Detailed Answer Key Medsurge Respiratory g g g g
Latest 2025
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1.A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following
g g g g g g g g g g g g g g g g g g g g
room assignments should the nurse make for the client?
g g g g g g g g g
A. A room with air exhaust directly to the outdoor environment
g g g g g g g g g
Rationale:A room with air exhaust directly to the outside environment eliminates contamination of other
g g g g g g g g g g g g g
client-care areas. This type of ventilation system is referred to as an airborne infection
g g g g g g g g g g g g g g
isolation room. g g
B. A room with another nonsurgical client
g g g g g
Rationale:A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A
g g g g g g g g g g g g g
client who has tuberculosis should have a private room.
g g g g g g g g g
C. A room in the ICU
g g g g
Rationale:A client who has active tuberculosis and no other comorbidities is not critically ill.
g g g g g g g g g g g g g
D. A room that is within view of the nurses' station
g g g g g g g g g
Rationale:The client's room should be well ventilated and private, but it is not necessary for it to be close
g g g g g g g g g g g g g g g g g g
to the nurses' station. g g g g
2.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle
g g g g g g g g g g g g g g g g g g
crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing
g g g g g g g g g g g g g g g g g g g g
them in the selected order of performance. Use all the steps.) C. Open the airway using a jaw-thrust maneuver.
g g g g g g g g g g g g g g g g g g g
D. Determine effectiveness of ventilator efforts.
g g g g g
B. Establish IV access.
g g g
A. Perform a Glasgow Coma Scale assessment.
g g g g g g
E. Remove clothing for a thorough assessment.
g g g g g g
3.A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to
g g g g g g g g g g g g g g g g g g g
assess in this client? (Select all that apply.)
g g g g g g g g
A. Dyspnea
B. Bradycardia
, C. Barrel chest g
D. Clubbing of the fingers g g g
E. Deep respirations
g
Rationale:
Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which
g g g g g g g g g g g g g g
they become weakened and collapse. Dyspnea is seen in clients with emphysema as the
g g g g g g g g g g g g g g
lungs try to increase the amount of oxygen available to the tissues.</br></br>Bradycardia is
g g g g g g g g g g g g g
incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for
g g g g g g g g g g g g g g g
less oxygen to the tissues. </br></br>Barrel chest is correct. Clients with emphysema lose
g g g g g g g g g g g g g
lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs;
g g g g g g g g g g g g
the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel
g g g g g g g g g g g g g g g g g
chest typical of emphysema clients.</br></br>Clubbing of the fingers is correct. Clubbing
g g g g g g g g g g g
results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails
g g g g g g g g g g g g g g g
become extremely curved from front to back.</br></br>Deep respirations is incorrect. Clients
g g g g g g g g g g g
with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations
g g g g g g g g g g g
become increasingly shallow.
g g g
4.A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible.
g g g g g g g g g g g g g g g g g g g
gThe client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the
g g g g g g g g g g g g g g g g g
gpriority for the nurse to take?
g g g g g
A. Prevent aspiration. g
Rationale:When using the airway, breathing, circulation approach to client care, the nurse should
g g g g g g g g g g g g
determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired
g g g g g g g g g g g g g g g g g g
together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and
g g g g g g g g g g g g g g g g g
wire cutters should be kept at the bedside in case of vomiting. B. Ensure adequate nutrition.
g g g g g g g g g g g g g g g g
Rationale:The client should be NPO initially after surgery until the gag reflex has returned. Once the
g g g g g g g g g g g g g g g
client is able to eat, the client may advance to a calorie-appropriate, high-protein liquid diet.
g g g g g g g g g g g g g g g
However, this is not the priority at this time.
g g g g g g g g g
C. Promote oral hygiene
g g g
Rationale:The client will have an incision inside the mouth. While it is important that the client receive
g g g g g g g g g g g g g g g g
frequent mouth cleaning, this is not the priority at this time. D. Relieve the client's pain.
g g g g g g g g g g g g g g g g
Rationale:While the client may be in pain and will need to be medicated, this is not the priority at this time.
g g g g g g g g g g g g g g g g g g g g
5.A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
g g g g g g g g g g g g g g g g g g g
gmanifestations should the nurse monitor? g g g g
A. Confusion
Rationale:Myasthenia gravis does not affect cognition, level of consciousness, or orientation. g g g g g g g g g g
, B. Weakness
Rationale:Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory g g g g g g g g g g
distress or predispose the client to respiratory infections.
