CHA EXAM 4 PRACTICE QUESTIONS & ANSWERS
A client with an upper respiratory infection asks the nurse why the health care provider
did not prescribe an antibiotic. What would be the best response from the nurse? -
Answers - "Upper respiratory infections generally are caused by viruses and therefore
should not be treated with antibiotics."
Generally, upper respiratory infections are viral; therefore, antibiotics should not be
used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics
are used to treat bacteria, not viruses.
The nurse auscultates fine crackles in a client who has arrived in the emergency
department with respiratory distress. When the nurse is providing information to the
client about crackles, which would be appropriate to include? - Answers - Crackles are
located in the smaller air passages
Which sounds are described as abnormal extra breath sounds to include crackles,
rhonchi, wheezes, and pleural friction rubs? - Answers - Adventitious
Adventitious sounds are described as abnormal extra breath sounds to include crackles,
rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-
pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and
resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium
pitch and intensity and heard over the main stem bronchi on either side of the sternum
and posteriorly between the scapulae.
The nurse performs a respiratory assessment and auscultates breath sounds that are
high pitched, creaking, and accentuated on expiration. Which term best describes the
findings? - Answers - Wheezes
Wheezes are one of the most common breath sounds assessed and auscultated in
clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are
produced as air flows through narrowed passageways. Rhonchi are coarse, rattling
sounds similar to snoring and are usually caused by secretions in the bronchial airways.
A pleural friction rub is an abrasive sound made by two acutely inflamed serous
surfaces rubbing together during respiratory cycle. Bronchovesicular sounds are
intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are
normal when heard between the first and second intercoastal spaces anteriorly and
posteriorly between scapulae.
A client who wakes up after a surgery spits out the oral airway placed during the
recovery from anesthesia. What does this behavior indicate to the nurse? - Answers -
The client's gag reflex has returned
The ability to spit out the oral airway indicates that the normal gag reflex has returned,
and the client can protest his or her airway. Confusion due to anesthesia may be
,manifested as disorientation. the ability to spit put the airway does not mean that the
client is nauseated. Oral airway is meant to keep the airway patent; it may not be
obstruct the airway,
A client is receiving oxygen therapy with a non-rebreather mask. What is an
appropriately flow rate for this oxygen device. - Answers - 10-15L/min
Fine crackles (Sometimes called rales) are the sounds of fluid bubbling within smaller
airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a
sound with a grating quality heard over the anterolateral area of the chest; it is
attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or
wheezes. Crackles are heard during inspiration.
Which pulmonary risk may be increased in a postoperative client due to anesthesia? -
Answers - Atelectasis
Postoperative clients are at risk for atelectasis, which involves the collapse of the
alveoli. this condition is caused by the effects of anesthesia. Rhonchi are continuous or
snoring sounds caused by the obstruction of the larger airways. fremitus is the vibration
of the chest wall during vocalization. Dyspnea is a shortness of breath; this condition is
an after effect of atelectasis.
A flow rate for a non-rebreather mask should be from 10-15L/min. A flow rate less than
this will not adequately inflate the bag.
In order to start employment, a nursing student is required to have a PPD test. During
the test reading an induration of 14mm is identified. What is the interpretation of this
result? - Answers - The student nurse has had an exposure to TB.
A positive PPD test has an induration of >10mm. This indicated the patient has had
exposure to TB and a chest x-ray is needed to detect TB. If the x-ray detects TB, a
sputum culture is needed to confirm the diagnosis.
A client scheduled for a permanent tracheostomy is receiving education on
tracheostomy care by the nurse. Which statement by the client requires further
education? - Answers - "If a fenestrated tube is placed, I will not be able to speak."
Fenestrated tubes, if capped, can allow patient to cough and speak as air moves
through fenestration and up through the natural airway. Providing inner cannula care will
help prevent secretion buildup and tube obstruction. Cuffs are inflated to create a seal
between the trachea and cuff, but does not protect against aspiration during feeding or
mouth care. Suctioning is a sterile technique to help prevent infection.
The nurse is preparing to suction a client with a tracheostomy in place. Which action by
the nurse should be completed first? - Answers - Assess the patient's respiratory status.
