Nursing Quiz: NCLEX Questions On Respiratory System Disorder

1. A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?

Activity intolerance related to fatigue

Anxiety related to actual threat to health status

Risk for infection related to retained secretions

Impaired gas exchange related to airflow obstruction

A patient airway and an adequate breathing pattern are the top priority for any patient. making “impaired gas exchange related to airflow obstruction” the most important nursing diagnosis. The other options also may apply to this patient but less important.

Explanation

A patient airway and an adequate breathing pattern are the top priority for any patient. making “impaired gas exchange related to airflow obstruction” the most important nursing diagnosis. The other options also may apply to this patient but less important.

2. Miriam. a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis. nasal drainage normally is:

Yellow

Green

Clear

Gray

Normally. nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.

Explanation

Normally. nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.

3. A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon). 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?

Leg movement

Finger movement

Lip movement

Fighting the ventilator

Pancuronium. a nondepolarizing blocking agent. is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs. or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

Explanation

Pancuronium. a nondepolarizing blocking agent. is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs. or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

4. A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly. and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator. alarm sounds. the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing

A disconnected ventilator tube

An endotracheal cuff leak

A change in the oxygen concentration without resetting the oxygen level alarm

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 endotracheal tube. and the patient’s being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.

Explanation

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 endotracheal tube. and the patient’s being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.

5. On auscultation. which finding suggests a right pneumothorax?

Bilateral inspiratory and expiratory crackles

Absence of breaths sound in the right thorax

Inspiratory wheezes in the right thorax

Bilateral pleural friction rub.

In pneumothorax. the alveoli are deflated and no air exchange occurs in the lungs. Therefore. breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion. inspiratory wheezes may signal asthma. and a pleural friction rub may indicate pleural inflammation.

Explanation

In pneumothorax. the alveoli are deflated and no air exchange occurs in the lungs. Therefore. breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion. inspiratory wheezes may signal asthma. and a pleural friction rub may indicate pleural inflammation.

6. Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug. the nurse should explain that it may cause:

Nasal congestion

Nervousness

Lethargy

Hyperkalemia

Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat. not nasal congestion; insomnia. not lethargy; and hypokalemia (with high doses). not hyperkalemia. Other adverse effects of albuterol include tremor. dizziness. headache. tachycardia. palpitations. hypertension. heartburn. nausea. vomiting and muscle cramps.

Explanation

Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat. not nasal congestion; insomnia. not lethargy; and hypokalemia (with high doses). not hyperkalemia. Other adverse effects of albuterol include tremor. dizziness. headache. tachycardia. palpitations. hypertension. heartburn. nausea. vomiting and muscle cramps.

7. A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Nausea or vomiting

Abdominal pain or diarrhea

Hallucinations or tinnitus

Lightheadedness or paresthesia

The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea. vomiting. abdominal pain. and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.

Explanation

The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea. vomiting. abdominal pain. and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.

8. Rhea. confused and short breath. is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem. the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report. the nurses sees many abbreviations. What does a lowercase "a" in ABG value present?

Acid-base balance

Arterial Blood

Arterial oxygen saturation

Alveoli

A lowercase “a” in an ABG value represents arterial blood. For instance. the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid-base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase “A” represents alveolar conditions: for example. PA02 indicates the partial pressure of oxygen in the alveoli.

Explanation

A lowercase “a” in an ABG value represents arterial blood. For instance. the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid-base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase “A” represents alveolar conditions: for example. PA02 indicates the partial pressure of oxygen in the alveoli.

9. Before administering ephedrine. Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects. it is not recommended for:

Patients with an acute asthma attack

Patients with narcolepsy

Patients under age 6

Elderly patients

Ephedrine is not recommended for elderly patients. who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure. coldness in the extremities. and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.

Explanation

Ephedrine is not recommended for elderly patients. who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure. coldness in the extremities. and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.

10. Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:

Contralateral side in a simple pneumothorax

Affected side in a hemothorax

Affected side in a tension pneumothorax

Contralateral side in hemothorax

The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax. accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation. the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

Explanation

The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax. accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation. the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.