Preview Extract
Chapter 33
1. The nurse knows that the caregiver of a client with a respiratory illness understands
discharge teaching when which statement is made by the caregiver?
1. “Adventitious sounds may be heard during inspiration or expiration because of secretions
or inflammation.”
2. “I will know I am hearing adventitious breath sounds if I hear any sounds when I listen
over the lower chest.”
3. “If I hear extra sounds during a deep breath, I know I am hearing adventitious sounds.”
4. “I can expect to hear adventitious sounds only in the mornings; the rest of the day, breath
sounds should be normal.”
Answer: “Adventitious sounds may be heard during inspiration or expiration because of
secretions or inflammation.”
Rationale:
Adventitious or abnormal breath sounds may be heard at any time of day or night, during
inspiration and expiration, over any portion of the chest or back, and do not require that the
client take a deep breath for the sounds to be heard.
2. Which indicates normal variations in breath sounds?
Select all that apply.
1. Tracheal breath sounds equal in inspiration and expiration
2. Bronchial breath sounds with expiration longer than inspiration
3. Vesicular breath sounds with expiration longer than inspiration
4. Bronchovesicular breath sounds with inspiration longer than expiration
5. Tracheovesicular breath sounds with inspiration longer than expiration
Answer: 1. Tracheal breath sounds equal in inspiration and expiration
2. Bronchial breath sounds with expiration longer than inspiration
3. Vesicular breath sounds with expiration longer than inspiration
Rationale:
Tracheal breath sounds equal in inspiration and expiration. Tracheal, bronchial, and vesicular
breath sounds describes a place where breath sounds are most prominent with auscultation.
Breath sounds heard over the tracheal region sound equal in inspiration and expiration.
Bronchial breath sounds with expiration longer than inspiration. Tracheal, bronchial, and
vesicular breath sounds describes a place where breath sounds are most prominent with
auscultation. For bronchial breath sounds, expiration sounds longer than inspiration.
Vesicular breath sounds with expiration longer than inspiration. Tracheal, bronchial, and
vesicular breath sounds describes a place where breath sounds are most prominent with
auscultation. For vesicular breath sounds, expiration sounds longer than inspiration.
Bronchovesicular breath sounds with inspiration longer than expiration. Bronchovesicular
breath sounds are heard equally during inspiration and expiration. Tracheovesicular breath
sounds with inspiration longer than expiration. Tracheovesicular breath sounds do not exist.
3. Upon auscultation of the chest, the nurse reports to the preceptor what is heard. About
which statement should the preceptor be most concerned?
1. “I heard crackles earlier, but now I am not able to hear anything.”
2. “I hear wheezing in the right lobes, but clear on the left.”
3. “There are coarse crackles that clear with coughing.”
4. “The client was clear, but now there are scattered wheezes bilaterally.”
Answer: “I heard crackles earlier, but now I am not able to hear anything.”
Rationale:
The preceptor would be most concerned about the nurse not hearing anything. This statement
needs immediate follow-up assessment as to whether the nurse hears nothing, or no
adventitious breath sounds. The other options indicate adventitious breath sounds, but none is
indicative of the need for immediate action.
4. Which indicates the need for further discharge teaching for a client with a history of
chronic respiratory disease?
1. “As long as I take my medications and use my inhalers as prescribed, I should not have
difficulty when traveling.”
2. “I should avoid traveling to places at higher elevations, as I will have increased difficulty
breathing.”
3. “To decrease my risk, any traveling I do should not be to places with recent outbreaks of
respiratory illnesses.”
4. “If I am acclimated to higher elevations, I should not experience problems with worsening
symptoms.”
Answer: “As long as I take my medications and use my inhalers as prescribed, I should not
have difficulty when traveling.”
Rationale:
If the client travels to elevations above 5000 feet without being acclimated, increased
symptoms result from the decreased oxygen in the air at higher elevations. Travel avoidance
to higher elevations and to places with recent outbreaks are correct, so would not indicate the
need for further teaching. Just because the client is acclimated to higher elevations does not
preclude the client from worsening symptoms.
5. Which symptom is a client with high-altitude pulmonary edema most likely to exhibit
first?
1. Change in the level of consciousness
2. Polycythemia
3. Vasoconstriction
4. Vasodilation
Answer: Change in the level of consciousness
Rationale:
High-altitude pulmonary edema results from the decrease in atmospheric pressure and lower
level of oxygen in the air at high altitudes. This results in hypoxemia, which will cause both
fatigue and a change in the level of consciousness. Polycythemia is a compensatory
mechanism, as more red blood cells are formed to try to get more oxygen to the cells.
Vasoconstriction occurs before vasodilation, but both are compensatory mechanisms
occurring later than the initial change in level of consciousness.
6. A client is admitted with a diagnosis of asbestos-related pulmonary disease. This is most
likely due to working in which environments?
Select all that apply.
1. Construction
2. Auto mechanics
3. Shipyards
4. Farming
5. Food industry
Answer: 1. Construction
2. Auto mechanics
3. Shipyards
Rationale:
Construction. Those with a history of working in construction and demolition of buildings
built prior to 1970 risked exposure to asbestos. Auto mechanics. Auto mechanics work in
environments in which asbestos is present. Shipyards. Shipyards are environments in which
asbestos is present. Farming. Farmers are at risk for asthmatic reactions. Food industry. Food
preparers are at risk for asthmatic reactions.
7. If a client is scheduled to have a magnetic resonance imaging scan (MRI), which
information is most important for the nurse to obtain before the procedure?