, A nurse is caring for a client that was recently exposed to a caustic chemical while at
work. The nurse is needing to frequently titrate the oxygen level to maintain SpO2
above 92%. What physiological process does the nurse suspect is occur? - Answers -
Refractory hypoxia from poor gas exchange at the alveoli
The client is experiencing acute respiratory distress syndrome (ARDS) ARDS is caused
by an injury to the lung tissue, which can be obstruction, chemical, infection, or
aspiration. The alveoli fill up with fluid and prevent appropriate O2/CO2 gas exchange.
This results in refractory hypoxia, or the persistent hypoxia despite increased oxygen
delivery.
A post-surgical client presents to the medical-surgical unit after a cholecystectomy.
What interventions should be included in the care plan to prevent an pulmonary
embolism in the post-surgical patient? Select all that apply. - Answers - Application of
SCDs as ordered
Cough and deep breathing exercises
Early and frequent ambulation
Deep vein thrombosis and pulmonary embolism prevention include: SCDs, TED hose,
early and frequent ambulation, ROM exercises, IS, cough and deep breathing
exercises, anticoagulation medication, IVC filters, embolectomy.
Bedrest is not recommended for post surgical patients. Rapid dorsiflexion of the foot
(Homans sign) is an older practice to diagnosis NOT prevent blood clots. The practice is
no longer recommended as it may cause a blood clot to break and cause a PE.
A 78 year old male patient with left sided congestive heart failure is undergoing a
thoracentesis. Which statement from the client reflects understanding of the procedure?
- Answers - " I will use a pillow and table to curve my back like an angry cat."
The ideal position for thoracentesis is for the patient to sit up at the edge of the bed
leaning forward to rest arms and face on a table such that the back is accessible for the
procedure However, this may not be possible in many patients in the ICU due to
mechanical ventilation or other reasons. Access from the infra-axillary area is another
approach, with the patient in a semireclined position with the arm to the side.
A elderly client presents to their PCP office with complaints of fever, cough, and green-
sputum production. Which assessment findings are consistent with the diagnosis of
pneumonia? Select all that apply. - Answers - WBC 13,500
Increase density on a CXR
Pleuritic pain with breathing
Signs and symptoms of pneumonia include: increased respiratory rate, pleuritic CP with
breathing, fever, crackles, cough with green/yellow sputum production, increased WBC.
A client with an upper respiratory infection asks the nurse why the health care provider
did not prescribe an antibiotic. What would be the best response from the nurse? -
Answers - "Upper respiratory infections generally are caused by viruses and therefore
should not be treated with antibiotics."
Generally, upper respiratory infections are viral; therefore, antibiotics should not be
used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics
are used to treat bacteria, not viruses.
The nurse auscultates fine crackles in a client who has arrived in the emergency
department with respiratory distress. When the nurse is providing information to the
client about crackles, which would be appropriate to include? - Answers - Crackles are
located in the smaller air passages
Which sounds are described as abnormal extra breath sounds to include crackles,
rhonchi, wheezes, and pleural friction rubs? - Answers - Adventitious
Adventitious sounds are described as abnormal extra breath sounds to include crackles,
rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-
pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and
resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium
pitch and intensity and heard over the main stem bronchi on either side of the sternum
and posteriorly between the scapulae.
The nurse performs a respiratory assessment and auscultates breath sounds that are
high pitched, creaking, and accentuated on expiration. Which term best describes the
findings? - Answers - Wheezes
Wheezes are one of the most common breath sounds assessed and auscultated in
clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are
produced as air flows through narrowed passageways. Rhonchi are coarse, rattling
sounds similar to snoring and are usually caused by secretions in the bronchial airways.
A pleural friction rub is an abrasive sound made by two acutely inflamed serous
surfaces rubbing together during respiratory cycle. Bronchovesicular sounds are
intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are
normal when heard between the first and second intercoastal spaces anteriorly and
posteriorly between scapulae.
A client who wakes up after a surgery spits out the oral airway placed during the
recovery from anesthesia. What does this behavior indicate to the nurse? - Answers -
The client's gag reflex has returned
The ability to spit out the oral airway indicates that the normal gag reflex has returned,
and the client can protest his or her airway. Confusion due to anesthesia may be
,manifested as disorientation. the ability to spit put the airway does not mean that the
client is nauseated. Oral airway is meant to keep the airway patent; it may not be
obstruct the airway,
A client is receiving oxygen therapy with a non-rebreather mask. What is an
appropriately flow rate for this oxygen device. - Answers - 10-15L/min
Fine crackles (Sometimes called rales) are the sounds of fluid bubbling within smaller
airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a
sound with a grating quality heard over the anterolateral area of the chest; it is
attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or
wheezes. Crackles are heard during inspiration.
