma B. As bicarbonate ions in plasma C. As hydrogen ions in red blood cells D. As part of hemoglobin in red blood cells Answer: B Explanation: Most carbon dioxide is transported as bicarbonate ions (HCO3-) in plasma, formed when CO2 reacts with water in red blood cells, then diffuses into plasma. Why Other Options Are Wrong: A is incorrect because only a small fraction of CO2 dissolves directly in plasma. C is incorrect because hydrogen ions are byproducts, not transporters, of CO2 conversion. D is incorrect because CO2 binds to hemoglobin as carbaminohemoglobin, but this is a minor transport mechanism. 4. A patient is having problems with oxygenation of body tissues. What is important for the nurse to consider about the transport of oxygen in the blood? A. It is in blood plasma as free oxygen. B. It travels on red blood cell membranes. C. It is bonded to hemoglobin in blood plasma. D. It is bonded to hemoglobin in red blood cells. Answer: D Explanation: Oxygen binds reversibly to hemoglobin molecules within red blood cells, which carry 98% of oxygen in the blood. Why Other Options Are Wrong: A is incorrect because minimal oxygen dissolves freely in plasma. B is incorrect because oxygen does not attach to cell membranes. C is incorrect because hemoglobin is inside red blood cells, not plasma. 5. The nurse is reviewing the physiology of the respiratory system with a patient being treated for pneumonia. What structure should the nurse identify as sweeping mucus and pathogens from the nasal cavities and trachea to the pharynx? A. Ciliated epithelium B. Alveolar macrophages C. Elastic connective tissue D. Simple squamous epithelium Answer: A Explanation: Ciliated epithelial cells line the respiratory tract and use coordinated beating motions to propel mucus and trapped particles upward for expulsion or swallowing. Why Other Options Are Wrong: B is incorrect because alveolar macrophages destroy pathogens in alveoli, not airways. C is incorrect because connective tissue provides structural support but does not move mucus. D is incorrect because squamous epithelium is thin and lacks cilia. 6. The nurse is coaching a patient to empty the lungs of all air before using a metered-dose inhaler. What air that is expired beyond tidal volume in a forceful exhalation is the nurse coaching the patient to remove from the lungs? A. Tidal volume B. Expiratory reserve C. Forced vital capacity D. Peak expiratory flow rate Answer: B Explanation: Expiratory reserve volume is the additional air expelled beyond tidal volume during maximal forced exhalation, ensuring optimal medication delivery. Why Other Options Are Wrong: A is incorrect because tidal volume is the air moved during normal breathing. C is incorrect because forced vital capacity includes all air exhaled after maximal inhalation. D is incorrect because peak flow measures speed, not volume, of expiration. 7. A patient has a low oxygen level. Which body structure should the nurse consider as being responsible for this low level? A. Larynx B. Alveoli C. Bronchi D. Nasal passages Answer: B Explanation: Alveoli are the primary sites of gas exchange; impaired function (e.g., fluid accumulation in pneumonia) directly reduces oxygen diffusion into the blood. Why Other Options Are Wrong: A and C are incorrect because the larynx and bronchi are airways that transport air but do not participate in gas exchange. D is incorrect because nasal passages filter/humidify air but do not affect oxygenation. 8. The nurse is providing care to a patient who experienced an ischemic stroke and now requires respiratory support with mechanical ventilation. The nurse realizes that the stroke most likely occurred in which part of the brain? A. Medulla B. Cerebrum C. Cerebellum D. Hypothalamus Answer: A Explanation: The medulla contains the respiratory centers that control involuntary breathing; damage disrupts automatic respiratory drive. Why Other Options Are Wrong: B is incorrect because the cerebrum governs voluntary breathing but not automatic respiration. C is incorrect because the cerebellum coordinates movement, not breathing. D is incorrect because the hypothalamus regulates homeostasis, not respiration. 9. A nurse is providing care for a patient who complains of difficulty breathing. Which assessment will best help the nurse determine the severity of the patient's dyspnea? A. Count the patient's respiratory rate. B. Ask the patient to describe the dyspnea. C. Have the patient rate the dyspnea on a 0-to-10 scale. D. Observe the patient throughout two to three respirations. Answer: C Explanation: A numeric rating scale quantifies subjective dyspnea severity, allowing for objective monitoring and intervention thresholds. Why Other Options Are Wrong: A is incorrect because rate alone does not reflect perceived distress. B is incorrect because descriptions are qualitative, not measurable. D is incorrect because observation lacks patient-reported severity. 