Saunders NCLEX Respiratory Latest
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,A registered nurse who is orienting a new nursing graduate to the hospital emergency department
instructs the new graduate to monitor a client for one-sided chest movement on the right side while the
client is being intubated by the primary health care provider (PHCP). Which statement made by the new
nursing graduate indicates understanding of the importance of this observation?
1"It will enter the left main bronchus if inserted too far."
2"It will enter the right main bronchus if inserted too far."
3"It may enter the left main bronchus if not inserted far enough."
4"It may enter the right main bronchus if not inserted far enough." - correct ans:A: "It will enter the right
main bronchus if inserted too far."
Rationale:If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the
right main bronchus. This occurs because the right bronchus is shorter and wider than the left and
extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at
all will occur. The other options are incorrect.
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the
nurse how to manage the amount of oxygen given. How would the nurse instruct the client?
1Do not exceed 1 L/min.
2Do not exceed 2 L/min.
3Adjust the oxygen depending on SpO2.
4Adjust the oxygen depending on respiratory rate. - correct ans:A: Adjust the oxygen depending on
SpO2.
Rationale: The client with COPD is often dependent on oxygen. The oxygen would be adjusted
depending on the SpO2, which needs to be 88% to 92%. All other options are incorrect.
The nurse who is participating in a client care conference with other members of the health care team is
discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health
care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What
does the nurse anticipate as a physiological consequence?
, 1Atelectasis and viral infection
2Bronchoconstriction and stridor
3Collapse of alveoli and decreased compliance
4Decreased ciliary action and retained secretions - correct ans:A: Collapse of alveoli and decreased
compliance
Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs.
This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli
collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased
surfactant production are ARDS and atelectasis. The remaining options are incorrect.
The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are
being perfused but are not being ventilated. How does the nurse correctly interpret this
documentation?
1A shunt unit exists.
2Anatomical dead space is present.
3Physiological dead space is present.
4Ventilation-perfusion matching is occurring. - correct ans:A: A shunt unit exists.
Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists.
As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead
space normally is present in the conducting airways, where pulmonary capillaries are absent.
Physiological dead space occurs with conditions such as emphysema and pulmonary embolism.
Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary
capillaries and air exchange in the alveolar units of the lungs.
A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the
best nursing action?
1Ask a family member to stay with the client at all times.
2Encourage the client to sleep until arterial blood gas results improve.
3Ask the primary health care provider for a prescription for succinylcholine.
Verified Version And Frequently tested
Exam With Expected real Questions
With Well Elaborated Correct Answers
GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
,A registered nurse who is orienting a new nursing graduate to the hospital emergency department
instructs the new graduate to monitor a client for one-sided chest movement on the right side while the
client is being intubated by the primary health care provider (PHCP). Which statement made by the new
nursing graduate indicates understanding of the importance of this observation?
1"It will enter the left main bronchus if inserted too far."
2"It will enter the right main bronchus if inserted too far."
3"It may enter the left main bronchus if not inserted far enough."
4"It may enter the right main bronchus if not inserted far enough." - correct ans:A: "It will enter the right
main bronchus if inserted too far."
Rationale:If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the
right main bronchus. This occurs because the right bronchus is shorter and wider than the left and
extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at
all will occur. The other options are incorrect.
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the
nurse how to manage the amount of oxygen given. How would the nurse instruct the client?
1Do not exceed 1 L/min.
2Do not exceed 2 L/min.
3Adjust the oxygen depending on SpO2.
4Adjust the oxygen depending on respiratory rate. - correct ans:A: Adjust the oxygen depending on
SpO2.
Rationale: The client with COPD is often dependent on oxygen. The oxygen would be adjusted
depending on the SpO2, which needs to be 88% to 92%. All other options are incorrect.
The nurse who is participating in a client care conference with other members of the health care team is
discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health
care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What
does the nurse anticipate as a physiological consequence?
, 1Atelectasis and viral infection
2Bronchoconstriction and stridor
3Collapse of alveoli and decreased compliance
4Decreased ciliary action and retained secretions - correct ans:A: Collapse of alveoli and decreased
compliance
Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs.
This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli
collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased
surfactant production are ARDS and atelectasis. The remaining options are incorrect.
The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are
being perfused but are not being ventilated. How does the nurse correctly interpret this
documentation?
1A shunt unit exists.
2Anatomical dead space is present.
3Physiological dead space is present.
4Ventilation-perfusion matching is occurring. - correct ans:A: A shunt unit exists.
Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists.
As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead
space normally is present in the conducting airways, where pulmonary capillaries are absent.
Physiological dead space occurs with conditions such as emphysema and pulmonary embolism.
Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary
capillaries and air exchange in the alveolar units of the lungs.
A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the
best nursing action?
1Ask a family member to stay with the client at all times.
2Encourage the client to sleep until arterial blood gas results improve.
3Ask the primary health care provider for a prescription for succinylcholine.