1. Whether or not the client has any metal on, such as a protective amulet
2. When the client last ate or drank
3. Whether or not the client is allergic to shellfish
4. Whether or not the client has any loose teeth
Answer: Whether or not the client has any metal on, such as a protective amulet
Rationale:
The nurse must know whether the client is wearing any metal. If the client is from a culture
that believes in the protection provided by amulets, it is important for the nurse to obtain this
information during the history taking. The other options are not usually applicable as
preparation for an MRI.
8. A client’s susceptibility to chronic pulmonary disease is most likely due to which aspect in
the client’s history?
1. Owned and worked a farm
2. Worked in a hospital
3. Worked as a air traffic controller
4. Played in a band
Answer: Owned and worked a farm
Rationale:
Farmers are exposed to pesticides every day while they are preparing the land for farming
and while crops are growing. Working in a hospital may increase the risk for colds and
influenza, but does not increase the risk for chronic pulmonary disease. Air traffic controllers
and band members are not more likely to have increased risk of chronic pulmonary disease.
9. A client presents to the emergency department with a history of edema in the lower
extremities. What information is most important to obtain before determining the nurse’s next
action?
1. Ask the client for his or her position of comfort.
2. Auscultate breath sounds.
3. Inspect the skin for pallor.
4. Palpate the thorax.
Answer: Ask the client for his or her position of comfort.
Rationale:
When the client has edema in the lower extremities, the nurse is concerned about right-sided
heart failure as fluid backs up into the peripheral circulation. If the position of comfort is
upright with an inability to lie supine, pulmonary hypertension is present; the nurse needs to
notify a care provider immediately. Pallor, breath sounds, and palpating the thorax can also
indicate respiratory distress and obstruction, but right-sided heart failure is the priority.
10. Which of the following are the correctly included in the evaluation of pulmonary
symptoms?
Select all that apply.
1. Severity
2. Associated factors
3. Duration
4. Pressure
5. Relief
Answer: 1. Severity
2. Associated factors
3. Duration
Rationale:
Severity. The PQRST and COLDSA mnemonics are useful so that pulmonary symptoms can
be assessed systematically; severity is included. Associated factors. The PQRST and
COLDSA mnemonics are useful so that pulmonary symptoms can be assessed systematically;
associated factors is included. Duration. The PQRST and COLDSA mnemonics are useful so
that pulmonary symptoms can be assessed systematically; duration is included. Pressure.
Pressure is not included in the evaluation of pulmonary symptoms. Relief. Relief is not
included in the evaluation of pulmonary symptoms.
11. The nurse is going over discharge instruction for a client with pulmonary disease. Which
statement indicates learning has been unsuccessful?
1. “If I notice a change in the shape of my chest, I should immediately call my health care
provider.”
2. “When I am assessing changes in my condition, I should notice increased use of abdominal
muscles to exhale.”
3. “It is important for me to report even subtle changes in energy and ability to complete daily
tasks.”
4. “I should keep records not only of my respiratory rate, but also the depth and rhythm for a
full minute.”
Answer: “If I notice a change in the shape of my chest, I should immediately call my
healthcare provider.”
Rationale:
A change in the shape of the client’s chest is not noticeable over a short period of time. Barrel
chest occurs slowly and over a long period of time. The other options are correct; as the
increased use of accessory muscles, changes in energy, and rate, depth, and rhythm should be
noted and reported as needed.
12. Capnography would most likely be used in which of the following situations?
1. A client in intensive care has been intubated.
2. A client in the emergency department arrives with circumoral cyanosis.
3. A client with a history of chronic obstructive pulmonary disease is admitted for increased
difficulty breathing.
4. An ambulance arrives with a client following a house fire.
Answer: A client in intensive care has been intubated.
Rationale:
Capnography indicates the presence of carbon dioxide and is used to assist in determining
whether an endotracheal tube is correctly placed following intubation. The clients with
circumoral cyanosis and chronic obstructive pulmonary disease would at least require pulse
oximetry. The client with an inhalation injury requires an arterial blood gas.
13. The nurse is planning a class for nursing assistants. Which should be included as causing
interference with accurate pulse oximeter readings?
Select all that apply.
1. Ambient light
2. Nail polish
3. Inhalation injuries
4. Arterial pulses
5. Placement on cartilage
Answer: 1. Ambient light
2. Nail polish
3. Inhalation injuries
Rationale:
Ambient light. Other sources of light can cause inaccurate readings. Nail polish. Nail polish
on fingernails/toenails can cause inaccurate readings. Inhalation injuries. Clients with
inhalation injuries can cause inaccurate readings. Arterial pulses. Venous pulsations, not
arterial, can also cause interference. Placement on cartilage. Cartilage will prevent the sensors
from interacting, which will produce inaccurate readings.
14. The nurse is caring for a client who was admitted in respiratory distress. Which is the
nurse’s priority action based on the data obtained from this ABG:
pH: 7.32
PaCO2: 52
PaO2: 94
HCO3: 20
1. Place the client on O2 via mask.
2. Document and continue to monitor.
3. Call the healthcare provider to report the results.
4. Suction the client using a Yankeur.
Answer: Place the client on O2 via mask.
Rationale:
In blood gases, normal pH: 7.35−7.45; normal PaCO2: 34−45 mmHg; normal PaO2: 80−100
mmHg; normal HCO3: 22−26 mEq/L; so respiratory acidosis occurs when the pH drops
below 7.35, the PaCO2 is >45 mmHg, the PaO2 is normal or decreased, and the HCO3 is < 22
mmHg. Thus, this client requires oxygen. Once placed, the nurse can report the results.
Suctioning is not indicated. The nurse should continue to document and monitor, but not until
the patient has been placed on oxygen.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