10. While providing care for a patient with asthma, the nurse notes the patient's shoulders are rising with each breath. What should the nurse realize this action represents? A. Hyperinflation of the chest B. The use of accessory muscles to aid breathing C. Shoulder muscle fatigue related to difficulty breathing D. Effective use of a breathing exercise to increase ventilation Answer: B Explanation: Shoulder elevation indicates use of sternocleidomastoid and trapezius muscles, which are accessory muscles recruited during respiratory distress. Why Other Options Are Wrong: A is incorrect because hyperinflation does not cause shoulder movement. C is incorrect because fatigue would reduce, not increase, muscle use. D is incorrect because accessory muscle use signals distress, not controlled breathing. 11. During the admission assessment of an individual admitted to the medical respiratory unit, the nurse notes the patient has a barrel-shaped chest. Which assessment should the nurse perform next? A. Assess the patient's rate and character of respirations. B. Ask the patient about presence of a productive cough. C. Palpate the patient's thorax to determine presence of tenderness. D. Obtain a blood sample for arterial blood gas (ABG) to detect respiratory acidosis. Answer: A Explanation: Barrel chest suggests chronic air trapping (e.g., COPD); assessing respirations evaluates current ventilatory status as the priority. Why Other Options Are Wrong: B is incorrect because cough assessment is secondary to respiratory status. C is incorrect because tenderness is unrelated to barrel chest. D is incorrect because ABGs are not immediately needed without respiratory distress. 12. The nurse is auscultating a patient's chest and hears an adventitious sound in the left lower lobe. What is the first step in determining whether this is an abnormality? A. Call another nurse to listen to the patient's lungs. B. Ask the patient if this has ever occurred in the past. C. Have the physician listen and verify what the nurse is hearing. D. Listen to the corresponding area in the patient's right lower lobe. Answer: D Explanation: Comparing bilateral lung sounds identifies unilateral abnormalities (e.g., pneumonia) versus normal variants. Why Other Options Are Wrong: A and C are incorrect because verification by others is unnecessary before self-assessment. B is incorrect because patient history does not confirm current pathology. 13. The nurse is auscultating a patient's lungs but is unable to hear much air movement. What should the nurse do to most effectively hear the lung sounds? A. Try another stethoscope. B. Have the patient rest between breaths. C. Have the patient assume a side-lying position. D. Ask the patient to breathe deeply through the mouth. Answer: D Explanation: Deep mouth breathing increases airflow, enhancing sound transmission for accurate auscultation. Why Other Options Are Wrong: A is incorrect because equipment issues are unlikely if the stethoscope was functional. B is incorrect because rest does not improve sound quality. C is incorrect because positioning affects ventilation, not auscultation clarity. 14. The nurse observes a patient who has periods of fast, deep respirations alternating with periods of apnea. What term should the nurse use to describe this pattern? A. Tachypnea B. Kussmaul's C. Cheyne-Stokes D. Hyperventilation Answer: C Explanation: Cheyne-Stokes respiration involves cyclical waxing/waning of breath depth with apneic pauses, often seen in heart failure or brain injury. Why Other Options Are Wrong: A is incorrect because tachypnea is persistently rapid breathing without apnea. B is incorrect because Kussmaul's is deep, rapid breathing without pauses. D is incorrect because hyperventilation is sustained rapid breathing. 15. An adult patient has a respiratory rate of 36 breaths per minute. Which term should the nurse use to document this finding? A. Apnea B. Bradypnea C. Tachypnea D. Within normal limits Answer: C Explanation: Tachypnea is defined as a respiratory rate >20 breaths/min in adults; 36 is significantly elevated. Why Other Options Are Wrong: A is incorrect because apnea is absence of breathing. B is incorrect because bradypnea is <12 breaths/min. D is incorrect because the normal range is 12 20 breaths/min. 16. A patient with pulmonary edema has moist, bubbling lung sounds. How should the nurse describe this finding? A. Wheezing B. Fine crackles C. Coarse crackles D. Pleural friction rub Answer: C Explanation: Coarse crackles are loud, bubbly sounds caused by fluid in larger airways, typical of pulmonary edema. Why Other Options Are Wrong: A is incorrect because wheezing is a high-pitched whistling from narrowed airways. B is incorrect because fine crackles are softer, like hair rubbing. D is incorrect because friction rubs are grating sounds from inflamed pleura. 