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Respiratory System Questions and Answers for NCLEX-PN and NCLEX-RN
Question 1: An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen?
The best time for the nurse to collect a sputum specimen for culture is early in the morning, immediately after the client wakes up. This is because during the night, secretions have accumulated in the client’s airways, which makes it easier to produce a good-quality sputum specimen. In addition, the client should rinse their mouth with water before expectorating the sputum to minimize contamination with oral flora.
It’s important for the nurse to provide clear instructions to the client on how to produce a sputum sample. The nurse should inform the client to take three deep breaths and then cough deeply, expectorating the sputum into a sterile container. The nurse should also instruct the client not to contaminate the specimen with saliva or oral secretions, and to avoid touching the inside of the container with their hands.
Question 2: A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
The hemoptysis (coughing up blood) is of greatest concern to the nurse as it indicates bleeding in the lungs, which is a potential complication of a thoracentesis. The nurse should monitor the client’s respiratory status closely and notify the healthcare provider immediately. The client’s vital signs are also important to monitor, but the hemoptysis takes priority as it could be life-threatening.
Question 3: An adult client is to have postural drainage four times a day. In developing the care plan, what the nurse should schedule this for?
When scheduling postural drainage for an adult client, the nurse should consider the following factors:
- Timing of meals: Postural drainage should be done at least 1-2 hours after a meal to prevent vomiting or aspiration.
- Medications: If the client is receiving bronchodilators or other respiratory medications, postural drainage should be done before these medications are administered.
- Other activities: Postural drainage should be scheduled around other activities such as physical therapy, diagnostic tests, or procedures.
- Client preference: The nurse should also consider the client’s preference for the timing of postural drainage.
- Based on these factors, the nurse may schedule postural drainage for the client before breakfast, mid-morning, mid-afternoon, and before bedtime, or at other appropriate times as indicated by the client’s individual needs and preferences.
It’s important to note that postural drainage should be done in conjunction with chest percussion and vibration to help loosen and mobilize secretions. The client should also be instructed to cough or deep breathe to clear their airways after the procedure.
In addition, the nurse should assess the client’s respiratory status before and after postural drainage to evaluate the effectiveness of the procedure. The client’s oxygen saturation levels, respiratory rate, and breath sounds should be monitored. If the client experiences any adverse reactions such as increased shortness of breath, chest pain, or dizziness, the nurse should stop the procedure immediately and notify the healthcare provider.
Lastly, the nurse should provide the client with education on postural drainage techniques, the importance of adhering to the schedule, and how to perform the procedure at home if appropriate. The client should also be advised to drink plenty of fluids to help thin secretions and promote their removal.
Question 4: An adult man has a tracheostomy tube in place. Which actions is most appropriate for the nurse to take when suctioning the tracheostomy?
However, in general, here are some steps a nurse might take when suctioning a patient with a tracheostomy tube:
- Ensure that the suction equipment is functioning correctly and that the suction catheter is appropriate for the size of the tracheostomy tube.
- Wash hands and put on gloves.
- Explain the suctioning procedure to the patient.
- Place the patient in a semi-Fowler’s position, if tolerated, to facilitate breathing and access to the tracheostomy site.
- Disconnect the patient’s ventilator or oxygen source, if applicable, and ventilate the patient with a bag-mask device with 100% oxygen for several breaths before suctioning.
- Insert the suction catheter into the tracheostomy tube until resistance is felt or until the patient coughs.
- Apply suction intermittently for no longer than 10-15 seconds while rotating and withdrawing the catheter.
- Allow the patient to rest and recover for a minute or two before suctioning again, if needed.
- Assess the patient’s breathing and oxygen saturation before, during, and after suctioning.
Document the procedure, including the patient’s response to suctioning, the amount and character of secretions, and the patient’s vital signs. It is essential to follow institutional guidelines, manufacturer instructions, and the healthcare provider’s orders when performing suctioning in patients with a tracheostomy tube. The nurse should also monitor the patient’s response to suctioning and report any adverse reactions or changes in the patient’s condition to the healthcare provider promptly.
