- Answer B. To obtain a sputum specimen, the client should rinse the
mouth to reduce contamination, breathe deeply, and then cough into a
sputum specimen container. The client should be encouraged to cough and
not spit so as to obtain sputum. Sputum can be thinned by fluids or by a
respiratory treatment such as inhalation of nebulized saline or water.
The optimal time to obtain a specimen is on arising in the morning.
- Answer D. If a biopsy was performed during a bronchoscopy,
blood-streaked sputum is expected for several hours. Frank blood
indicates hemorrhage. A dry cough may be expected. The client should be
assessed for signs of complications, which would include cyanosis,
dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia,
and dysrhythmias. Hematuria is unrelated to this procedure.
- Answer C. Hypoxemia can be caused by prolonged suctioning, which
stimulates the pacemaker cells in the heart. A vasovagal response may
occur, causing bradycardia. The nurse must preoxygenate the client
before suctioning and limit the suctioning pass to 10 seconds.
- Answer C. During suctioning, the nurse should monitor the client
closely for side effects, including hypoxemia, cardiac irregularities
such as a decrease in heart rate resulting from vagal stimulation,
mucosal trauma, hypotension, and paroxysmal coughing. If side effects
develop, especially cardiac irregularities, the procedure is stopped and
the client is reoxygenated.
- Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.
- Answer A. When percussing the chest wall, the nurse expects to
elicit resonant sounds — low-pitched, hollow sounds heard over normal
lung tissue. Hyperresonant sounds indicate increased air in the lungs or
pleural space; they’re louder and lower pitched than resonant sounds.
Although hyperresonant sounds occur in such disorders as emphysema and
pneumothorax, they may be normal in children and very thin adults. Dull
sounds, normally heard only over the liver and heart, may occur over
dense lung tissue, such as from consolidation or a tumor. Dull sounds
are thudlike and of medium pitch. Flat sounds, soft and high-pitched,
are heard over airless tissue and can be replicated by percussing the
thigh or a bony structure.
- Answer A. A therapeutic theophylline level is 10 to 20 mcg/ml. The
client is currently receiving 0.5 mg/kg/hour of aminophylline. Because
the client’s theophylline level is sub-therapeutic, reducing the dose
(which is what the physician’s order would do) would be inappropriate.
Therefore, the nurse should question the order.
- Answer C. In chronic bronchitis the diaphragm is flat and weak.
Diaphragmatic breathing helps to strengthen the diaphragm and maximizes
ventilation. Exhalation should be longer than inhalation to prevent
collapse of the bronchioles. The client with chronic bronchitis should
exhale through pursed lips to prolong exhalation, keep the bronchioles
from collapsing, and prevent air trapping. Diaphragmatic breathing — not
chest breathing — increases lung expansion.
- Answer C. Tidal volume refers to the volume of air inspired and
expired with a normal breath. Total lung capacity is the maximal amount
of air the lungs and respiratory passages can hold after a forced
inspiration. Forced vital capacity is the vital capacity performed with a
maximally forced expiration. Residual volume is the maximal amount of
air left in the lung after a maximal expiration.
- Answer B. A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
- Answer C. Decreased hearing acuity indicates ototoxicity, a serious
adverse effect of streptomycin therapy. The client should notify the
physician immediately if it occurs so that streptomycin can be
discontinued and an alternative drug can be prescribed. The other
options aren’t associated with streptomycin. Impaired color
discrimination indicates color blindness; increased urinary frequency
and increased appetite accompany diabetes mellitus.
- Answer B. The Mantoux test doesn’t differentiate between active and
dormant infections. If a positive reaction occurs, a sputum smear and
culture as well as a chest X-ray are necessary to provide more
information. Although the area of redness is measured in 3 days, a
second test may be needed; neither test indicates that tuberculosis is
active. In the Mantoux test, an induration 5 to 9 mm in diameter
indicates a borderline reaction; a larger induration indicates a
positive reaction. The presence of a wheal within 2 days doesn’t
indicate active tuberculosis.
- Answer B. Initially, the nurse should plug the opening in the
tracheostomy tube for 5 to 20 minutes, then gradually lengthen this
interval according to the client’s respiratory status. A client who
doesn’t require continuous mechanical ventilation already is breathing
without assistance, at least for short periods; therefore, plugging the
opening of the tube for only 15 to 60 seconds wouldn’t be long enough to
reveal the client’s true tolerance to the procedure. Plugging the
opening for more than 20 minutes would increase the risk of acute
respiratory distress because the client requires an adjustment period to
start breathing normally.
- Answer C. Constant bubbling in the chamber indicates an air leak and
requires immediate intervention. The client with a pneumothorax will
have intermittent bubbling in the water-seal chamber. Clients without a
pneumothorax should have no evidence of bubbling in the chamber. If the
tube is obstructed, the nurse should notice that the fluid has stopped
fluctuating in the water-seal chamber.
- Answer B. Skin color doesn’t affect the mucous membranes. The lips,
nail beds, and earlobes are less reliable indicators of cyanosis because
they’re affected by skin color.
- Answer A. For a client with an ET tube, the most important nursing
action is auscultating the lungs regularly for bilateral breath sounds
to ensure proper tube placement and effective oxygen delivery. Although
the other options are appropriate for this client, they’re secondary to
ensuring adequate oxygenation.
- Answer B. The use of accessory muscles for respiration indicates
the client is having difficulty breathing. Diaphragmatic and pursed-lip
breathing are two controlled breathing techniques that help the client
- Answer D. The nurse observes respiratory excursion to help assess
chest movements. Normally, thoracic expansion is symmetrical; unequal
expansion may indicate pleural effusion, atelectasis, pulmonary embolus,
or a rib or sternum fracture. The nurse assesses vocal sounds to
evaluate air flow when checking for tactile fremitus; after asking the
client to say "99," the nurse palpates the vibrations transmitted from
the bronchopulmonary system along the solid surfaces of the chest wall
to the nurse’s palms. The nurse assesses breath sounds during
- Answer A. Erythromycin is the drug of choice for treating
legionnaires’ disease. Rifampin may be added to the regimen if
erythromycin alone is ineffective; however, it isn’t administered first.