17. A patient is making a loud crowing sound caused by an obstruction of the airways by a foreign body. How should the nurse document this patient's lung sound? A. Stridor B. Wheeze C. Crackles D. Pleural friction rub Answer: A Explanation: Stridor is a high-pitched crowing sound from upper airway obstruction, requiring immediate intervention. Why Other Options Are Wrong: B is incorrect because wheezing originates in lower airways. C is incorrect because crackles are fluid-related. D is incorrect because friction rubs are pleural, not airway, sounds. 18. The nurse is providing care for a patient diagnosed with asthma. Which adventitious sound should the nurse expect when auscultating this patient's lung sounds? A. Crackles B. Wheezes C. Pleural friction rub D. Diminished breath sounds Answer: B Explanation: Wheezing (musical, high-pitched sounds) occurs when air passes through narrowed airways, hallmark of asthma. Why Other Options Are Wrong: A is incorrect because crackles suggest fluid, not bronchospasm. C is incorrect because friction rubs indicate pleural inflammation. D is incorrect because diminished sounds occur with severe obstruction or emphysema. 19. A patient with pneumonia is having difficulty raising secretions for a sputum culture. Which action should the nurse take first? A. Administer a bronchodilator. B. Suction the patient to obtain a specimen. C. Encourage the patient to take deep breaths. D. Obtain the specimen with a cotton-tipped swab. Answer: C Explanation: Deep breathing stimulates coughing, the least invasive method to expectorate sputum. Why Other Options Are Wrong: A is incorrect because bronchodilators treat airway constriction, not secretion mobilization. B is incorrect because suctioning is invasive and unnecessary if coughing is effective. D is incorrect because swabs only collect oropharyngeal, not lower respiratory, specimens. 20. A laboratory technician has just completed drawing arterial blood gases from a patient. What action should the nurse take first? A. Increase the patient's oxygen to 4 L/min. B. Hold pressure on the puncture site for 5 minutes. C. Have the patient hold his or her hand in a fist for 2 to 3 minutes. D. Notify the physician that the blood is in the laboratory for analysis. Answer: B Explanation: Prolonged pressure prevents hematoma formation at the arterial puncture site, which can compromise circulation. Why Other Options Are Wrong: A is incorrect because oxygen should not be adjusted without orders. C is incorrect because fist-clenching is for venous, not arterial, blood draws. D is incorrect because lab notification is not urgent. 21. A patient's arterial blood gas analysis shows a PaCO2 of 68 mm Hg. What action should the nurse take first? A. Notify the physician. B. Remove the patient's oxygen mask. C. Have the patient breathe into a paper bag. D. Place the patient in a left side-lying position. Answer: A Explanation: PaCO2 >45 mm Hg indicates hypercapnia requiring prompt intervention; the physician must be notified for orders. Why Other Options Are Wrong: B is incorrect because removing oxygen worsens hypoxia. C is incorrect because paper bags treat hypocapnia, not hypercapnia. D is incorrect because positioning does not address elevated CO2. 22. A patient's arterial blood gas analysis shows a pH of 7.28. The PaCO2 is high. Which acid-base imbalance is the patient experiencing? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Answer: C Explanation: Low pH with high PaCO2 indicates respiratory acidosis, caused by hypoventilation and CO2 retention. Why Other Options Are Wrong: A is incorrect because metabolic acidosis involves low HCO3, not high CO2. B is incorrect because alkalosis shows high pH. D is incorrect because respiratory alkalosis involves low CO2 and high pH. 23. A patient's oxygen saturation value is 92% on room air. What does this value mean to the nurse? A. The percentage of oxygen in the lungs B. The partial pressure of the oxygen in the blood C. The amount of oxygen saturating the lymphocytes D. The percentage of hemoglobin that is saturated with oxygen Answer: D Explanation: SpO2 measures the percentage of hemoglobin binding sites occupied by oxygen, reflecting oxygenation status. Why Other Options Are Wrong: A is incorrect because it describes FiO2, not saturation. B is incorrect because partial pressure is PaO2, measured by ABG. C is incorrect because lymphocytes do not carry oxygen. 24. A patient's oxygen saturation is 89%. Which actions should the nurse take first? A. Raise the head of the patient's bed. B. Call the respiratory therapist STAT. C. Place the patient in a supine position. D. No action; this is a normal oxygen saturation. Answer: A Explanation: Elevating the head improves lung expansion and oxygenation, the first step for mild hypoxia (SpO2 89%). Why Other Options Are Wrong: B is incorrect because 89% is not an emergency. C is incorrect because supine positioning worsens ventilation. D is incorrect because normal SpO2 is ≥95%. 