Question 5: During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
If the catheter appears to attach to the tracheal wall during suctioning and creates a pulling sensation, the best action for the nurse to take is to stop suctioning immediately and remove the catheter.
Applying suction while the catheter is attached to the tracheal wall can cause trauma to the tracheal mucosa, leading to bleeding, swelling, and pain. It can also dislodge the tracheostomy tube, increasing the risk of airway obstruction and respiratory distress.
Once the catheter is removed, the nurse should assess the patient’s breathing and oxygen saturation and notify the healthcare provider of the incident. The healthcare provider may order further interventions, such as administering oxygen or bronchodilators, and may evaluate the patient’s tracheal site for signs of trauma or bleeding.
To prevent future incidents, the nurse should ensure that the suction catheter is the appropriate size and length for the tracheostomy tube and that the suction pressure is set to the appropriate level. The nurse should also use a rotating motion when inserting and withdrawing the catheter to minimize the risk of it attaching to the tracheal wall.
Question 6: A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
However, in general, here are some steps that a healthcare provider might recommend to a client who presents with a bloody nose:
- Stay calm and sit down with the head tilted forward slightly.
- Pinch the nostrils together with the thumb and forefinger and apply pressure for at least 10 minutes.
- Breathe through the mouth while holding pressure on the nose.
- Release the pressure after 10 minutes to check if the bleeding has stopped. If not, reapply pressure for another 10 minutes.
- Avoid blowing the nose, which can increase bleeding.
- Avoid picking the nose or inserting anything into the nostrils.
- Apply a cold compress or ice pack to the nose and cheeks to help reduce swelling and bleeding.
- If bleeding continues after 20-30 minutes of pressure, or if there are other symptoms such as dizziness or difficulty breathing, seek medical attention immediately.
It is important to note that these instructions are general guidelines, and the appropriate treatment for a bloody nose will depend on the severity and underlying cause of the bleeding. The healthcare provider should perform a thorough assessment and provide specific instructions based on the client’s individual needs and medical history.
Question 7: A client is admitted with a diagnosis of cancer of the larynx. Which statement made by the client is most likely related to the cause of his illness?
Laryngeal cancer is a type of cancer that starts in the cells of the larynx or voice box. The exact cause of laryngeal cancer is unknown, but several factors can increase the risk of developing the disease, including:
- Tobacco use: Smoking cigarettes, cigars, pipes, or using smokeless tobacco products, such as chewing tobacco, greatly increases the risk of laryngeal cancer.
- Alcohol consumption: Regular and heavy alcohol use, especially when combined with smoking, can increase the risk of laryngeal cancer.
- Human papillomavirus (HPV) infection: Certain strains of HPV can increase the risk of laryngeal cancer, especially in younger people.
- Occupational exposure: Exposure to certain chemicals and substances, such as asbestos, wood dust, and paint fumes, can increase the risk of laryngeal cancer, especially in people who work in certain occupations such as painting, woodworking, or construction.
- Gender: Men are more likely than women to develop laryngeal cancer.
- Age: Laryngeal cancer is more common in people over the age of 55.
It is important to note that not all people who have one or more of these risk factors will develop laryngeal cancer, and some people who develop laryngeal cancer may not have any known risk factors. If the client has questions or concerns about the cause of their illness, they should discuss them with their healthcare provider, who can provide personalized information and guidance.
Question 8: During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
During the preoperative period, the nursing action that will be of greatest priority for a person who is to have a laryngectomy is airway management. A laryngectomy is a surgical procedure that involves removing the larynx or voice box, which can result in the loss of the ability to speak and breathe normally. Therefore, it is crucial to ensure that the client’s airway is clear and that they are able to breathe effectively before, during, and after the surgery.
- The following nursing actions may be helpful in ensuring effective airway management for a client who is scheduled for a laryngectomy:
- Assess the client’s breathing and respiratory status, including oxygen saturation levels, lung sounds, and respiratory rate.
- Teach the client deep breathing and coughing exercises to help improve lung function and prevent complications such as pneumonia.
- Encourage the client to stay hydrated, as dry mucous membranes can increase the risk of respiratory complications.