Amantadine, an antiviral agent, and amphotericin B, an antifungal
agent, are ineffective against legionnaires’ disease, which is caused by
- Answer C. In a client with COPD, an ineffective cough impedes
secretion removal. This, in turn, causes mucus plugging, which leads to
localized airway obstruction — a known cause of atelectasis. An
ineffective cough doesn’t cause pleural effusion (fluid accumulation in
the pleural space). Pulmonary edema usually results from left-sided
heart failure, not an ineffective cough. Although many noncardiac
conditions may cause pulmonary edema, an ineffective cough isn’t one of
them. Oxygen toxicity results from prolonged administration of high
oxygen concentrations, not an ineffective cough.
- Answer A. Pursed-lip breathing helps prevent early airway collapse.
Learning this technique helps the client control respiration during
periods of excitement, anxiety, exercise, and respiratory distress. To
increase inspiratory muscle strength and endurance, the client may need
to learn inspiratory resistive breathing. To decrease accessory muscle
use and thus reduce the work of breathing, the client may need to learn
diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client
mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client
with emphysema may have an I:E ratio as high as 1:4.)
- Answer A. Codeine’s onset of action is 30 minutes. Its peak
concentration occurs in about 1 hour; its half-life, in 2.5 hours; and
its duration of action is 4 to 6 hours.
- Answer A. Conditions that trigger the high-pressure alarm include
kinking of the ventilator tubing, bronchospasm or pulmonary embolus,
mucus plugging, water in the tube, coughing or biting on the ET tube,
and the client’s being out of breathing rhythm with the ventilator. A
disconnected ventilator tube or an ET cuff leak would trigger the
low-pressure alarm. Changing the oxygen concentration without resetting
the oxygen level alarm would trigger the oxygen alarm.
- Answer A. Anhydrous theophylline and other methylxanthine agents make the central respiratory center more sensitive to CO2
and stimulate the respiratory drive. Inhibition of phosphodiesterase is
the drug’s mechanism of action in treating asthma and other reversible
obstructive airway diseases — not COPD. Methylxanthine agents inhibit
rather than stimulate adenosine receptors. Although these agents reduce
diaphragmatic fatigue in clients with chronic bronchitis or emphysema,
they don’t alter diaphragm movement to increase chest expansion and
enhance gas exchange.
- Answer A. The common feature of all types of pneumonia is an
inflammatory pulmonary response to the offending organism or agent.
Although most types of pneumonia have a sudden onset, a few (such as
anaerobic bacterial pneumonia and mycoplasmal pneumonia) have an
insidious onset. Antibiotic therapy is the primary treatment for most
types of pneumonia; however, the antibiotic must be specific for the
causative agent, which may not be responsive to penicillin. A few types
of pneumonia, such as viral pneumonia, aren’t treated with antibiotics.
Although pneumonia usually causes an elevated WBC count, some types,
such as mycoplasmal pneumonia, don’t.
- Answer D. In respiratory acidosis, ABG analysis reveals an arterial
pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2
value of 30 mm Hg indicates respiratory alkalosis. Options B and C
represent normal ABG values, reflecting normal gas exchange in the
- Answer A. Hypoxia is the main breathing stimulus for a client with
COPD. Excessive oxygen administration may lead to apnea by removing that
stimulus. Anginal pain results from a reduced myocardial oxygen supply.
A client with COPD may have anginal pain from generalized
vasoconstriction secondary to hypoxia; however, administering oxygen at
any concentration dilates blood vessels, easing anginal pain.
Respiratory alkalosis results from alveolar hyperventilation, not
excessive oxygen administration. In a client with COPD, high oxygen
concentrations decrease the ventilatory drive, leading to respiratory
acidosis, not alkalosis. High oxygen concentrations don’t cause
- Answer D. The client is hypoxemic because of bronchoconstriction as
evidenced by wheezes and a subnormal arterial oxygen saturation level.
The client’s greatest need is bronchodilation, which can be accomplished
by administering bronchodilators. Albuterol is a beta2
adrenergic agonist, which causes dilation of the bronchioles. It’s given
by nebulization or metered-dose inhalation and may be given as often as
every 30 to 60 minutes until relief is accomplished. Alprazolam is an
anxiolytic and central nervous system depressant, which could suppress
the client’s breathing. Propranolol is contraindicated in a client who’s
wheezing because it’s a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.
- Answer D. Respiratory depression is the most serious complication of
epidural analgesia. Other potential complications include hypotension,
decreased sensation and movement of the extremities, allergic reactions,
and urine retention. Typically, epidural analgesia causes central
nervous system depression (indicated by drowsiness) as well as a
decreased heart rate and blood pressure.
- Answer B.
Conditions that increase oxygen demands include obesity,
smoking, exposure to temperature extremes, and stress. A client with
chronic bronchitis should drink at least 2,000 ml of fluid daily to thin
mucus secretions; restricting fluid intake may be harmful. The nurse
should encourage the client to eat a high-protein snack at bedtime
because protein digestion produces an amino acid with sedating effects
that may ease the insomnia associated with chronic bronchitis. Eating
more than three large meals a day may cause fullness, making breathing
uncomfortable and difficult; however, it doesn’t increase oxygen
demands. To help maintain adequate nutritional intake, the client with
chronic bronchitis should eat small, frequent meals (up to six a day).