25. A patient returns to the medical unit after a pulmonary angiogram. Which instructions by the nurse would help prevent complications from the test? A. "Lie flat for 8 hours so the injection site does not bleed." B. "Stay in Fowler's position to help excrete the radioactive gas." C. "Try not to cough for 6 hours because this could cause irritation and bleeding." D. "Don't eat or drink anything for 6 hours after the test, because your gag reflex may not be intact." Answer: A Explanation: Prolonged bed rest prevents bleeding at the arterial puncture site used for angiography. Why Other Options Are Wrong: B is incorrect because Fowler's increases puncture site pressure. C is incorrect because coughing does not typically cause bleeding post-angiogram. D is incorrect because gag reflex is unaffected by angiography. 26. After a bronchoscopic examination, the patient must remain NPO (nothing by mouth) until the return of the gag reflex. How can the nurse determine when the gag reflex has returned? A. Ask the patient to swallow. B. Give the patient a sip of water. C. Touch the back of the throat with a cotton swab. D. Touch the roof of the mouth with a gloved finger. Answer: C Explanation: Gag reflex is tested by stimulating the posterior pharynx; a cough or gag confirms its presence. Why Other Options Are Wrong: A is incorrect because swallowing does not test the gag reflex. B is incorrect because giving liquids risks aspiration if the reflex is absent. D is incorrect because the palate does not trigger gagging. 27. The nurse is caring for a patient experiencing dyspnea. What should the nurse instruct the patient to breathe more effectively? A. "Use deep breathing, and exhale as forcefully as you are able." B. "Take four quick, panting breaths, and then blow out for 6 seconds." C. "Hold your breath for 3 seconds after each exhalation to empty all the alveoli." D. "Breathe using your abdominal muscles, and blow out slowly through pursed lips." Answer: D Explanation: Diaphragmatic breathing with pursed-lip exhalation improves ventilation and reduces air trapping in COPD. Why Other Options Are Wrong: A is incorrect because forceful exhalation increases airway collapse. B is incorrect because panting causes hyperventilation. C is incorrect because breath holding does not aid expiration. 28. The nurse places a patient who is experiencing dyspnea in the Fowler's position. What is the rationale for the nurse to use this position? A. Fowler's position helps dilate diseased bronchioles. B. Fowler's position allows maximum lung expansion. C. Fowler's position increases use of accessory muscles. D. Fowler's position relieves stress on the back and chest. Answer: B Explanation: Fowler's position reduces abdominal pressure on the diaphragm, permitting greater lung expansion. Why Other Options Are Wrong: A is incorrect because positioning does not dilate bronchioles. C is incorrect because accessory muscle use indicates distress, not benefit. D is incorrect while true, the primary benefit is improved ventilation. 29. A patient with cancer in the left lung is acutely short of breath. Which position should the nurse suggest the patient assume? A. Prone B. Supine C. Left side-lying D. Right side-lying Answer: D Explanation: "Good lung down" positioning (right side-lying) improves oxygenation by perfusing the healthier lung. Why Other Options Are Wrong: A and B are incorrect because prone/supine positions do not optimize ventilation-perfusion matching. C is incorrect because lying on the affected lung compromises the healthy lung. 30. The LPN is assigned to monitor a patient with chronic lung disease who is receiving oxygen via a non-rebreathing mask. Which observation indicates to the nurse that the system is functioning as expected? A. Both side vents open, reservoir bag inflated B. Both side vents open, reservoir bag deflated C. Both side vents closed, reservoir bag inflated D. Both side vents closed, reservoir bag deflated Answer: C Explanation: A functioning non-rebreathing mask has closed side vents (preventing air entrainment) and an inflated reservoir bag (ensuring high O2 delivery). Why Other Options Are Wrong: A and B are incorrect because open vents dilute oxygen concentration. D is incorrect because a deflated bag indicates insufficient oxygen flow. 31. A patient is being taught to administer nebulized mist treatments (NMTs) at home. Which outcome indicates that the patient is able to administer the treatments? A. The patient verbalizes all the steps in the NMT procedure correctly. B. The patient demonstrates the correct procedure for administering the NMT. C. The patient lists the side effects of the medications that are administered via the NMT. D. The patient states understanding of the importance of administering the NMTs during periods of shortness of breath. Answer: B Explanation: Return demonstration confirms the patient can correctly perform the procedure independently. Why Other Options Are Wrong: A and D are incorrect because verbalization does not ensure competency. C is incorrect because knowledge of side effects is important but does not confirm administration skills. 