Respiratory Exam Review - GNRS 555
A 66yr old male is found to have hospital acquired pneumonia, which of the following
statements made by the nurse indicates the correct understanding of HAP?
1. Occurring after inter-tracheal intubation
2. Occurring 48hrs or longer after admission
3. Onset before hospitalization
4. Occurring from normal entry of secretions into the lower airway - ANS 2. Occurring
48hrs or longer after admission
There is a 48hr window following a patients admission to determine whether a patient
came into the hospital with a condition or infection. After this period, it is determined that
it was acquired while the patient was in the hospital setting.
\A black client with asthma seeks emergency care for acute respiratory distress. Because
of the client's dark skin, the nurse assesses cyanosis by assessing the:
1. Lips
2. Earlobes
3. Mucous membranes
4. Nail beds - ANS 3. Mucous membranes
Lips, nail beds, and earlobes are less reliable indicators of cyanosis because they are all
affected by skin color, whereas mucous membranes are not.
\A male patient is admitted to a healthcare facility for COPD, which nursing diagnosis is
most appropriate for the patient?
1. Risk for infection related to retained secretions
2. Impaired gas exchange related to airway obstruction
3. Activity and tolerance related to fatigue
4. Anxiety related to acute threat to health status - ANS 2. Impaired gas change related to
airways obstructruction
\A nurse instructs a patient to use the pursed lip method of breathing, and the patient
asks the nurse the purpose of that breathing. The nurse response, knowing that the
primary purpose is to promote which outcome?
1. Strengthen your diaphragm
2. Promote CO2 elimination
3. Strengthen your intercostal muscles
4. Promote O2 intake - ANS 2. Promote CO2 elimination
, There is an excessive amount of CO2 in the lungs, that needs to be released through
methods like pursed-lip breathing. This method does not promote O2 intake.
\A nursing student tests positive for TB. A chest X-ray reveals no active TB, INH is
prescribed for prophylactic measurements. Which statement by the student nurse
indicates that further teaching is required?
1. I need INH to keep the TB inactive
2. I have to wear an N-95 respirator mask when I take care of immunocompromised
patients
3. I understand that I have been exposed with TB, but it is not active now
4. I plan to take Vitamin B6, while taking INH - ANS 2. I have to wear an N-95 respirator
mask when I take care of immunocompromised patients
The student does not have active TB, therefore she does not need to take airborne
precautions.
\A patient who is taking Rifampin, calls the clinic and reports having orange colored
urine and tears, which is the best response by the nurse?
1. Ask if the patient is experiencing shortness of breath, hives or itching
2. Explain that the orange discolored urine and tears are normal when taking this
medication
3. Ask the patient about any visual abnormalities, such as red-green color
4. Advise the patient to stop the drug and report any symptoms to the healthcare
provider - ANS 2. Explain that the orange discolored urine and tears are normal when
taking this medication
The nurse should explain that these are normal side effects os the medication Rifampin.
This would be the FIRST issue addressed.
\A patient with acute dyspnea is scheduled for a CT scan. Which information obtained by
the nurse is important to tell the healthcare provider before they have a CT?
1. The RR is 22
2. O2 saturation is 93%
3. Apical pulse is 102
4. The patient is allergic to shellfish - ANS 4. The patient is allergic to shellfish
An allergy to shellfish usually means the patient will also be allergic to iodine. The
healthcare provider must be made aware before they expose the patient to the iodine
solution.
\A patient with COPD has a nursing diagnosis of impaired breathing pattern. Which
nursing action would be most important o include in your plan of care?
1. Keep the patient NPO
2. Teach the patient how to effectively use pursed lip breathing
A 66yr old male is found to have hospital acquired pneumonia, which of the following
statements made by the nurse indicates the correct understanding of HAP?
1. Occurring after inter-tracheal intubation
2. Occurring 48hrs or longer after admission
3. Onset before hospitalization
4. Occurring from normal entry of secretions into the lower airway - ANS 2. Occurring
48hrs or longer after admission
There is a 48hr window following a patients admission to determine whether a patient
came into the hospital with a condition or infection. After this period, it is determined that
it was acquired while the patient was in the hospital setting.
\A black client with asthma seeks emergency care for acute respiratory distress. Because
of the client's dark skin, the nurse assesses cyanosis by assessing the:
1. Lips
2. Earlobes
3. Mucous membranes
4. Nail beds - ANS 3. Mucous membranes
Lips, nail beds, and earlobes are less reliable indicators of cyanosis because they are all
affected by skin color, whereas mucous membranes are not.
\A male patient is admitted to a healthcare facility for COPD, which nursing diagnosis is
most appropriate for the patient?
1. Risk for infection related to retained secretions
2. Impaired gas exchange related to airway obstruction
3. Activity and tolerance related to fatigue
4. Anxiety related to acute threat to health status - ANS 2. Impaired gas change related to
airways obstructruction
\A nurse instructs a patient to use the pursed lip method of breathing, and the patient
asks the nurse the purpose of that breathing. The nurse response, knowing that the
primary purpose is to promote which outcome?
1. Strengthen your diaphragm
2. Promote CO2 elimination
3. Strengthen your intercostal muscles
4. Promote O2 intake - ANS 2. Promote CO2 elimination
, There is an excessive amount of CO2 in the lungs, that needs to be released through
methods like pursed-lip breathing. This method does not promote O2 intake.
\A nursing student tests positive for TB. A chest X-ray reveals no active TB, INH is
prescribed for prophylactic measurements. Which statement by the student nurse
indicates that further teaching is required?
1. I need INH to keep the TB inactive
2. I have to wear an N-95 respirator mask when I take care of immunocompromised
patients
3. I understand that I have been exposed with TB, but it is not active now
4. I plan to take Vitamin B6, while taking INH - ANS 2. I have to wear an N-95 respirator
mask when I take care of immunocompromised patients
The student does not have active TB, therefore she does not need to take airborne
precautions.
\A patient who is taking Rifampin, calls the clinic and reports having orange colored
urine and tears, which is the best response by the nurse?
1. Ask if the patient is experiencing shortness of breath, hives or itching
2. Explain that the orange discolored urine and tears are normal when taking this
medication
3. Ask the patient about any visual abnormalities, such as red-green color
4. Advise the patient to stop the drug and report any symptoms to the healthcare
provider - ANS 2. Explain that the orange discolored urine and tears are normal when
taking this medication
The nurse should explain that these are normal side effects os the medication Rifampin.
This would be the FIRST issue addressed.
\A patient with acute dyspnea is scheduled for a CT scan. Which information obtained by
the nurse is important to tell the healthcare provider before they have a CT?
1. The RR is 22
2. O2 saturation is 93%
3. Apical pulse is 102
4. The patient is allergic to shellfish - ANS 4. The patient is allergic to shellfish
An allergy to shellfish usually means the patient will also be allergic to iodine. The
healthcare provider must be made aware before they expose the patient to the iodine
solution.
\A patient with COPD has a nursing diagnosis of impaired breathing pattern. Which
nursing action would be most important o include in your plan of care?
1. Keep the patient NPO
2. Teach the patient how to effectively use pursed lip breathing