g g g g g g g g
C. Increased intracranial pressure g g
Rationale:
Myasthenia gravis does not affect pressure within the brain.
g g g g g g g g
D. Increased urinary output g g
Rationale:Myasthenia gravis does not cause increased urine output. g g g g g g g
6.A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The
g g g g g g g g g g g g g g g g g g g g
nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia.
g g g g g g g g g g g g g g g
Rationale:Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It occurs as the
g g g g g g g g g g g g g g g
tumor grows in size and impedes the esophagus.
g g g g g g g g g B. hoarseness. g
Rationale:Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to
g g g g g g g g g g g g g g g
tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of
g g g g g g g g g g g g g g g g
cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may
g g g g g g g g g g g g g g g g g g g
sound harsh and lower in pitch than normal. C. dyspnea.
g g g g g g g g g g
Rationale:Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the
g g g g g g g g g g g g g g
tumor grows in size and impedes the airway opening. D. weight loss.
g g g g g g g g g g g g
Rationale:Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
g g g g g g g g g g g g
7.A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of
g g g g g g g g g g g g g g g g g g
the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks
g g g g g g g g g g g g g g g g g g g
as the priority for assessment and intervention?
g g g g g g g
A. Airway obstruction g
Rationale:When using the airway, breathing, circulation approach to client care, the nurse determines
g g g g g g g g g g g g
that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve
g g g g g g g g g g g g g g g g
damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can
g g g g g g g g g g g g g g g g g
result in severe g g g
respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this
g g g g g g g g g g g g g
client's care. g g
B. Infection
Rationale:Prevention of infection is essential throughout hospitalization and treatment; however, another
g g g g g g g g g g
risk is the priority. g g g g
, C. Fluid imbalance g
Rationale:Adequate fluid replacement is essential throughout the acute phase of burn treatment; however,
g g g g g g g g g g g g
another risk is the priority. g g g g g
D. Paralytic ileus g
Rationale:Paralytic ileus can develop during the acute phase of burn care and might require nasogastric
g g g g g g g g g g g g g g
decompression; however, another risk is the priority.
g g g g g g g
8.A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse,
g g g g g g g g g g g g g g g g g g
"I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which
g g g g g g g g g g g g g g g g g g g g g g g
of the following actions should the nurse take to help this client with tenacious bronchial secretions?
g g g g g g g g g g g g g g g g
A. Maintaining a semi-Fowler's position as often as possible
g g g g g g g
Rationale:Although a semi-Fowler's position can help the client breathe more easily, it will not alter the
g g g g g g g g g g g g g g g
consistency of secretions. g g g
B. Administering oxygen via nasal cannula at 2 L/min g g g g g g g
Rationale:Administration of oxygen helps correct hypoxemia, but it will not alter the consistency of g g g g g g g g g g g g g
secretions. g
C. Helping the client select a low-salt diet
g g g g g g
Rationale:Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of
g g g g g g g g g g g g g g g
secretions. g
D. Encouraging the client to drink 2 to 3 L of water daily g g g g g g g g g g g
Rationale:COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema.
g g g g g g g g g g g g g g
Maintaining hydration through the consumption of adequate fluids will help liquefy thick g g g g g g g g g g g
secretions and facilitate their expectoration.
g g g g g
9.A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes
g g g g g g g g g g g g g g g g g g g g
slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A.
g g g g g g g g g g g g g g g g g g
Check the tubing connections for leaks.
g g g g g g
Rationale:This action is used to determine why a water seal chamber has continuous bubbling, not slow,
g g g g g g g g g g g g g g g
steady bubbling. g g
B. Check the suction control outlet on the wall.
g g g g g g g
Rationale:This action is used to determine why a suction control chamber that is hooked to wall suction
g g g g g g g g g g g g g g g g
g has little or no bubbling. C. Clamp the chest tube.
g g g g g g g g g
Rationale:The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage
g g g g g g g g g g g g g g g g g
system. This is not an appropriate action for the nurse to take at this time.
g g g g g g g g g g g g g g g g D. Continue to monitor the client's
g g g g g
respiratory status.
g g
Latest 2025
g g
1.A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following
g g g g g g g g g g g g g g g g g g g g
room assignments should the nurse make for the client?