32. A nurse is providing discharge instructions for a patient who is to use an adrenergic bronchodilator metered dose inhaler (MDI). What should be included in the teaching? A. "Avoid using the MDI at night." B. "Take one puff every 5 minutes until your symptoms are relieved." C. "Using the MDI more often than prescribed can result in worsening symptoms." D. "Take two puffs whenever you feel wheezy but no more than six puffs per day." Answer: C Explanation: Overuse of adrenergic bronchodilators can cause paradoxical bronchospasm and tachycardia. Why Other Options Are Wrong: A is incorrect because nighttime use may be needed for symptom control. B is incorrect because frequent dosing risks toxicity. D is incorrect because exceeding prescribed doses is unsafe. 33. A postoperative patient is taking shallow breaths because of fear of incisional pain. Which action should the nurse take first? A. Instruct the patient on the use of an incentive spirometer. B. Measure peak expiratory flow rate with a peak flow meter. C. Call respiratory therapy to provide a metered-dose inhaler (MDI). D. Contact the physician to request nebulized mist treatments (NMTs). Answer: A Explanation: Incentive spirometry encourages deep breathing to prevent atelectasis, the priority for postoperative patients. Why Other Options Are Wrong: B is incorrect because peak flow measures airway obstruction, not lung expansion. C and D are incorrect because bronchodilators are unnecessary without evidence of bronchospasm. 34. After providing chest physiotherapy, the nurse notes the patient has loose secretions and a slight rattle with expiration. Which action should the nurse take first? A. Administer an expectorant. B. Suction the patient's airway. C. Keep the patient on bedrest for 4 hours. D. Encourage the patient to cough and deep breathe. Answer: D Explanation: Coughing clears mobilized secretions naturally, minimizing infection risk from invasive suctioning. Why Other Options Are Wrong: A is incorrect because expectorants are slower-acting than coughing. B is incorrect because suctioning is reserved for inability to expectorate. C is incorrect because mobility aids secretion clearance. 35. A patient has a thoracentesis for dyspnea caused by a pleural effusion. The physician obtains 1000 mL of fluid. Which outcome indicates that the thoracentesis has been effective? A. No bleeding at the site is noted. B. No cancer cells are found in the fluid. C. The patient states that the dyspnea has lessened. D. The fluid is sent to the laboratory in a timely manner. Answer: C Explanation: Symptom relief (reduced dyspnea) is the primary goal of thoracentesis for pleural effusion. Why Other Options Are Wrong: A is incorrect because absence of bleeding is expected but not the treatment goal. B is incorrect because cytology results are diagnostic, not therapeutic. D is incorrect because lab processing does not indicate clinical success. 36. A patient enters the emergency department with a stab wound to the chest. The physician places chest tubes to drain air and blood from the patient's thoracic cavity. The nurse sets up the chest tube drainage system. Where should the nurse place the system? A. Below the patient's chest B. At the level of the patient's heart C. 1 inch higher than the head of the bed D. At the level of the patient's diaphragm Answer: A Explanation: The drainage system must remain below chest level to prevent fluid/air reflux into the pleural space. Why Other Options Are Wrong: B, C, and D are incorrect because elevated placement risks backflow and compromises drainage. 37. A patient with a chest drainage system is admitted to the respiratory unit. The nurse notes vigorous bubbling in the water seal chamber of the system. What should the nurse do? A. Lower the level of suction. B. Ask the patient to cough forcefully. C. No action is necessary; this is an expected finding. D. Examine the entire system and tubing for air leaks. Answer: D Explanation: Vigorous bubbling in the water seal indicates an air leak, requiring inspection of the system for disconnections or cracks. Why Other Options Are Wrong: A is incorrect because suction level affects the suction chamber, not water seal. B is incorrect because coughing does not address leaks. C is incorrect because continuous bubbling is abnormal. 