- Monitor for signs of respiratory distress, such as shortness of breath, rapid breathing, and wheezing.
- Collaborate with the healthcare team to develop a plan for airway management during and after the surgery, which may include intubation, tracheostomy, or other interventions.
- Provide emotional support and education to the client and their family members about the potential changes in breathing and speech after the surgery, and the importance of follow-up care and rehabilitation.
Question 9: A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to:
The reason for ordering low-flow oxygen (2 L/min) in a patient with emphysema and acute upper respiratory infection is to avoid suppressing the patient’s respiratory drive.
In patients with chronic obstructive pulmonary disease (COPD) and emphysema, their respiratory drive is stimulated by low oxygen levels rather than high carbon dioxide levels, as is the case in healthy individuals. Therefore, providing too much supplemental oxygen can lead to the suppression of the patient’s respiratory drive, leading to hypoventilation and potentially worsening respiratory failure.
Low-flow oxygen, on the other hand, provides a small amount of supplemental oxygen without suppressing the patient’s respiratory drive, thereby allowing the patient to maintain adequate ventilation and oxygenation.
Question 10: An adult is admitted with chronic obstructive pulmonary disease (COPD). The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of the following:
The onset of neck vein distention and peripheral edema in a patient with chronic obstructive pulmonary disease (COPD) may signal the onset of right-sided heart failure or cor pulmonale.
In COPD, the lungs become damaged, which leads to decreased oxygenation of the blood and increased resistance to blood flow through the lungs. This increased resistance causes the right ventricle of the heart to work harder to pump blood through the lungs, which can eventually lead to right-sided heart failure or cor pulmonale.
Neck vein distention and peripheral edema are signs of fluid buildup in the body, which can occur with right-sided heart failure. Therefore, the practical nurse is correct to notify the registered nurse and continue frequent assessments, as prompt intervention is necessary to prevent further deterioration of the patient’s condition.
Question 11: A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client’s temperature is 102°F., respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
Bed rest is primarily ordered for a 79-year-old client with pneumococcal pneumonia and dyspnea to reduce the workload on the lungs and minimize oxygen demand.
Pneumococcal pneumonia is an infection of the lungs caused by the Streptococcus pneumoniae bacteria. Dyspnea, or difficulty breathing, is a common symptom of pneumonia, and the elevated temperature, increased respirations, and elevated heart rate suggest that the client is experiencing respiratory distress.
By placing the client on bed rest, the workload on the lungs is reduced, and the body’s oxygen demand is minimized. This can help alleviate the client’s symptoms and improve oxygenation. Additionally, bed rest may also help prevent further complications, such as fatigue and respiratory failure, which can occur when the body is overworked during a respiratory illness.
Therefore, bed rest is a key part of the treatment plan for clients with pneumococcal pneumonia and dyspnea, as it allows the body to conserve energy and focus its resources on fighting the infection.
Question 12: An adult is to have a tracheostomy performed. What is the nursing priority?
The nursing priority before a tracheostomy is performed on an adult is to ensure that the client understands the procedure, the reasons for it, and the potential risks and complications involved.
The nurse should explain the procedure to the client, answer any questions the client may have, and obtain informed consent from the client or the client’s legal representative. The nurse should also assess the client’s understanding and readiness for the procedure, including their emotional and psychological state.
In addition to client education and preparation, the nurse should also ensure that the client is in a stable condition, with adequate oxygenation, ventilation, and hydration. The nurse should also ensure that the client has received appropriate preoperative medications, such as antibiotics or bronchodilators, as ordered by the healthcare provider.
Overall, the nursing priority before a tracheostomy is to ensure that the client is fully informed, prepared, and optimized for the procedure, while also addressing any concerns or questions the client may have.
Question 13: Which nursing action is essential during tracheal suctioning?
During tracheal suctioning, the essential nursing action is to maintain the client’s oxygenation and ventilation while minimizing the risk of infection and trauma.
To achieve this, the nurse should:
- Assess the client’s respiratory status, including oxygen saturation, breath sounds, and respiratory rate, before and after suctioning.