g g g g g g g g g
A. A room with air exhaust directly to the outdoor environment
g g g g g g g g g
Rationale:A room with air exhaust directly to the outside environment eliminates contamination of other
g g g g g g g g g g g g g
client-care areas. This type of ventilation system is referred to as an airborne infection
g g g g g g g g g g g g g g
isolation room. g g
B. A room with another nonsurgical client
g g g g g
Rationale:A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A
g g g g g g g g g g g g g
client who has tuberculosis should have a private room.
g g g g g g g g g
C. A room in the ICU
g g g g
Rationale:A client who has active tuberculosis and no other comorbidities is not critically ill.
g g g g g g g g g g g g g
D. A room that is within view of the nurses' station
g g g g g g g g g
Rationale:The client's room should be well ventilated and private, but it is not necessary for it to be close
g g g g g g g g g g g g g g g g g g
to the nurses' station. g g g g
2.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle
g g g g g g g g g g g g g g g g g g
crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing
g g g g g g g g g g g g g g g g g g g g
them in the selected order of performance. Use all the steps.) C. Open the airway using a jaw-thrust maneuver.
g g g g g g g g g g g g g g g g g g g
D. Determine effectiveness of ventilator efforts.
g g g g g
B. Establish IV access.
g g g
A. Perform a Glasgow Coma Scale assessment.
g g g g g g
E. Remove clothing for a thorough assessment.
g g g g g g
3.A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to
g g g g g g g g g g g g g g g g g g g
assess in this client? (Select all that apply.)
g g g g g g g g
A. Dyspnea
B. Bradycardia
, C. Barrel chest g
D. Clubbing of the fingers g g g
E. Deep respirations
g
Rationale:
Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which
g g g g g g g g g g g g g g
they become weakened and collapse. Dyspnea is seen in clients with emphysema as the
g g g g g g g g g g g g g g
lungs try to increase the amount of oxygen available to the tissues.</br></br>Bradycardia is
g g g g g g g g g g g g g
incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for
g g g g g g g g g g g g g g g
less oxygen to the tissues. </br></br>Barrel chest is correct. Clients with emphysema lose
g g g g g g g g g g g g g
lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs;
g g g g g g g g g g g g
the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel
g g g g g g g g g g g g g g g g g
chest typical of emphysema clients.</br></br>Clubbing of the fingers is correct. Clubbing
g g g g g g g g g g g
results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails
g g g g g g g g g g g g g g g
become extremely curved from front to back.</br></br>Deep respirations is incorrect. Clients
g g g g g g g g g g g
with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations
g g g g g g g g g g g
become increasingly shallow.
g g g
4.A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible.
g g g g g g g g g g g g g g g g g g g
gThe client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the
g g g g g g g g g g g g g g g g g
gpriority for the nurse to take?
g g g g g
A. Prevent aspiration. g
Rationale:When using the airway, breathing, circulation approach to client care, the nurse should
g g g g g g g g g g g g
determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired
g g g g g g g g g g g g g g g g g g
together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and
g g g g g g g g g g g g g g g g g
wire cutters should be kept at the bedside in case of vomiting. B. Ensure adequate nutrition.
g g g g g g g g g g g g g g g g
Rationale:The client should be NPO initially after surgery until the gag reflex has returned. Once the
g g g g g g g g g g g g g g g
client is able to eat, the client may advance to a calorie-appropriate, high-protein liquid diet.
g g g g g g g g g g g g g g g
However, this is not the priority at this time.
g g g g g g g g g
C. Promote oral hygiene
g g g
Rationale:The client will have an incision inside the mouth. While it is important that the client receive
g g g g g g g g g g g g g g g g
frequent mouth cleaning, this is not the priority at this time. D. Relieve the client's pain.
g g g g g g g g g g g g g g g g
Rationale:While the client may be in pain and will need to be medicated, this is not the priority at this time.
g g g g g g g g g g g g g g g g g g g g
5.A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following
g g g g g g g g g g g g g g g g g g g
gmanifestations should the nurse monitor? g g g g
A. Confusion
Rationale:Myasthenia gravis does not affect cognition, level of consciousness, or orientation. g g g g g g g g g g
, B. Weakness
Rationale:Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory g g g g g g g g g g
distress or predispose the client to respiratory infections.