Which pulmonary risk may be increased in a postoperative client due to anesthesia? -
Answers - Atelectasis
Postoperative clients are at risk for atelectasis, which involves the collapse of the
alveoli. this condition is caused by the effects of anesthesia. Rhonchi are continuous or
snoring sounds caused by the obstruction of the larger airways. fremitus is the vibration
of the chest wall during vocalization. Dyspnea is a shortness of breath; this condition is
an after effect of atelectasis.
A flow rate for a non-rebreather mask should be from 10-15L/min. A flow rate less than
this will not adequately inflate the bag.
In order to start employment, a nursing student is required to have a PPD test. During
the test reading an induration of 14mm is identified. What is the interpretation of this
result? - Answers - The student nurse has had an exposure to TB.
A positive PPD test has an induration of >10mm. This indicated the patient has had
exposure to TB and a chest x-ray is needed to detect TB. If the x-ray detects TB, a
sputum culture is needed to confirm the diagnosis.
A client scheduled for a permanent tracheostomy is receiving education on
tracheostomy care by the nurse. Which statement by the client requires further
education? - Answers - "If a fenestrated tube is placed, I will not be able to speak."
Fenestrated tubes, if capped, can allow patient to cough and speak as air moves
through fenestration and up through the natural airway. Providing inner cannula care will
help prevent secretion buildup and tube obstruction. Cuffs are inflated to create a seal
between the trachea and cuff, but does not protect against aspiration during feeding or
mouth care. Suctioning is a sterile technique to help prevent infection.
The nurse is preparing to suction a client with a tracheostomy in place. Which action by
the nurse should be completed first? - Answers - Assess the patient's respiratory status.
, A nurse is caring for a client that was recently exposed to a caustic chemical while at
work. The nurse is needing to frequently titrate the oxygen level to maintain SpO2
above 92%. What physiological process does the nurse suspect is occur? - Answers -
Refractory hypoxia from poor gas exchange at the alveoli
The client is experiencing acute respiratory distress syndrome (ARDS) ARDS is caused
by an injury to the lung tissue, which can be obstruction, chemical, infection, or
aspiration. The alveoli fill up with fluid and prevent appropriate O2/CO2 gas exchange.
This results in refractory hypoxia, or the persistent hypoxia despite increased oxygen
delivery.
A post-surgical client presents to the medical-surgical unit after a cholecystectomy.
What interventions should be included in the care plan to prevent an pulmonary
embolism in the post-surgical patient? Select all that apply. - Answers - Application of
SCDs as ordered
Cough and deep breathing exercises
Early and frequent ambulation
Deep vein thrombosis and pulmonary embolism prevention include: SCDs, TED hose,
early and frequent ambulation, ROM exercises, IS, cough and deep breathing
exercises, anticoagulation medication, IVC filters, embolectomy.
Bedrest is not recommended for post surgical patients. Rapid dorsiflexion of the foot
(Homans sign) is an older practice to diagnosis NOT prevent blood clots. The practice is
no longer recommended as it may cause a blood clot to break and cause a PE.
A 78 year old male patient with left sided congestive heart failure is undergoing a
thoracentesis. Which statement from the client reflects understanding of the procedure?
- Answers - " I will use a pillow and table to curve my back like an angry cat."
The ideal position for thoracentesis is for the patient to sit up at the edge of the bed
leaning forward to rest arms and face on a table such that the back is accessible for the
procedure However, this may not be possible in many patients in the ICU due to
mechanical ventilation or other reasons. Access from the infra-axillary area is another
approach, with the patient in a semireclined position with the arm to the side.
A elderly client presents to their PCP office with complaints of fever, cough, and green-
sputum production. Which assessment findings are consistent with the diagnosis of
pneumonia? Select all that apply. - Answers - WBC 13,500
Increase density on a CXR
Pleuritic pain with breathing
Signs and symptoms of pneumonia include: increased respiratory rate, pleuritic CP with
breathing, fever, crackles, cough with green/yellow sputum production, increased WBC.
