1.
The function of the respiratory system is to obtain oxygen from atmospheric air, transport this air through the respiratory tract into the ________________ , and ultimately diffuse oxygen into the blood to carry oxygen to all the cells of the body.
Explanation
The alveoli are small, thin-walled sacs located at the end of the respiratory tract in the lungs. They are responsible for the exchange of oxygen and carbon dioxide between the air and the bloodstream. Oxygen from the inhaled air diffuses into the alveoli and then into the surrounding capillaries, where it binds to red blood cells for transport to the body's cells. Carbon dioxide, a waste product, is released from the cells into the bloodstream and then diffuses from the capillaries into the alveoli to be exhaled. Therefore, the alveoli play a crucial role in facilitating the exchange of gases and ensuring oxygen is delivered to all cells in the body.
2.
Breathing, typically is an __________process.
Correct Answer
A. Automatic
Explanation
Breathing is typically an automatic process. This means that it occurs without conscious effort or control. The body's respiratory system automatically regulates the intake of oxygen and the expulsion of carbon dioxide to maintain a balanced level of gases in the blood. The brain and the respiratory muscles work together to control the rate and depth of breathing based on the body's needs. This automatic process ensures that the body receives a constant supply of oxygen and removes waste gases efficiently.
3.
In a normal patient, when oxygenation decreases, the respiratory system
Correct Answer
A. The respiratory system compensates by increasing the respiratory rate.
Explanation
When oxygenation decreases in a normal patient, the respiratory system compensates by increasing the respiratory rate. This is because the body needs to take in more oxygen and remove more carbon dioxide to maintain proper oxygen levels in the blood. By increasing the respiratory rate, the lungs can deliver more oxygen to the body and remove carbon dioxide more efficiently. This compensatory mechanism helps to ensure that the body's oxygen needs are met and prevents a decrease in oxygen levels that could lead to further complications.
4.
Alterations in breathing patterns can be addressed when the nurse has accessed all other patients.
Correct Answer
B. False
Explanation
impaired oxygen delivery can be life-threatening.
5.
Normal oxygenation depends on
Correct Answer(s)
A. development
B. Function of the respiratory system
C. effective gas exchange
Explanation
Normal oxygenation depends on healthy development and function of the respiratory system, as well as intricate cellular and organic processes that allow for effective gas exchange.
6.
Adequate oxygenation depends on a healthy, intact ________________ ___________________.
Correct Answer(s)
respiratory system
Explanation
The respiratory system is responsible for the exchange of oxygen and carbon dioxide in the body. It includes organs such as the lungs, trachea, and bronchi, which help in the process of breathing. Adequate oxygenation is crucial for the proper functioning of the body's cells and tissues. Without a healthy and intact respiratory system, the body would not be able to efficiently take in oxygen and remove carbon dioxide, leading to respiratory difficulties and potential health issues.
7.
What is the pathway of oxygenation?
Correct Answer
A. Oxygen from the air, transports it into the alveoli, where oxygen diffuses into capillaries and is carried by the blood to all cells of the body
Explanation
The correct answer is "oxygen from the air, transports it into the alveoli, where oxygen diffuses into capillaries and is carried by the blood to all cells of the body." This is the correct pathway of oxygenation in the respiratory system. Oxygen enters the body through inhalation and travels down the trachea into the lungs. In the lungs, oxygen is exchanged with carbon dioxide in the alveoli, tiny air sacs. The oxygen then diffuses into the surrounding capillaries, where it binds to hemoglobin in red blood cells and is transported throughout the body to be used by cells for various metabolic processes.
8.
The ________ typically is the primary entry for air.
Correct Answer
nose
Explanation
The nose is typically the primary entry for air. This is because the nose contains the nostrils, which are responsible for inhaling air into the respiratory system. The nostrils filter and warm the air before it enters the lungs, helping to protect the respiratory system from harmful particles and irritants. Additionally, the nose also plays a role in the sense of smell, as it contains olfactory receptors that detect and interpret different odors.
9.
What are things to look for when assessing a patient's nares?
Correct Answer(s)
B. Pink
C. Mucosa-lined passageways
Explanation
The nose is divided into two nares, which are moist, pink, mucosa-lined passageways. a nurse would not put their fingers in a patients nostrils to feel for warmth
10.
Foreign matter that enters the nose irritates the nasal passages and induces __________
Correct Answer(s)
sneezing
Explanation
Foreign matter that enters the nose can cause irritation to the nasal passages. This irritation triggers a reflex action known as sneezing. Sneezing is the body's way of forcefully expelling the irritants from the nasal passages. It involves a sudden and involuntary expulsion of air through the nose and mouth, often accompanied by a characteristic sound. Sneezing helps to protect the respiratory system by clearing out any foreign particles that may have entered the nose.