g g g g g g g g
C. Increased intracranial pressure g g
Rationale:
Myasthenia gravis does not affect pressure within the brain.
g g g g g g g g
D. Increased urinary output g g
Rationale:Myasthenia gravis does not cause increased urine output. g g g g g g g
6.A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The
g g g g g g g g g g g g g g g g g g g g
nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia.
g g g g g g g g g g g g g g g
Rationale:Dysphagia, difficulty swallowing, is a later manifestation of cancer of the larynx. It occurs as the
g g g g g g g g g g g g g g g
tumor grows in size and impedes the esophagus.
g g g g g g g g g B. hoarseness. g
Rationale:Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to
g g g g g g g g g g g g g g g
tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of
g g g g g g g g g g g g g g g g
cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may
g g g g g g g g g g g g g g g g g g g
sound harsh and lower in pitch than normal. C. dyspnea.
g g g g g g g g g g
Rationale:Dyspnea, shortness of breath, is a later manifestation of laryngeal cancer. It occurs as the
g g g g g g g g g g g g g g
tumor grows in size and impedes the airway opening. D. weight loss.
g g g g g g g g g g g g
Rationale:Weight loss is a later manifestation of laryngeal cancer, usually indicative of metastasis.
g g g g g g g g g g g g
7.A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of
g g g g g g g g g g g g g g g g g g
the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks
g g g g g g g g g g g g g g g g g g g
as the priority for assessment and intervention?
g g g g g g g
A. Airway obstruction g
Rationale:When using the airway, breathing, circulation approach to client care, the nurse determines
g g g g g g g g g g g g
that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve
g g g g g g g g g g g g g g g g
damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can
g g g g g g g g g g g g g g g g g
result in severe g g g
respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this
g g g g g g g g g g g g g
client's care. g g
B. Infection
Rationale:Prevention of infection is essential throughout hospitalization and treatment; however, another
g g g g g g g g g g
risk is the priority. g g g g
, C. Fluid imbalance g
Rationale:Adequate fluid replacement is essential throughout the acute phase of burn treatment; however,
g g g g g g g g g g g g
another risk is the priority. g g g g g
D. Paralytic ileus g
Rationale:Paralytic ileus can develop during the acute phase of burn care and might require nasogastric
g g g g g g g g g g g g g g
decompression; however, another risk is the priority.
g g g g g g g
8.A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse,
g g g g g g g g g g g g g g g g g g
"I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which
g g g g g g g g g g g g g g g g g g g g g g g
of the following actions should the nurse take to help this client with tenacious bronchial secretions?
g g g g g g g g g g g g g g g g
A. Maintaining a semi-Fowler's position as often as possible
g g g g g g g
Rationale:Although a semi-Fowler's position can help the client breathe more easily, it will not alter the
g g g g g g g g g g g g g g g
consistency of secretions. g g g
B. Administering oxygen via nasal cannula at 2 L/min g g g g g g g
Rationale:Administration of oxygen helps correct hypoxemia, but it will not alter the consistency of g g g g g g g g g g g g g
secretions. g
C. Helping the client select a low-salt diet
g g g g g g
Rationale:Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of
g g g g g g g g g g g g g g g
secretions. g
D. Encouraging the client to drink 2 to 3 L of water daily g g g g g g g g g g g
Rationale:COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema.
g g g g g g g g g g g g g g
Maintaining hydration through the consumption of adequate fluids will help liquefy thick g g g g g g g g g g g
secretions and facilitate their expectoration.
g g g g g
9.A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes
g g g g g g g g g g g g g g g g g g g g
slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A.
g g g g g g g g g g g g g g g g g g
Check the tubing connections for leaks.
g g g g g g
Rationale:This action is used to determine why a water seal chamber has continuous bubbling, not slow,
g g g g g g g g g g g g g g g
steady bubbling. g g
B. Check the suction control outlet on the wall.
g g g g g g g
Rationale:This action is used to determine why a suction control chamber that is hooked to wall suction
g g g g g g g g g g g g g g g g
g has little or no bubbling. C. Clamp the chest tube.
g g g g g g g g g
Rationale:The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage
g g g g g g g g g g g g g g g g g
system. This is not an appropriate action for the nurse to take at this time.
g g g g g g g g g g g g g g g g D. Continue to monitor the client's
g g g g g
respiratory status.
g g
