CHAPTER 30: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 30: Nursing Care of Patients With Upper Respiratory Tract Disorders 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 regulator of respiration because it directly affects blood pH. Even small changes in CO2 levels trigger chemoreceptors to adjust breathing rate. Why Other Options Are Wrong: A has minimal impact unless levels are critically low. B is inert and does not influence respiration. D affects oxygen transport but not respiratory drive. 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 (FRC) is the volume of air remaining in the lungs after passive exhalation, maintaining alveolar stability. Why Other Options Are Wrong: A is the volume inhaled/exhaled during normal breathing. B is the additional air expelled forcefully. C is the total air expelled after maximal inhalation. 3. The nurse is reviewing the exchange of gases in the bloodstream 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 CO2 (70%) is transported as bicarbonate (HCO3-) after reacting with water in RBCs, then diffusing into plasma. Why Other Options Are Wrong: A accounts for only 7-10% of CO2 transport. C and D misrepresent CO2 binding sites. 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 in RBCs (oxyhemoglobin), enabling efficient transport to tissues. Why Other Options Are Wrong: A and C are incorrect because oxygen is poorly soluble in plasma. B misidentifies hemoglobin's location. 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 propel mucus-trapped particles upward via coordinated beating. Why Other Options Are Wrong: B destroy pathogens in alveoli, not airways. C and D lack ciliary function. 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 after normal exhalation, ensuring maximal medication delivery. Why Other Options Are Wrong: A is normal breath volume. C measures total exhaled air after deep inhalation. D assesses airflow speed. 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., edema, collapse) reduces oxygenation. Why Other Options Are Wrong: A, C, and D are conduits for air but do not perform gas exchange. 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 respiratory drive. Why Other Options Are Wrong: B governs voluntary movement/sensation. C coordinates movement. D 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 dyspnea severity objectively, guiding intervention prioritization. Why Other Options Are Wrong: A, B, and D provide subjective or indirect data but lack standardized measurement. 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 accessory muscle (sternocleidomastoid/scalene) recruitment due to increased work of breathing. Why Other Options Are Wrong: A may occur but does not cause shoulder rise. C and D are unrelated to accessory muscle use. 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. Why Other Options Are Wrong: B, C, and D are relevant but secondary to immediate respiratory assessment. 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 versus normal variants. Why Other Options Are Wrong: A, B, and C are appropriate after confirming asymmetry. 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 enhances airflow and sound transmission during auscultation. Why Other Options Are Wrong: A is unnecessary unless equipment is faulty. B and C do not improve sound 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 hyperpnea/apnea, often due to heart failure or neurological injury. Why Other Options Are Wrong: A is rapid breathing without apnea. B is deep, labored breathing. D is sustained hyperpnea. 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, indicating respiratory distress. Why Other Options Are Wrong: A is absence of breathing. B is <12 breaths/min. D is incorrect for this elevated rate. 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 high-pitched whistling. B is softer sounds from alveolar fluid. D is a grating sound. 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 lower-pitched and from narrowed lower airways. C and D are unrelated to obstruction. 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 results from bronchoconstriction and narrowed airways, hallmark features of asthma. Why Other Options Are Wrong: A suggests fluid. C indicates pleural inflammation. D occurs 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 mobilize secretions. Why Other Options Are Wrong: A is for bronchospasm, not secretion clearance. B and D are invasive if coughing fails. 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 bleeds more than veins. Why Other Options Are Wrong: A may alter future ABG results. C is for venous draws. D is unnecessary unless results are critical. 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: A PaCO2 of 68 mm Hg (normal: 35-45) indicates severe hypercapnia requiring urgent intervention. Why Other Options Are Wrong: B and C worsen hypoventilation. D does not address CO2 retention. 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 from hypoventilation and CO2 retention. Why Other Options Are Wrong: A involves low HCO3-. B and D show alkalosis (high pH) with opposite CO2/HCO3 changes. 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 percent of hemoglobin binding sites occupied by oxygen, reflecting oxygenation status. Why Other Options Are Wrong: A misinterprets SpO2. B describes PaO2. C is nonsensical (lymphocytes don't 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: Positioning upright (Fowler's) improves lung expansion and oxygenation before escalating interventions. Why Other Options Are Wrong: B may be needed if positioning fails. C worsens ventilation. D is incorrect (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: Immobilization prevents bleeding at the arterial puncture site used for angiography. Why Other Options Are Wrong: B is unnecessary. C and D are irrelevant (angiography doesn't affect cough/gag reflexes). 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; return ensures safe swallowing post-procedure. Why Other Options Are Wrong: A and B risk aspiration if gag reflex is absent. D tests a different reflex. 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 lips prolongs exhalation, reduces air trapping, and improves gas exchange. Why Other Options Are Wrong: A and B increase work of breathing. C is ineffective for dyspnea relief. 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/semi-Fowler's positioning reduces abdominal pressure on the diaphragm, enhancing lung expansion. Why Other Options Are Wrong: A is incorrect (positioning doesn't dilate airways). C and D are secondary benefits. 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 perfusion to the healthy lung, optimizing oxygenation. Why Other Options Are Wrong: A and B don't prioritize the healthy lung. C would compress the functional 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 non-rebreathing mask requires closed side vents and an inflated reservoir bag to deliver high FiO2 (60-100%). Why Other Options Are Wrong: A and B allow air dilution. D 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 ensures competency in performing the procedure independently. Why Other Options Are Wrong: A, C, and D assess knowledge but not practical ability. 