38. The nurse is examining a chest drainage system on a patient with a pneumothorax and notes the water level in the water seal chamber fluctuating with each of the patient's respirations. What should the nurse do? A. Clamp the tubing and call for help. B. Have the patient take a deep breath. C. Examine the entire system and tubing for leaks. D. No action is necessary; this is an expected finding. Answer: D Explanation: Tidaling (water level fluctuation with respiration) confirms system patency and is normal. Why Other Options Are Wrong: A is incorrect because clamping risks tension pneumothorax. B is incorrect because deep breathing is unrelated to tidaling. C is incorrect because tidaling does not indicate a leak. 39. A patient with a tracheostomy is dyspneic and has coarse crackles anteriorly on auscultation. What should the nurse do first? A. Suction the tracheostomy. B. Perform routine tracheostomy care. C. Administer a prn nebulized mist treatment. D. Ask the patient to take a deep breath and cough. Answer: A Explanation: Coarse crackles in a tracheostomy patient suggest secretions obstructing the airway, requiring immediate suctioning. Why Other Options Are Wrong: B is incorrect because routine care does not address acute obstruction. C is incorrect because nebulizers are slower-acting than suctioning. D is incorrect because coughing may be ineffective with thick secretions. 40. A patient with a tracheostomy requires suctioning. How many seconds can the nurse suction safely with each pass of the catheter? A. 3 seconds B. 15 seconds C. 30 seconds D. 60 seconds Answer: B Explanation: Suctioning beyond 15 seconds risks hypoxia and mucosal trauma. Why Other Options Are Wrong: A is insufficient to clear secretions. C and D exceed safe limits, increasing complications. 41. The nurse is asked to assist with the intubation of a confused patient with respiratory failure. What should the nurse do first? A. Ask the patient to sign a consent form. B. Check the patient's advance directives. C. Place the patient in a supine position with neck extended. D. Obtain necessary equipment according to institution policy. Answer: B Explanation: Verifying advance directives ensures the patient's wishes are respected regarding life-sustaining interventions. Why Other Options Are Wrong: A is incorrect because confused patients cannot provide consent. C and D are preparatory steps after confirming treatment appropriateness. 42. The nurse is caring for a patient with myasthenia gravis who is on a ventilator. The high-pressure alarm sounds. What should the nurse consider as the cause for this alarm? A. The patient is fatigued. B. The tubing is disconnected. C. The electricity is interrupted. D. The patient needs to be suctioned. Answer: D Explanation: High-pressure alarms indicate increased airway resistance, often due to secretions requiring suctioning. Why Other Options Are Wrong: A is incorrect because fatigue reduces respiratory effort, triggering low-pressure alarms. B and C are incorrect because disconnections/power loss trigger apnea alarms. 43. A patient being mechanically ventilated is prescribed peak end-expiratory pressure (PEEP). How does this setting assist the ventilated patient? A. It delivers a breath only if the patient does not breathe spontaneously. B. It provides positive pressure on expiration to keep small airways open. C. It delivers a breath in a set pattern regardless of the patient's respiratory pattern. D. It provides positive pressure on inspiration and expiration to increase oxygenation. Answer: B Explanation: PEEP maintains positive pressure at end-exhalation, preventing alveolar collapse and improving oxygenation. Why Other Options Are Wrong: A describes assist-control mode. C describes controlled ventilation. D describes continuous positive airway pressure (CPAP), not PEEP. 44. The nurse hears a ventilator alarm from the hallway. Which action should the nurse take first? A. Call for help. B. Check the patient. C. Turn off the alarm. D. Check the ventilator. Answer: B Explanation: Patient assessment takes priority to determine if the alarm reflects clinical deterioration. Why Other Options Are Wrong: A is premature without assessing the patient. C and D are incorrect because silencing the alarm or checking equipment delays intervention if the patient is in distress. 45. A patient is prescribed noninvasive positive-pressure ventilation (NIPPV). How can the nurse increase the patient's comfort when using this ventilation system? A. Administer opioid analgesics. B. Remove the unit while the patient is sleeping. C. Re-tape the tube to the opposite side of the mouth every 24 hours. D. Use a skin barrier on the area where the mask comes in contact with the skin. Answer: D Explanation: Skin barriers prevent irritation and pressure injuries from mask contact, enhancing comfort. Why Other Options Are Wrong: A is incorrect because opioids depress respiration. B is incorrect because NIPPV must be continuous. C is incorrect because NIPPV uses masks, not taped tubes. 46. A patient's chest x-ray shows a suspicious area, and the physician plans a bronchoscopy. How should the nurse describe this procedure to the patient? A. "You will be asked to use a mouthpiece to blow into a machine." B. "You will need to drink a thick white liquid that will be opaque on the x-rays." C. "A dye will be injected to help visualize the structures of the bronchioles. Do you have any allergies?" D. "The physician will place a small tube through your nose or mouth and into the bronchi to look at your airways." Answer: D Explanation: Bronchoscopy involves inserting a flexible scope into the airways for direct visualization. Why Other Options Are Wrong: A describes spirometry. B describes barium swallow. C describes contrast-enhanced imaging, not bronchoscopy. 