- Preoxygenate the client with 100% oxygen for at least 30 seconds before suctioning to prevent hypoxemia and minimize the risk of cardiac arrhythmias.
- Use sterile technique and appropriate personal protective equipment to prevent infection.
- Insert the suction catheter gently and advance it only until resistance is met or until the client coughs, to avoid trauma to the tracheal mucosa.
- Apply suction intermittently for no more than 10-15 seconds at a time to avoid hypoxemia and trauma.
- Monitor the client’s vital signs and respiratory status throughout the procedure, and stop suctioning immediately if the client experiences significant respiratory distress, hypoxemia, or cardiac arrhythmias.
- Administer appropriate medications, such as bronchodilators or nebulized saline, before and after suctioning to promote airway clearance and reduce inflammation.
Overall, the essential nursing action during tracheal suctioning is to maintain the client’s oxygenation and ventilation while minimizing the risk of infection and trauma.
Question 14: An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
The absence of bubbling in the water seal chamber of a chest drainage system several hours after the chest tube was inserted may indicate that the lung has re-expanded and that there is no longer an air leak.
The water seal chamber in a chest drainage system is used to detect air leaks from the lung. As the lung re-expands, the air leak should decrease, and eventually, there should be no air leak at all. When there is no air leak, the water in the water seal chamber should remain still and not bubble.
If there is still an air leak, the water in the water seal chamber will bubble continuously, indicating that air is still escaping from the lung. In this case, the nurse should notify the healthcare provider and monitor the client closely for any signs of respiratory distress.
However, if there is no bubbling in the water seal chamber, this may indicate that the lung has re-expanded and that the chest tube may be ready for removal. The nurse should notify the healthcare provider, who will assess the client’s condition and determine if the chest tube can be removed.
Question 15: An adult has a chest drainage system. The client’s wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:
If a client with a chest drainage system pulls out their chest tube, the nurse should take the following steps:
Stay calm and assess the client’s respiratory status: Check the client’s breathing, oxygen saturation, and lung sounds to determine if there is an immediate threat to their airway or breathing. If the client is in distress or has significant bleeding, immediately call for assistance from the healthcare provider or emergency response team.
Cover the insertion site with a sterile dressing: Use a sterile dressing or gauze to cover the insertion site to prevent air from entering the chest cavity and to minimize the risk of infection.
Reinforce the dressing and apply firm pressure: Apply firm pressure over the dressing to prevent air from entering the chest cavity and to control bleeding. Encourage the client to take slow, deep breaths to prevent hyperventilation and anxiety.
Notify the healthcare provider: Inform the healthcare provider of the situation and the actions taken. The provider may order a chest x-ray or other tests to assess the client’s condition and determine the next steps.
Prepare for reinsertion of the chest tube: If necessary, prepare the client for the reinsertion of the chest tube. This may involve administering sedatives or pain medication to reduce discomfort and anxiety, and providing emotional support to the client and their family.
Overall, the most appropriate initial action for the nurse to take if a client with a chest drainage system pulls out their chest tube is to stay calm, assess the client’s respiratory status, cover the insertion site with a sterile dressing, reinforce the dressing and apply firm pressure, notify the healthcare provider, and prepare for reinsertion of the chest tube if necessary.
Question 16: An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest x-ray. This indicated that at that time the client:
A purified protein derivative (PPD) test is used to determine if a person has been exposed to tuberculosis (TB). A positive PPD test indicates that a person has been infected with the TB bacteria at some point in their life, but it does not necessarily mean that the person has active TB disease. A negative PPD test indicates that a person has not been infected with the TB bacteria, or that the infection is too recent for the immune system to produce a response.
In the case of this adult, they had a negative PPD test when they were first employed two years ago. However, a year later, the client had a positive PPD test and a negative chest x-ray. This indicates that at that time, the client was infected with the TB bacteria, but did not have active TB disease.
A positive PPD test means that the client’s immune system has responded to the TB bacteria, indicating that the bacteria is present in the body. However, a negative chest x-ray indicates that the client does not have any visible signs of active TB disease, such as lung lesions or cavities.