11.
This reflexive action is active even in the neonatal period.
Correct Answer
A. True
Explanation
The involuntary functioning or movement of any organ or body part in response to a particular stimulus. The function or action occurs immediately, without the involvement of the will or consciousness. ex- sneezing.
12.
__________________ microscopic hairs within the posterior portion of the nares that trap small particles of foreign matter to prevent their entry into the lower respiratory tract.
Correct Answer
cilia
Explanation
Cilia are microscopic hairs located in the posterior portion of the nares. These cilia have the function of trapping small particles of foreign matter, such as dust or bacteria, to prevent them from entering the lower respiratory tract. This helps to protect the lungs and respiratory system from potential harm or infection caused by these particles.
13.
_______________ prevents food and fluids from passing through the glottis.
Correct Answer
epiglottis
Explanation
The epiglottis is a flap of tissue located at the base of the tongue that prevents food and fluids from entering the windpipe or trachea when swallowing. It acts as a protective mechanism to ensure that these substances are directed towards the esophagus and into the stomach, rather than entering the respiratory system.
14.
___________________serves as the entryway into the lower respiratory tract.
Correct Answer
glottis
Explanation
The glottis serves as the entryway into the lower respiratory tract. It is the opening between the vocal cords in the larynx, allowing air to pass through to the trachea and into the lungs.
15.
Which bronchus is shorter and wider?
Correct Answer
A. Right
Explanation
The right bronchus is shorter and wider compared to the left bronchus. This is because the right bronchus has a more vertical orientation, allowing for a more direct pathway for air to enter the right lung. The left bronchus, on the other hand, is longer and narrower due to its position being more horizontal, as it needs to accommodate the space for the heart.
16.
___________ is where gas exchange occurs.
Correct Answer
alveoli
Explanation
The alveoli are small air sacs in the lungs where gas exchange occurs. Oxygen from inhaled air diffuses across the thin walls of the alveoli into the bloodstream, while carbon dioxide, a waste product, diffuses from the bloodstream into the alveoli to be exhaled. This exchange of gases is essential for the body to obtain oxygen and get rid of carbon dioxide.
17.
The nares are responsible for
Correct Answer(s)
A. Warm air
B. Humidify air
C. Filters air
Explanation
Nares warm, humidify, and filter air as it is breathed into the nose.
18.
_______________entrance for air into lungs.
Correct Answer(s)
trachea
Explanation
The trachea is the tube-like structure that connects the throat to the lungs. It serves as the entrance for air into the lungs, allowing oxygen to reach the respiratory system.
19.
Vesicular sounds:
Correct Answer(s)
A. Most prominently heard in lung bases
B. Typically longer on inhalation than exhalation
Explanation
Bronchovesicular sounds are equal in duration during inhalation and exhalation Bronchial sounds Longer on exhalation than inhalation
20.
Breathing within normal range
Correct Answer
A. Eupnea
Explanation
Eupnea refers to normal breathing within a healthy range. It is the opposite of apnea, which is the temporary cessation of breathing, and dyspnea, which is difficulty in breathing. Wheezing is a high-pitched whistling sound that occurs during breathing and is often associated with respiratory conditions. Therefore, the correct answer, eupnea, indicates normal and healthy breathing.
21.
The nurse is assessing a patient with a cough.
Which question about the cough, if answered in the affirmative, is most concerning to the nurse?
Correct Answer
C. Do you cough up blood and how often?
Explanation
If the patient answers affirmatively to the question "Do you cough up blood and how often?", it is most concerning to the nurse because coughing up blood, also known as hemoptysis, can be a sign of a serious underlying condition such as lung cancer, tuberculosis, or pulmonary embolism. It requires immediate medical attention and further investigation to determine the cause and provide appropriate treatment.
22.
The nurse is discussing plans to care for a patient experiencing dyspnea.
Which statement reflects the priority of independent intervention?
Correct Answer
B. I should place the patient in high Fowler position.
Explanation
Fowler's position facilitates the relaxing of tension of the abdominal muscles, allowing for improved breathing
23.
_________________ A progressive pulmonary disease characterized by destruction of the walls of the alveoli, with resulting enlargement of abnormal air spaces.
Correct Answer
Emphysema
Explanation
Emphysema is a progressive pulmonary disease where the walls of the alveoli (tiny air sacs in the lungs) are destroyed, leading to the enlargement of abnormal air spaces. This condition impairs the ability of the lungs to effectively exchange oxygen and carbon dioxide, causing symptoms such as shortness of breath, coughing, and wheezing. Smoking is the most common cause of emphysema, although long-term exposure to air pollution or certain genetic factors can also contribute to its development. Treatment typically involves lifestyle changes, medications, and in severe cases, oxygen therapy or surgery.
