Chapter 9: Care of the Patient with a Respiratory Disorder
MULTIPLE CHOICE
1. What is the purpose of the cilia?
a. Warm and moisturize inhaled air
b. Sweep debris toward nasal cavity
c. Stimulate cough reflex
d. Produce mucus
ANS: B
The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion
that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate
the cough reflex, but not the cilia themselves.
DIF: Cognitive Level: Knowledge REF: Page 384 OBJ: 2
TOP: Secretions KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
2. What happens when there is a decrease in the oxygen level in the blood?
a. Pituitary stimulates the respiratory system to increase respiratory rate
b. The alveoli diffuse more oxygen into the blood
c. Chemoreceptors in the carotid body and aortic body stimulate the respiratory
centers to modify respiratory rates
d. The parietal pleura increases the negative pressure
ANS: C
The chemoreceptors in the carotid bodies and the aortic bodies send a message to the
respiratory centers to modify respirations.
DIF: Cognitive Level: Application REF: Page 386 OBJ: 1
TOP: Respiratory rate modification KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related
to impaired verbal communication related to removal of the larynx. What is an appropriate
nursing intervention?
a. Complete care quickly
b. Provide a pad and pencil or magic slate
c. Refrain from conversations with the patient to reduce stress level
d. Offer books or jigsaw puzzles for entertainment
ANS: B
Provide patient with implements for communication. Rapidly completing care and provision
of solitary activities does not reduce social isolation.
DIF: Cognitive Level: Application REF: Page 309 OBJ: 10
TOP: Laryngectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
, 4. A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he
has frequent nosebleeds that he can usually control himself. What would be the most helpful
assessment after the nurse has stopped the bleeding?
a. Obtain a blood pressure
b. Record the approximate amount of blood lost
c. Inquire about a headache
d. Record the last episode of epistaxis
ANS: A
Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as
much as 1 L of blood in an hour with heavy epistaxis.
DIF: Cognitive Level: Application REF: Page 393 OBJ: 9
TOP: Epistaxis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse assessing an 11-year-old who is having an asthma attack expects to hear
adventitious sounds of:
a. friction rub.
b. sibilant wheezes.
c. crackles.
d. sonorous wheezes.
ANS: B
The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes,
which are high-pitched whistling sounds.
DIF: Cognitive Level: Application REF: Page 387 OBJ: 16
TOP: Asthma KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. How will the kidneys behave in respiratory acidosis?
a. Retain bicarbonate to increase the pH
b. Excrete more urine to reduce potassium
c. Concentrate the urine to conserve circulating fluid in the blood stream
d. Lower the pH by excretion of bicarbonate
ANS: A
In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH.
DIF: Cognitive Level: Analysis REF: Page 392, Table 9-2
OBJ: 11 TOP: Respiratory acidosis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and
fatigue. What is the infected fluid that the physician removes called?
a. Emboli
b. Emphysema
c. Sputum
d. Empyema
ANS: D
MULTIPLE CHOICE
1. What is the purpose of the cilia?
a. Warm and moisturize inhaled air
b. Sweep debris toward nasal cavity
c. Stimulate cough reflex
d. Produce mucus
ANS: B
The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion
that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate
the cough reflex, but not the cilia themselves.
DIF: Cognitive Level: Knowledge REF: Page 384 OBJ: 2
TOP: Secretions KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
2. What happens when there is a decrease in the oxygen level in the blood?
a. Pituitary stimulates the respiratory system to increase respiratory rate
b. The alveoli diffuse more oxygen into the blood
c. Chemoreceptors in the carotid body and aortic body stimulate the respiratory
centers to modify respiratory rates
d. The parietal pleura increases the negative pressure
ANS: C
The chemoreceptors in the carotid bodies and the aortic bodies send a message to the
respiratory centers to modify respirations.
DIF: Cognitive Level: Application REF: Page 386 OBJ: 1
TOP: Respiratory rate modification KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related
to impaired verbal communication related to removal of the larynx. What is an appropriate
nursing intervention?
a. Complete care quickly
b. Provide a pad and pencil or magic slate
c. Refrain from conversations with the patient to reduce stress level
d. Offer books or jigsaw puzzles for entertainment
ANS: B
Provide patient with implements for communication. Rapidly completing care and provision
of solitary activities does not reduce social isolation.
DIF: Cognitive Level: Application REF: Page 309 OBJ: 10
TOP: Laryngectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
, 4. A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he
has frequent nosebleeds that he can usually control himself. What would be the most helpful
assessment after the nurse has stopped the bleeding?
a. Obtain a blood pressure
b. Record the approximate amount of blood lost
c. Inquire about a headache
d. Record the last episode of epistaxis
ANS: A
Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as
much as 1 L of blood in an hour with heavy epistaxis.
DIF: Cognitive Level: Application REF: Page 393 OBJ: 9
TOP: Epistaxis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse assessing an 11-year-old who is having an asthma attack expects to hear
adventitious sounds of:
a. friction rub.
b. sibilant wheezes.
c. crackles.
d. sonorous wheezes.
ANS: B
The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes,
which are high-pitched whistling sounds.
DIF: Cognitive Level: Application REF: Page 387 OBJ: 16
TOP: Asthma KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. How will the kidneys behave in respiratory acidosis?
a. Retain bicarbonate to increase the pH
b. Excrete more urine to reduce potassium
c. Concentrate the urine to conserve circulating fluid in the blood stream
d. Lower the pH by excretion of bicarbonate
ANS: A
In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH.
DIF: Cognitive Level: Analysis REF: Page 392, Table 9-2
OBJ: 11 TOP: Respiratory acidosis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and
fatigue. What is the infected fluid that the physician removes called?
a. Emboli
b. Emphysema
c. Sputum
d. Empyema
ANS: D