47. A patient is recovering after a bronchoscopy. Which action is a priority for this patient? A. Encourage oral fluids. B. Check for swallow and gag reflexes. C. Monitor the patient for return to consciousness. D. Order a meal because the patient has been NPO for 8 hours. Answer: B Explanation: Assessing gag reflex post-procedure ensures safe oral intake, preventing aspiration. Why Other Options Are Wrong: A and D are incorrect until gag reflex is confirmed. C is incorrect because bronchoscopy typically uses sedation, not general anesthesia. 48. A patient with ineffective airway clearance is being discharged home. Which home therapy will help the patient loosen and expectorate secretions? A. Capnography B. Water-seal chest drainage C. Transtracheal oxygenation D. Vibratory positive expiratory pressure device Answer: D Explanation: PEP devices use vibrations and positive pressure to mobilize secretions for easier expectoration. Why Other Options Are Wrong: A is incorrect because capnography monitors CO2, not clearance. B is incorrect because chest drainage treats pneumothorax. C is incorrect because transtracheal oxygen delivers O2, not clearance. 49. The nurse is reviewing the results of a patient's pulmonary function studies. Which result indicates the patient's tidal volume is within normal limits? A. 100 to 200 mL B. 400 to 600 mL C. 800 to 1100 mL D. 1500 to 2000 mL Answer: B Explanation: Normal tidal volume is 400–600 mL per breath at rest. Why Other Options Are Wrong: A is insufficient for gas exchange. C and D approach inspiratory reserve/vital capacity volumes. 50. The nurse documents that a patient's chest is within normal limits. What does this statement mean? A. The chest is deeper than it is wide. B. The chest is equally wide and deep. C. The chest is twice as wide as it is deep. D. The chest is greater than 30 inches in diameter. Answer: C Explanation: Normal chests have a 2:1 width-to-depth ratio; barrel chests approach 1:1. Why Other Options Are Wrong: A describes emphysema. B describes barrel chest. D is incorrect because size varies by body habitus. 51. The nurse coaches a patient with chronic obstructive pulmonary disease to make one long "huff" when performing huff coughing. What should the nurse explain as the purpose of the long huff when using this approach to clear the airway? A. Increases oxygenation B. Removes excess carbon dioxide C. Ensures thorough lung expansion D. Helps to open and clear smaller airways Answer: D Explanation: Prolonged huffing generates airflow to mobilize secretions from small airways. Why Other Options Are Wrong: A and B are incorrect because huffing primarily clears secretions, not gases. C is incorrect because huffing follows full inhalation. 52. The nurse observes a patient place one hand on the abdomen and the other on the chest as the abdomen is pushed out with each breath. Which breathing technique did the nurse observe the client perform? A. Huff coughing B. Pursed-lip breathing C. Controlled breathing D. Diaphragmatic breathing Answer: D Explanation: Diaphragmatic breathing involves abdominal movement to maximize diaphragmatic excursion. Why Other Options Are Wrong: A is incorrect because huffing is an expiratory maneuver. B is incorrect because pursed-lip breathing focuses on exhalation. C is too vague to describe the technique. 53. The nurse is caring for a patient who has just had a chest tube inserted. What should the nurse ensure is available at the bedside while this chest tube is in place? A. 2 padded clamps B. Suture removal set C. 1 L sterile normal saline D. Suction catheter and equipment Answer: A Explanation: Padded clamps are emergency equipment to occlude the tube if the system is disrupted. Why Other Options Are Wrong: B is incorrect because sutures secure the tube but are not removed bedside. C and D are unnecessary for routine chest tube care. Multiple Response Questions 54. The nurse is caring for an individual whose respiratory rate of 14 is even and easy; breath sounds are normal. Which terms should the nurse use in this patient's narrative note? (Select all that apply.) A. Apnea B. Eupnea C. Rhonchi D. Bradypnea E. Clear to auscultation F. Inspiratory crackles Answer: B, E Explanation: Eupnea describes normal respiratory rate/effort; "clear to auscultation" indicates normal breath sounds. Why Other Options Are Wrong: A is incorrect because apnea is absence of breathing. C and F are incorrect because rhonchi and crackles are abnormal sounds. D is incorrect because bradypnea is <12 breaths/min. 55. A licensed practical nurse (LPN) is helping prepare a patient for a thoracentesis. What should the nurse include in the teaching? (Select all that apply.) A. "You will need to be NPO for 6 hours." B. "You will need to sign a consent form for the procedure." C. "You will assume a sitting position at the side of the bed." D. "This is a sterile procedure, so the site will be covered in a drape." E. "You will need to take frequent deep breaths during the procedure." F. "The doctor will collect fluid from the space between your lung and your chest wall." Answer: B, C, D, F Explanation: Thoracentesis requires consent, sterile technique, sitting position, and involves pleural fluid removal. Why Other Options Are Wrong: A is incorrect because NPO status is unnecessary for local anesthesia. E is incorrect because patients hold still during needle insertion. 