24.
A patient with diffuse emphysema asks about options for improving lung health.
Which statement by the nurse is correct?
Correct Answer
C. Surgical options can be considered to improve lung health with diffuse empHysema.
Explanation
Lung reduction surgery is an experimental surgical intervention for advanced diffuse emphysema. Diffuse emphysema can be terminal due to significant lung impairment, but surgery is an option. Exercise will not improve diffuse emphysema.
25.
While teaching parents about toy safety, a parent asks the nurse why their toddler is not able to play with their 10-year-old sibling's toys.
Which explanation should the nurse provide?
Correct Answer
A. Due to children's narrower airways, toddlers are at risk for airway obstruction.
Explanation
Toddlers have narrower airways compared to older children, which puts them at a higher risk for airway obstruction. This means that small objects or toys can easily block their airways and cause difficulty in breathing. Therefore, it is important to ensure that toddlers play with age-appropriate toys that do not pose a choking hazard.
26.
A patient with respiratory distress is showing signs of decreasing cardiac output and hypoxemia.
Which action should the nurse take first?
Correct Answer
B. Administer oxygen via face mask.
Explanation
With signs of hypoxemia, oxygen via face mask should be administered first. Pulmonary function can be assessed after oxygenation is restored. Assessment of the nail beds for cyanosis and arterial blood gases are not the first actions due to signs of hypoxemia being seen already.
27.
The nurse is auscultating tracheal sounds of a patient.
Which sound should the nurse recognize as a normal finding?
Correct Answer
C. Harsh, high-pitched sound
Explanation
Harsh, high-pitched sounds are normal sounds heard over the trachea when the patient inhales and exhales. Bronchovesicular sounds are medium in loudness and pitch, and they are heard between the scapulae, posteriorly and next to the sternum. Vesicular sounds are soft and low pitched, and they are heard over the remainder of the lung. Vesicular sounds are longer on inhalation than exhalation. Bronchial sounds are loud, high-pitched sounds next to the trachea.
28.
Which oxygen delivery device should the nurse understand is indicated for a patient with a CO2 level of 55 mmHg?
Correct Answer
C. Nonrebreather mask
Explanation
A nonrebreather mask is indicated for a patient with a high CO2 level of 55 mmHg because it delivers a high concentration of oxygen. It has a reservoir bag that allows the patient to breathe in oxygen from the bag without rebreathing exhaled air, preventing the accumulation of CO2. This device is suitable for patients who require a high concentration of oxygen and have a compromised respiratory status. The other options, such as the Oxymizer, simple face mask, and nasal cannula, may not provide a high enough concentration of oxygen for a patient with a CO2 level of 55 mmHg.
29.
Where should the nurse feel the strongest vibration when performing tactile fremitus on a patient?
Correct Answer
A. Over the trachea
Explanation
The strongest vibration should be felt over the trachea. Harsh, high-pitched sounds are normal sounds heard over the trachea when the patient inhales and exhales. They will diminish over the bronchi and become almost nonexistent over the alveoli of the lungs. The lower half of the sternum is too low.
30.
____________ used to remove fluid from the pleural space.
Correct Answer
Thoracentesis
Explanation
Thoracentesis is a medical procedure used to remove fluid from the pleural space. The pleural space is the area between the two layers of tissue that surround the lungs. Excess fluid in this space can cause difficulty in breathing and other respiratory problems. Thoracentesis involves inserting a thin needle or tube into the pleural space to drain the fluid, relieving symptoms and allowing for further examination of the fluid if needed. This procedure is commonly performed for diagnostic purposes or to provide therapeutic relief for conditions such as pleural effusion or pneumothorax.
31.
_____________ a decreased volume of circulating blood in the body.
Correct Answer
hypovolemia
Explanation
Hypovolemia refers to a decreased volume of circulating blood in the body. This condition can occur due to various reasons such as excessive bleeding, dehydration, or fluid loss from severe vomiting or diarrhea. When there is a decrease in blood volume, the body's ability to deliver oxygen and nutrients to tissues is compromised, leading to symptoms like dizziness, low blood pressure, rapid heart rate, and fatigue. Prompt medical attention is necessary to restore blood volume and address the underlying cause of hypovolemia.
32.
A patient presents with chest congestion and a cough. Which skill should the nurse expect to use to specifically assess for chest congestion?