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 (nocturnal symptoms may require treatment). B and D exceed safe dosing. 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, addressing pain-related hypoventilation. Why Other Options Are Wrong: B assesses airflow, not lung expansion. C and D are for bronchospasm, not pain. 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 before considering suctioning or medications. Why Other Options Are Wrong: A is unnecessary if coughing is effective. B is for patients unable to cough. C is counterproductive. 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: Relief of dyspnea confirms successful fluid removal and lung re-expansion, the primary goal. Why Other Options Are Wrong: A and D are procedural standards. B is a diagnostic, not therapeutic, outcome. 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: Placing the system below chest level ensures gravity drainage and prevents fluid backflow into the pleural space. Why Other Options Are Wrong: B, C, and D risk reflux or impaired 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: Continuous bubbling in the water seal chamber indicates an air leak requiring immediate investigation. Why Other Options Are Wrong: A addresses suction chamber bubbling. B is unrelated. C is incorrect (expected bubbling is intermittent). 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 (rise/fall with respiration) confirms system patency and is normal in pneumothorax treatment. Why Other Options Are Wrong: A and C are for abnormal findings (e.g., continuous bubbling). B is unnecessary. 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 suggest secretions in the trachea; suctioning is the priority to maintain airway patency. Why Other Options Are Wrong: B is routine maintenance. C is for bronchospasm. D is ineffective if secretions are thick. 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 due to oxygen interruption. Why Other Options Are Wrong: A is too brief for effective clearance. C and D exceed safe limits. 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 ethical/legal compliance before performing life-saving interventions. Why Other Options Are Wrong: A is inappropriate for confused patients. C and D follow after confirming consent. 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 airway obstruction, often from secretions requiring suctioning. Why Other Options Are Wrong: B and C trigger low-pressure/power failure alarms. A doesn't directly cause 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 prevents alveolar collapse at end-exhalation, improving oxygenation in conditions like ARDS. Why Other Options Are Wrong: A describes assist-control mode. C describes controlled ventilation. D misrepresents PEEP's action. 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: Assessing the patient ensures safety before troubleshooting equipment (e.g., disconnection, hypoxia). Why Other Options Are Wrong: A, C, and D follow after confirming the patient's status. 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 pressure injuries and irritation from mask straps, enhancing tolerance. Why Other Options Are Wrong: A is unnecessary unless pain exists. B disrupts therapy. C applies to endotracheal 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 to visualize airways, often with sedation. Why Other Options Are Wrong: A describes spirometry. B describes barium studies. C describes angiography. 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: Gag reflex assessment ensures safe oral intake post-procedure due to topical anesthetic effects. Why Other Options Are Wrong: A and D follow reflex confirmation. C is for general anesthesia, not moderate sedation. 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 (e.g., Acapella) mobilize secretions via vibrations and positive pressure during exhalation. Why Other Options Are Wrong: A monitors CO2. B treats pneumothorax. C delivers oxygen, not secretion 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 5-7 mL/kg (∼400-600 mL for adults), representing air moved during quiet breathing. Why Other Options Are Wrong: A is too low (approaches dead space volume). C and D approach vital capacity. 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 chest anatomy has a 2:1 width-to-depth ratio; barrel chest (1:1) suggests chronic hyperinflation. Why Other Options Are Wrong: A and B describe abnormal configurations. D is irrelevant without context. 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 shearing forces to dislodge secretions from small airways. Why Other Options Are Wrong: A, B, and C are secondary effects but not the primary purpose of huff coughing. 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 expansion to maximize diaphragmatic excursion and ventilation. Why Other Options Are Wrong: A is a forced exhalation technique. B focuses on prolonged exhalation. C is a general term. 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, preventing pneumothorax. Why Other Options Are Wrong: B, C, and D are unnecessary for routine chest tube management. 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" documents normal breath sounds. Why Other Options Are Wrong: A is absence of breathing. C and F are abnormal sounds. D is slow breathing. 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 pleural fluid removal. NPO status and deep breathing are unnecessary. Why Other Options Are Wrong: A is not required (only local anesthesia used). E is incorrect (patient holds breath 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 not age-specific. C is incorrect (cilia decrease with age). E is false (PEFR declines). 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 (scalene, SCM) and primary muscles (diaphragm, intercostals) augment ventilation during exertion. Why Other Options Are Wrong: C are expiratory muscles. D is a leg muscle unrelated to respiration. 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: Hypoventilation (shallow breathing) and chronic lung disease (e.g., COPD) cause CO2 retention and respiratory acidosis. 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 priorities include monitoring lung sounds, maintaining airway patency (suctioning), and stoma care to prevent infection. Why Other Options Are Wrong: A is contraindicated (fluids thin secretions). B 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: These measures prevent VAP (suctioning, HOB elevation, oral care) and support recovery (nutrition). Alarms should remain audible. Why Other Options Are Wrong: C increases risk of undetected complications.