Silvestri: Saunders Comprehensive Review for the NCLEX-PN®
Examination, 4th Edition
Chapter 48: Respiratory System
Test Bank
MULTIPLE CHOICE
1. A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to:
1.
Expel mucus from the airways.2.Dilate the terminal bronchioles.3.Provide for increased oxygen tension in the alveoli.4.Exercise the muscles of respiration.
ANS: 1
Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in
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(2007). Introduction to medical-surgical nursing (4th ed.). Philadelphia: Saunders. OBJ: Client Needs: Physiological Integrity
TOP: Content Area: Adult Health/Respiratory
MSC: Integrated Process: Nursing Process/Data Collection
4. A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?
1.Asks the client to sit upright2.Asks the client to breathe slowly and deeply through the mouth3.Places the stethoscope on the client’s gown4.Uses the diaphragm of the stethoscope
ANS: 3
Rationale: To listen to breath sounds, the stethoscope is always placed directly on the client’s skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using the diaphragm of the stethoscope, which is warmed prior to use.
Test-Taking Strategy: Note the strategic words “incorrect procedure.” Thinking about this data collection procedure and noting the words “on the client’s gown” in option 3 will direct you to this option. Review the correct method for listening to breath sounds if you had difficulty with this question.
DIF: Level of Cognitive Ability: Analysis
REF: Linton, A., & Maebius, N. (2007). Introduction to medical-surgical nursing (4th ed.). Philadelphia: Saunders.
OBJ: Client Needs: Health Promotion and Maintenance
TOP: Content Area: Adult Health/Respiratory
MSC:
FEV 1 (%) will decrease as the airway radius is decreased. FEV 1 (%) is
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A. How can the nurse quickly determine the lawfulness of this transport at 3 o’clock in the morning?
Selection of the best techniques varies from person to person depending on their age and personal preferences. Esophageal speech is popular among laryngectomies because it costs less and can provide a more normal sounding voice than some of the other options.
The physician needs to insert a chest tube. What are your responsibilities as the nurse?
A cough reflex clears up sputum from the nasal passages and pharynx. In the trachea there are cilia that move mucus up from the lungs. The mucus causes the cough reflex.
2. An 56-year-old established patient presents to her doctor's office with chest pain and shortness of breath. The doctor orders an ambulance to take the patient to the ED to be checked out. From the ED the patient is admitted for some
The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician.
The respiratory system is a complex organ structure of the human body anatomy, and the primary purpose of this system is to supply the blood with oxygen in order for the blood vessels to carry the precious gaseous element to all parts of the body to accomplish cell respiration. The respiratory system completes this important function of breathing throughout inspiration. In the breathing process inhaling oxygen is essential for cells to metabolize nutrients and carry out some other tasks, but it must occur simultaneously with exhaling when the carbon dioxide is excreted, this exchange of gases is the respiratory system's means of getting oxygen to the blood (McGowan, Jefferies & Turley, 2004).
D) “I have to call the doctor if I get chest pain or shortness of breath that does not go away with rest”.
I would tell the doctor to stop if he didn’t start and grab a manual ventilator and try to find a replacement mechanical ventilator.
a. The LPN was engaged in caring for the emergency transport patient along with the RN and was also in the process of discharging the other two patients. 3. Why did the LPN not notify the RN of the alarm and reading? a. With the information provided, it appears that the LPN was distracted as well as did not follow her scope of practice.
Patient outcome consisted of performing 10 deep breaths per hour. We have reviewed details that were difficult for the patient to remember, such as breathing out before placing the lips on the mouthpiece, and holding breath for 3 to 5 seconds at the top of each inhalation. With empathy, I provided understanding that being hospitalized is never easy due to sensory overload, pain and lack of privacy. Additionally, we have discussed the basic pathophysiology of lung inflammation and what it can do to a person. So overall, the outcome included enhanced disease knowledge with effective use of incentive spirometer.
I then needed to carry out a respiratory assessment. I observed Mr Brown’s chest for any visible signs of scars or trauma. This appeared normal.
The nurse’s primary goals were to provide continuous monitoring over patient’s weight, administer prescribed medications and provide teaching on purse lip breathing, using the incentive spirometer and living with COPD. In order