Exam (elaborations)
Chapter 27 Alterations of Pulmonary Function
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- Galen College Of Nursing
Chapter 27 Alterations of Pulmonary Function
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Chapter 27: Alterations of Pulmonary FunctionMULTIPLE CHOICE
1. A 10-year-old develops pneumonia. Physical exam reveals subcostal and intercostal
retractions. The child reports that breathing is difficult with feelings that, “I cannot get
enough air.” What term should the nurse use to document this condition?
a. Cyanosis
b. Dyspnea
c. Hyperpnea
d. Orthopnea
ANS: B
Dyspnea is defined as “a subjective experience of breathing discomfort that consists of
qualitatively distinct sensations that vary in intensity.” Cyanosis is a bluish discoloration to
the skin. Hyperpnea is an increased ventilatory rate and orthopnea is dyspnea that occurs
when an individual lies flat.
REF: p. 687
2. A 20-year-old presents reporting difficulty breathing when lying down. What term should the
nurse use to document this condition?
a. Dyspnea
b. Orthopnea
c. Apnea
d. Tachypnea
ANS: B
Orthopnea is dyspnea that occurs when an individual lies flat. Dyspnea is shortness of breath
that occurs with activity. Apnea is cessation of breathing, and tachypnea is rapid breathing.
REF: p. 687
3. What type of breathing will the nurse observe while assessing a patient experiencing
both metabolic acidosis and Kussmaul respirations?
a. Audible wheezing or stridor
b. Increased rate, large tidal volumes, and no expiratory pause
c. Rapid respirations with periods of apnea
d. Very slow inhalations and rapid expirations
ANS: B
Kussmaul respirations are characterized by a slightly increased ventilatory rate, very
large tidal volumes, and no expiratory pause. Audible wheezing is usually associated
with conditions such as asthma, and stridor indicates a narrowed airway. Cheyne-Stokes
respirations are characterized by alternating periods of deep and shallow breathing, with
periods of apnea lasting from 15 to 60 seconds. Kussmaul respirations do not have slow
inhalations; bronchiolar disorders have these characteristics.
REF: p. 688
, 4. As a result of a severe head injury, a patient is now experiencing respiratory
abnormalities characterized by alternating periods of deep and shallow breathing with
periods of apnea. What term should the nurse use when charting this condition?
a. Cheyne-Stokes
b. Frank-Starling
c. Apnea
d. Orthopnea
ANS: A
Cheyne-Stokes respirations are characterized by alternating periods of deep and shallow
breathing, with periods of apnea lasting from 15 to 60 seconds. Frank-Starling is related to the
stretch of fibers. Apnea is cessation of respirations. Orthopnea is dyspnea that occurs when an
individual lies flat.
REF: p. 688
5. A patient’s arterial blood gas reveals decreased carbon dioxide (CO2) levels. What is the most
likely cause of this situation?
a. Hyperventilation
b. Hypoventilation
c. Apnea
d. Cyanosis
ANS: A
Individuals with hyperventilation blow off CO2 while individuals with hypoventilation retain
CO2.Apnea is cessation of breathing.Cyanosis is a blue color to the skin.
REF: p. 688
6. When giving report, what term should the nurse use to describe the coughing up of bloody
secretions?
a. Hematemesis
b. Cyanosis
c. Rhinitis
d. Hemoptysis
ANS: D
Hemoptysis is the coughing up of bloody secretions. Hematemesis is bloody vomiting.
Cyanosis is a bluish color to the skin. Rhinitis is a runny nose.
REF: p. 688
7. A 65-year-old diagnosed with emphysema presents to the ER for difficulty breathing.
Physical exam reveals both bluish skin and mucous membranes. What term will the nurse use
to document these observations?
a. Cyanosis
b. Hemoptysis
c. Hematemesis
d. Ischemia
ANS: A
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