In this case, the client is considered to have latent TB infection, which means that the bacteria is present in the body, but is not causing any symptoms or disease. Clients with latent TB infection may be asymptomatic and are not contagious. However, they may develop active TB disease in the future if their immune system becomes weakened, such as in the case of HIV infection or other medical conditions. It is important for clients with latent TB infection to be monitored closely and to receive treatment if necessary to prevent the development of active TB disease.
Question 17: An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. Which symptoms would suggest a toxic effect of INH?
Isoniazid (INH) is one of the drugs used to treat active tuberculosis. While INH is generally well-tolerated, it can have toxic effects on the liver and nervous system. Symptoms that suggest a toxic effect of INH include:
- Nausea and vomiting: These are common side effects of INH, but if they are severe and persistent, it may be a sign of liver toxicity.
- Jaundice: This is a yellowing of the skin and whites of the eyes, which may indicate liver damage.
- Abdominal pain: This may be a sign of liver damage.
- Fatigue and weakness: These are non-specific symptoms that may be associated with liver toxicity.
- Numbness or tingling in the hands or feet: This is a sign of nerve damage, which can be caused by INH toxicity.
- Vision changes: Blurred or double vision can be a sign of nerve damage.
- Confusion or hallucinations: These are rare but serious side effects that may indicate central nervous system toxicity.
If a client experiences any of these symptoms while taking INH, they should notify their healthcare provider immediately. The provider may order blood tests to monitor liver function and adjust the client’s medication regimen as needed.
Question 18: An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. He is also receiving pyridoxine (vitamin B6). Why is this medication prescribed for him?
Pyridoxine, also known as vitamin B6, is often prescribed along with isoniazid (INH) for the treatment of active tuberculosis. The reason for this is that INH can interfere with the body’s ability to use vitamin B6, which can lead to a deficiency of this essential nutrient. Pyridoxine supplementation can help to prevent this deficiency and reduce the risk of side effects associated with INH treatment.
Pyridoxine is important for the proper function of the nervous system and is involved in the production of neurotransmitters, such as serotonin and dopamine. A deficiency of vitamin B6 can lead to a range of neurological symptoms, including peripheral neuropathy (numbness, tingling, and pain in the hands and feet), seizures, and confusion. Pyridoxine supplementation can help to prevent these symptoms and ensure that the nervous system functions properly during INH treatment.
In addition to its role in nerve function, pyridoxine is also involved in the production of red blood cells and the metabolism of protein and carbohydrates. Supplementation with pyridoxine can help to support these processes and ensure that the body has adequate levels of this important nutrient during INH treatment.
Question 19: The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis?
The drug of choice for prophylaxis of tuberculosis is isoniazid (INH). It is recommended as the first-line treatment for both the treatment and prevention of tuberculosis. INH is effective in preventing the development of active tuberculosis in people with latent tuberculosis infection, including individuals who have had recent exposure to an active case of tuberculosis. The standard duration of INH prophylaxis is 9 months, although it can be shorter in certain situations. It is important to follow the prescribed regimen closely and to monitor for any adverse effects.
Question 20: A farmer who has had a cough for several months has noticed a lack of energy lately. He is being tested for histoplasmosis. Which factor reported by the client would be most related to the diagnosis of histoplasmosis?
Histoplasmosis is a fungal infection caused by the inhalation of spores of the Histoplasma capsulatum fungus. The fungus is commonly found in soil that has been contaminated with bird or bat droppings. The following factor reported by the client would be most related to the diagnosis of histoplasmosis:
The farmer has been working in soil contaminated with bird or bat droppings: Histoplasmosis is most commonly found in soil that has been contaminated with bird or bat droppings. People who work in areas where this type of soil is disturbed, such as farmers, construction workers, or landscapers, are at an increased risk of developing histoplasmosis. Therefore, the farmer’s history of working in contaminated soil is highly suggestive of histoplasmosis.
Other symptoms of histoplasmosis include fever, cough, chest pain, and fatigue, which the farmer also presents. However, the history of working in contaminated soil is a key factor that strongly supports the diagnosis of histoplasmosis.