Correct Answer
C. Percussion and auscultation
Explanation
The nurse should expect to use percussion and auscultation to specifically assess for chest congestion. Percussion involves tapping on the chest to assess the underlying structures and determine if there is any abnormal fluid or air accumulation. Auscultation involves using a stethoscope to listen to the sounds produced by the lungs and airways. By combining these two skills, the nurse can gather information about the presence of congestion in the chest and make an accurate assessment of the patient's condition.
33.
The nurse is caring for a patient with a pneumothorax. Which factor should the nurse suspect cause this alteration?
Correct Answer
A. Trauma
Explanation
While a pneumothorax may occur spontaneously, most occur as the result of trauma. Obesity can cause apnea. Asthma and pneumonia can cause orthopnea.
34.
A patient asks, "Why do I need to have my position changed every 2 hours?" Which response should the nurse provide?
Correct Answer
A. Low oxygen in the tissues increases the risk of skin breakdown
Explanation
Tissue hypoxia (low oxygen levels) increases the risk of skin breakdown, which in turn increases the risk of infection and sepsis in the patient. Changing positions does not prevent muscle atrophy in a patient. Changing position does not always help clear the airway or increase oxygenation.
35.
The nurse knows that which variations in pediatric anatomy places the child at higher risk for respiratory compromise?
Correct Answer(s)
C. The larynx of the child is funnel-shaped
D. The metabolic and oxygen needs of children are higher than adults
Explanation
Infants are obligatory nose breathers for the first 4 weeks of life, which can place them at a higher risk for airway blockage. The tongue and tonsillar tissue are proportionally LARGER in children than adults, which can also place them at a higher risk of airway compromise. The larynx is funnel-shaped in children, and the metabolic/oxygen needs are higher in children. Children are able to humidify their oxygen through their upper respiratory tract, just like adults.
36.
Which of the following does the nurse look for as early signs of respiratory distress in children?
Correct Answer
D. Restlessness and tachypnea
Explanation
Restlessness, irritability and tachypnea are often the first signs of respiratory distress
37.
The nurse is caring for a child born at 32 weeks gestation. After birth the child begins demonstrating nasal flaring, grunting, retractions, and central cyanosis. Which of the following does the nurse anticipate doing next?
Correct Answer
A. Assisting with intubation
Explanation
This child is premature and is most likely demonstrating Acute Respiratory Distress, specific to neonates. The child will need to be intubated and given surfactant to help prevent total respiratory failure.
38.
_______________ is the bluish or purplish discoloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation.
Correct Answer
cyanosis
Explanation
Cyanosis is the bluish or purplish discoloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation. This occurs when there is a decrease in the amount of oxygen in the blood, leading to a bluish coloration of the skin. It is often a sign of a respiratory or circulatory problem, indicating that the body is not getting enough oxygen.
39.
Pediatric Differences in the Respiratory System
Correct Answer(s)
A. Lack of or insufficient surfactant
C. Obligatory nose breather (infant)
D. Less well developed intercostal muscles
Explanation
Lack of or insufficient surfactant
Smaller airways and underdeveloped cartilage
Obligatory nose breather (infant)
Less well developed intercostal muscles
Brief periods of apnea common (newborn)
40.
__________________ is the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet.
Correct Answer(s)
Suctioning
Explanation
Suctioning refers to the process of removing secretions from the body by using a catheter connected to a suction machine or wall suction outlet. This procedure is commonly performed to clear the airway and improve breathing in patients who are unable to cough effectively or have excessive secretions. Suctioning helps to remove mucus, saliva, blood, or other fluids that may obstruct the airway and can be essential in maintaining a patient's respiratory function.
41.
A child’s airway is shorter and narrower than an adult’s
Correct Answer
A. True
Explanation
A child's airway is shorter and narrower than an adult's due to the anatomical differences between children and adults. The smaller size of a child's airway can make them more susceptible to airway obstruction or difficulty breathing, especially during respiratory illnesses or when exposed to irritants. This is why it is important to take extra precautions when caring for a child's respiratory health, such as avoiding smoking around them and ensuring proper supervision during activities that may pose a risk of choking.
42.
Incentive spirometry
Correct Answer(s)
A. Expand lungs
B. Clear mucus secretions
C. Increase amount of O2 delivered to bronchi and alveoli
D. Often prescribed for postop patients
Explanation
Incentive spirometry is a technique used to expand the lungs, clear mucus secretions, and increase the amount of oxygen delivered to the bronchi and alveoli. It is often prescribed for postoperative patients to prevent complications such as atelectasis and pneumonia. By using a device that provides visual feedback and encourages deep breathing, patients can improve lung function and prevent respiratory complications.