56. The LPN is providing care for an 88-year-old patient. Which age-related assessment findings should the nurse expect? (Select all that apply.) A. Peripheral cyanosis due to reduced gas exchange B. Weakened cough due to atrophied respiratory muscles C. Increased nasal discharge due to increased number of cilia D. Decreased gas exchange due to decreased number of alveoli E. Large peak expiratory flow rate due to increased lung elasticity F. Increased risk of respiratory infection due to decreased ciliary activity Answer: B, D, F Explanation: Aging reduces respiratory muscle strength, alveolar surface area, and ciliary function, increasing infection risk. Why Other Options Are Wrong: A is incorrect because cyanosis is pathological. C is incorrect because cilia decrease, not increase, with age. E is incorrect because lung elasticity decreases, reducing peak flow. 57. The nurse observes a patient use accessory muscles while walking for the first time after hip surgery. Which muscles are commonly used in respiration during exercise or strenuous activity? (Select all that apply.) A. Scalene B. Diaphragm C. Abdominal D. Vastus lateralis E. Intercostal muscles F. Sternocleidomastoid Answer: A, B, E, F Explanation: Accessory muscles (sternocleidomastoid, scalene) and primary muscles (diaphragm, intercostals) augment breathing during exertion. Why Other Options Are Wrong: C is incorrect because abdominal muscles aid forced expiration, not inspiration. D is incorrect because vastus lateralis is a leg muscle. 58. A patient is diagnosed with respiratory acidosis. Which health problems should the nurse consider as causing this patient's diagnosis? (Select all that apply.) A. Anxiety B. Kidney failure C. Hyperventilation D. Shallow respirations E. Chronic lung disease F. Uncontrolled diabetes Answer: D, E Explanation: Respiratory acidosis results from hypoventilation (shallow breathing) or chronic lung disease impairing CO2 elimination. Why Other Options Are Wrong: A and C cause respiratory alkalosis. B and F cause metabolic acidosis. 59. The nurse is participating in the planning of care for a patient with a newly placed tracheostomy. Which interventions should the nurse identify as a priority for this patient? (Select all that apply.) A. Restrict fluids. B. Turn and reposition every shift. C. Assess lung sounds every 4 hours. D. Suction using sterile technique as needed. E. Perform tracheostomy care according to policy. Answer: C, D, E Explanation: Tracheostomy care priorities include monitoring lung sounds, suctioning to maintain patency, and routine stoma care. Why Other Options Are Wrong: A is incorrect because hydration thins secretions. B is incorrect because repositioning should occur every 2 hours. 60. A client who is being mechanically ventilated is admitted to the care area. What should the nurse do to prevent this patient from developing ventilator-associated complications? (Select all that apply.) A. Suction the airway when needed. B. Ensure adequate nutritional intake. C. Adjust ventilator alarms to promote rest. D. Keep the head of the bed at a 45 degree angle. E. Provide oral care with 0.12% chlorhexidine solution. Answer: A, B, D, E Explanation: Ventilator-associated complications are reduced by secretion clearance, nutrition, head elevation, and oral hygiene. Why Other Options Are Wrong: C is incorrect because alarms should remain sensitive to detect patient distress. 61. The nurse is preparing to suction a patient's tracheostomy. Place in order the steps the nurse should take to complete this procedure. All options must be used. A. Connect oxygen source to manual resuscitation bag. B. Connect catheter to suction tubing, and turn on suction to level specified by institution policy. C. Pour saline into sterile container. D. Suction small amount of saline into catheter. E. Use thumb to stop suction, and insert catheter through tracheostomy tube until patient coughs or resistance is met. F. Oxygenate patient with three ventilations using a manual resuscitation bag connected to an oxygen source. Answer: B, A, C, D, F, E Explanation: The correct sequence ensures sterility and oxygenation: prepare suction system (B), oxygen source (A), saline (C), test suction (D), pre-oxygenate (F), then suction (E).