1. The nurse uses a diagram to show that when the diaphragm moves:
up, the increased negative pressure in the thoracic space forces air into the lungs.
down, the intercostal muscles retract, forcing air out of the lungs.
down, the negative pressure in the thoracic space pulls air into the lungs.
up, the decreased negative pressure allows air to enter the lungs.
2. The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:
hypoxia.
hypercapnia.
dyspnea.
hypoxemia.
3. The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:
halfway between the xiphoid process and the umbilicus.
directly over the sternum.
between the umbilicus and the symphysis pubis.
directly over the umbilicus.
4. A patient has collapsed and cannot be aroused by asking loudly, Are you okay? The next action should be to:
position the fingers over the carotid artery to feel for a pulse.
tilt the head by placing one hand on the forehead and lift the chin.
call for help or, if there is assistance, have that person get help.
deliver two quick short breaths into the patients airway.
5. The nurse instructing the patient to perform forceful exhalation coughing would teach the patient to take in:
one deep breath and quickly exhale.
two breaths and force the air out quickly.
two deep breaths, then inhale deeply again and force out the air quickly.
one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open.
6. The nurse is aware that the best time to schedule a postural drainage treatment is:
shortly after the patient arises in the morning, before breakfast.
in the morning immediately after breakfast.
30 minutes after lunch.
1 hour after supper.
7. A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?
High oxygen flow rate
A humidifier
A Venturi mask
A nasal cannula
8. A patient has a history of chronic obstructive pulmonary disease. The patients oxygen flow rate should be set to no more than _____ L/min.
5 to 10
4 to 5
2 to 3
1 to 2
9. The nurse loosens mucus plugs by using percussion on a patient over the area of the:
sternum.
thorax.
spine between the scapulae.
midaxillary line on the rib cage.
10. A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?
A simple face mask
A non-rebreather mask
A partial rebreathing mask
11. The nurse recognizes that a post-operative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefited by a(n):
pharyngeal airway.
endotracheal tube.
tracheostomy
partial rebreather oxygen mask.
12. A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between _____ mm Hg.
25 and 50
50 and 75
80 and 120
120 and 180
13. A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:
monitoring the rate of respirations.
determining the last time the patient was suctioned.
examining the character of the sputum.
auscultating the breath sounds.
14. A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:
apply suction while advancing the catheter into the airway.
suction the nasotracheal passage after suctioning the mouth.
hold the catheter with the dominant hand after donning sterile gloves.
insert the non-lubricated catheter into the nasal passage.
15. The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should:
be administered extra oxygen.
have the pharynx suctioned.
have the cuff pressure checked.
be monitored for respiratory rate.
16. The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include:
using clothing of synthetic cloth for the patient.
removing any adhesive from the patients skin with acetone.
assessing equipment in room for frayed cords.
reducing humidification on the oxygen delivery device.
17. A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:
immediately turn the patient to the side of the insertion site.
check for air leaks in drainage system.
include findings in documentation.
clamp the chest tube and place the patient in high Fowlers position.
18. A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least _____ mL/day.
500 to 1000
1000 to 1500
1500 to 2000
2500 to 3000
19. The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:
took 10 slow, deep breaths every hour.
took five quick huffs and then coughed vigorously.
exhaled deeply and then inhaled quickly and forcefully three times.
took five deep breaths slowly every 4 hours.
20. The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:
semi-Fowlers position with a single pillow behind the head.
high Fowlers position without a pillow behind the head.
right lateral with the head of the bed elevated 45 degrees.
sitting upright and forward with arms supported on an over-the-bed table.
21. The nurse performing tracheotomy care will:
raise the head of the bed to high Fowlers position.
remove the inner cannula with the ungloved hand.
suction tracheotomy before beginning care.
clean cannula with gauze and replace and lock.
22. The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:
taping all connections within the system.
keeping the system at the level of the patients chest.
turning on suction to 35 cm.
looping the tubing between the mattress and the bed rail to minimize length.
23. The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:
dark skinned.
jaundiced.
obese.
febrile.
24. The nurse clarifies that the cough mechanism is stimulated when:
foreign substances are propelled by the cilia toward the respiratory tract.
dehumidified air enters the upper airway passages.
more than 250 mL of air moves in and out of the lungs with each breath.
the blood transports carbon dioxide to the lungs.
25. When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration. This finding is documented as:
apnea.
stridor
retractions
26. A sputum specimen is best obtained just after the patient or after a treatment because this is when there is more mucus available or when it is easier to cough up.
27. When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and teach the patient to rinse her mouth with
28. The nurse explains that the rate of respiration is triggered when the medulla senses a change in the level of ions in the blood.
29. The nurse administering cardiopulmonary resuscitation (CPR) would administer chest compressions at the rate of compressions/minute.
30. When a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (Select all that apply.)
use sterile gloves during suctioning.
avoid going to crowded theaters and malls.
change catheters every 8 hours.
keep the home environment free of dust.
use bleach to clean suction equipment.
31. The nurse is aware that changes occur in the respiratory system after the age of 70 that put the elderly more at risk for respiratory problems. These changes include: (Select all that apply.)
decreased oxygen saturation.
increased elasticity in thorax and respiratory tissues.
incomplete expirations.
thinning of alveolar membrane.
impaired cilia.
32. The multiple causes for hypoxia include: (Select all that apply.)
extreme fright.
aspirated vomit.
pulmonary fibrosis.
hiccoughs.
high altitude.
